|
INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 26990
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$677.15 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$1,234.36
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$744.86
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$677.15
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL
|
Facility
|
OP
|
$1,463.00
|
|
|
Service Code
|
CPT 46050
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$100.52 |
| Max. Negotiated Rate |
$1,463.00 |
| Rate for Payer: Aetna Medicare |
$845.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,016.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,016.54
|
| Rate for Payer: BCBS Complete |
$467.12
|
| Rate for Payer: BCBS MAPPO |
$813.23
|
| Rate for Payer: BCBS Trust/PPO |
$556.46
|
| Rate for Payer: BCN Medicare Advantage |
$813.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$813.23
|
| Rate for Payer: Mclaren Medicaid |
$444.84
|
| Rate for Payer: Mclaren Medicare |
$813.23
|
| Rate for Payer: Meridian Medicaid |
$467.12
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$853.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$935.21
|
| Rate for Payer: PACE Medicare |
$772.57
|
| Rate for Payer: PACE SWMI |
$813.23
|
| Rate for Payer: PHP Medicare Advantage |
$813.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$444.84
|
| Rate for Payer: Priority Health Medicare |
$813.23
|
| Rate for Payer: Railroad Medicare Medicare |
$813.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$110.57
|
| Rate for Payer: UHC Core |
$1,463.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$813.23
|
| Rate for Payer: UHC Exchange |
$100.52
|
| Rate for Payer: UHC Medicare Advantage |
$837.63
|
| Rate for Payer: VA VA |
$813.23
|
|
|
INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 23930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$213.82 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,629.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,160.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,160.42
|
| Rate for Payer: BCBS Complete |
$1,452.28
|
| Rate for Payer: BCBS MAPPO |
$2,528.34
|
| Rate for Payer: BCBS Trust/PPO |
$668.96
|
| Rate for Payer: BCN Medicare Advantage |
$2,528.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,528.34
|
| Rate for Payer: Mclaren Medicaid |
$1,383.00
|
| Rate for Payer: Mclaren Medicare |
$2,528.34
|
| Rate for Payer: Meridian Medicaid |
$1,452.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,654.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,907.59
|
| Rate for Payer: PACE Medicare |
$2,401.92
|
| Rate for Payer: PACE SWMI |
$2,528.34
|
| Rate for Payer: PHP Medicare Advantage |
$2,528.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,383.00
|
| Rate for Payer: Priority Health Medicare |
$2,528.34
|
| Rate for Payer: Railroad Medicare Medicare |
$2,528.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.20
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,528.34
|
| Rate for Payer: UHC Exchange |
$213.82
|
| Rate for Payer: UHC Medicare Advantage |
$2,604.19
|
| Rate for Payer: VA VA |
$2,528.34
|
|
|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED
|
Facility
|
OP
|
$4,536.73
|
|
|
Service Code
|
CPT 10121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$180.75 |
| Max. Negotiated Rate |
$4,536.73 |
| Rate for Payer: Aetna Medicare |
$1,500.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,803.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,803.26
|
| Rate for Payer: BCBS Complete |
$828.64
|
| Rate for Payer: BCBS MAPPO |
$1,442.61
|
| Rate for Payer: BCBS Trust/PPO |
$871.35
|
| Rate for Payer: BCN Medicare Advantage |
$1,442.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,442.61
|
| Rate for Payer: Mclaren Medicaid |
$789.11
|
| Rate for Payer: Mclaren Medicare |
$1,442.61
|
| Rate for Payer: Meridian Medicaid |
$828.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,514.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,659.00
|
| Rate for Payer: PACE Medicare |
$1,370.48
|
| Rate for Payer: PACE SWMI |
$1,442.61
|
| Rate for Payer: PHP Medicare Advantage |
$1,442.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$789.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,536.73
|
| Rate for Payer: Priority Health Medicare |
$1,442.61
|
| Rate for Payer: Priority Health Narrow Network |
$3,629.38
|
| Rate for Payer: Railroad Medicare Medicare |
$1,442.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.82
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,442.61
|
| Rate for Payer: UHC Exchange |
$180.75
|
| Rate for Payer: UHC Medicare Advantage |
$1,485.89
|
| Rate for Payer: VA VA |
$1,442.61
|
|
|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE
|
Facility
|
OP
|
$1,076.20
|
|
|
Service Code
|
CPT 10120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$104.45 |
| Max. Negotiated Rate |
$1,076.20 |
| Rate for Payer: Aetna Medicare |
$368.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$443.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$443.50
|
| Rate for Payer: BCBS Complete |
$203.80
|
| Rate for Payer: BCBS MAPPO |
$354.80
|
| Rate for Payer: BCBS Trust/PPO |
$233.21
|
| Rate for Payer: BCN Medicare Advantage |
$354.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$354.80
|
| Rate for Payer: Mclaren Medicaid |
$194.08
|
| Rate for Payer: Mclaren Medicare |
$354.80
|
| Rate for Payer: Meridian Medicaid |
$203.80
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$372.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$408.02
|
| Rate for Payer: PACE Medicare |
$337.06
|
| Rate for Payer: PACE SWMI |
$354.80
|
| Rate for Payer: PHP Medicare Advantage |
$354.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$194.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,076.20
|
| Rate for Payer: Priority Health Medicare |
$354.80
|
| Rate for Payer: Priority Health Narrow Network |
$860.96
|
| Rate for Payer: Railroad Medicare Medicare |
$354.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$114.90
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$354.80
|
| Rate for Payer: UHC Exchange |
$104.45
|
| Rate for Payer: UHC Medicare Advantage |
$365.44
|
| Rate for Payer: VA VA |
$354.80
|
|
|
INCISION, BONE CORTEX, PELVIS AND/OR HIP JOINT (EG, OSTEOMYELITIS OR BONE ABSCESS)
|
Facility
|
OP
|
$6,837.00
|
|
|
Service Code
|
CPT 26992
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,001.65 |
| Max. Negotiated Rate |
$6,837.00 |
| Rate for Payer: BCBS Trust/PPO |
$1,940.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,101.82
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Exchange |
$1,001.65
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$4,336.79
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$349.71 |
| Max. Negotiated Rate |
$4,336.79 |
| Rate for Payer: Aetna Medicare |
$1,487.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,787.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,787.60
|
| Rate for Payer: BCBS Complete |
$821.44
|
| Rate for Payer: BCBS MAPPO |
$1,430.08
|
| Rate for Payer: BCBS Trust/PPO |
$999.08
|
| Rate for Payer: BCN Medicare Advantage |
$1,430.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,430.08
|
| Rate for Payer: Mclaren Medicaid |
$782.25
|
| Rate for Payer: Mclaren Medicare |
$1,430.08
|
| Rate for Payer: Meridian Medicaid |
$821.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,501.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,644.59
|
| Rate for Payer: PACE Medicare |
$1,358.58
|
| Rate for Payer: PACE SWMI |
$1,430.08
|
| Rate for Payer: PHP Medicare Advantage |
$1,430.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$782.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,336.79
|
| Rate for Payer: Priority Health Medicare |
$1,430.08
|
| Rate for Payer: Priority Health Narrow Network |
$3,469.43
|
| Rate for Payer: Railroad Medicare Medicare |
$1,430.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$384.68
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,430.08
|
| Rate for Payer: UHC Exchange |
$349.71
|
| Rate for Payer: UHC Medicare Advantage |
$1,472.98
|
| Rate for Payer: VA VA |
$1,430.08
|
|
|
INCISION OF LABIAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$1,408.21
|
|
|
Service Code
|
CPT 40806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$29.14 |
| Max. Negotiated Rate |
$1,408.21 |
| Rate for Payer: Aetna Medicare |
$509.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$611.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$611.96
|
| Rate for Payer: BCBS Complete |
$281.21
|
| Rate for Payer: BCBS MAPPO |
$489.57
|
| Rate for Payer: BCBS Trust/PPO |
$70.13
|
| Rate for Payer: BCN Medicare Advantage |
$489.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$489.57
|
| Rate for Payer: Mclaren Medicaid |
$267.79
|
| Rate for Payer: Mclaren Medicare |
$489.57
|
| Rate for Payer: Meridian Medicaid |
$281.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$514.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$563.01
|
| Rate for Payer: PACE Medicare |
$465.09
|
| Rate for Payer: PACE SWMI |
$489.57
|
| Rate for Payer: PHP Medicare Advantage |
$489.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$267.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,408.21
|
| Rate for Payer: Priority Health Medicare |
$489.57
|
| Rate for Payer: Priority Health Narrow Network |
$1,126.56
|
| Rate for Payer: Railroad Medicare Medicare |
$489.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.05
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$489.57
|
| Rate for Payer: UHC Exchange |
$29.14
|
| Rate for Payer: UHC Medicare Advantage |
$504.26
|
| Rate for Payer: VA VA |
$489.57
|
|
|
INCISION OF LINGUAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$3,138.00
|
|
|
Service Code
|
CPT 41010
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$109.04 |
| Max. Negotiated Rate |
$3,138.00 |
| Rate for Payer: Aetna Medicare |
$1,411.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,696.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,696.21
|
| Rate for Payer: BCBS Complete |
$779.44
|
| Rate for Payer: BCBS MAPPO |
$1,356.97
|
| Rate for Payer: BCBS Trust/PPO |
$550.65
|
| Rate for Payer: BCN Medicare Advantage |
$1,356.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,356.97
|
| Rate for Payer: Mclaren Medicaid |
$742.26
|
| Rate for Payer: Mclaren Medicare |
$1,356.97
|
| Rate for Payer: Meridian Medicaid |
$779.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,424.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,560.52
|
| Rate for Payer: PACE Medicare |
$1,289.12
|
| Rate for Payer: PACE SWMI |
$1,356.97
|
| Rate for Payer: PHP Medicare Advantage |
$1,356.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$742.26
|
| Rate for Payer: Priority Health Medicare |
$1,356.97
|
| Rate for Payer: Railroad Medicare Medicare |
$1,356.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.94
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,356.97
|
| Rate for Payer: UHC Exchange |
$109.04
|
| Rate for Payer: UHC Medicare Advantage |
$1,397.68
|
| Rate for Payer: VA VA |
$1,356.97
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$8,575.95
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,402.85 |
| Max. Negotiated Rate |
$7,718.36 |
| Rate for Payer: Aetna Commercial |
$7,289.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,574.37
|
| Rate for Payer: Cash Price |
$6,860.76
|
| Rate for Payer: Cofinity Commercial |
$6,003.16
|
| Rate for Payer: Cofinity Commercial |
$7,375.32
|
| Rate for Payer: Healthscope Commercial |
$7,718.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,289.56
|
| Rate for Payer: PHP Commercial |
$7,289.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,003.16
|
| Rate for Payer: Priority Health SBD |
$5,402.85
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 43975-304-10
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.59 |
| Max. Negotiated Rate |
$315.14 |
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.60
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Healthscope Commercial |
$315.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$297.63
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.10
|
| Rate for Payer: Priority Health SBD |
$220.59
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$300.80
|
|
|
Service Code
|
NDC 62559-511-01
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.50 |
| Max. Negotiated Rate |
$270.72 |
| Rate for Payer: Aetna Commercial |
$255.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.52
|
| Rate for Payer: Cash Price |
$240.64
|
| Rate for Payer: Cofinity Commercial |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$258.69
|
| Rate for Payer: Healthscope Commercial |
$270.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.68
|
| Rate for Payer: PHP Commercial |
$255.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.56
|
| Rate for Payer: Priority Health SBD |
$189.50
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 51079-868-01
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$261.12
|
|
|
Service Code
|
NDC 51079-868-20
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.51 |
| Max. Negotiated Rate |
$235.01 |
| Rate for Payer: Aetna Commercial |
$221.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.73
|
| Rate for Payer: Cash Price |
$208.90
|
| Rate for Payer: Cofinity Commercial |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$224.56
|
| Rate for Payer: Healthscope Commercial |
$235.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.95
|
| Rate for Payer: PHP Commercial |
$221.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health SBD |
$164.51
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$326.58 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$336.95
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cofinity Commercial |
$362.87
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$440.62
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.87
|
| Rate for Payer: Priority Health SBD |
$326.58
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 0517-0375-10
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$299.36 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.62
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 0517-0375-10
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$299.36 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.62
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.15 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.95
|
| Rate for Payer: Priority Health SBD |
$205.15
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$403.05
|
|
|
Service Code
|
NDC 70100-424-01
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$253.92 |
| Max. Negotiated Rate |
$362.74 |
| Rate for Payer: Aetna Commercial |
$342.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.98
|
| Rate for Payer: Cash Price |
$322.44
|
| Rate for Payer: Cofinity Commercial |
$282.14
|
| Rate for Payer: Cofinity Commercial |
$346.62
|
| Rate for Payer: Healthscope Commercial |
$362.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$342.59
|
| Rate for Payer: PHP Commercial |
$342.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.14
|
| Rate for Payer: Priority Health SBD |
$253.92
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238-424-06
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.40 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.67
|
| Rate for Payer: Priority Health SBD |
$146.40
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$403.05
|
|
|
Service Code
|
NDC 70100-424-02
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$253.92 |
| Max. Negotiated Rate |
$362.74 |
| Rate for Payer: Aetna Commercial |
$342.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.98
|
| Rate for Payer: Cash Price |
$322.44
|
| Rate for Payer: Cofinity Commercial |
$282.14
|
| Rate for Payer: Cofinity Commercial |
$346.62
|
| Rate for Payer: Healthscope Commercial |
$362.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$342.59
|
| Rate for Payer: PHP Commercial |
$342.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.14
|
| Rate for Payer: Priority Health SBD |
$253.92
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238-424-25
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.40 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.67
|
| Rate for Payer: Priority Health SBD |
$146.40
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155-010-01
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.01 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.42
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$294.46
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$357.55
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$294.46
|
| Rate for Payer: Priority Health SBD |
$265.01
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$117.33
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.92 |
| Max. Negotiated Rate |
$105.60 |
| Rate for Payer: Aetna Commercial |
$99.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.26
|
| Rate for Payer: Cash Price |
$93.86
|
| Rate for Payer: Cofinity Commercial |
$100.90
|
| Rate for Payer: Cofinity Commercial |
$82.13
|
| Rate for Payer: Healthscope Commercial |
$105.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.73
|
| Rate for Payer: PHP Commercial |
$99.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.13
|
| Rate for Payer: Priority Health SBD |
$73.92
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna Commercial |
$2.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.53
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$1.64
|
| Rate for Payer: Cofinity Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.00
|
| Rate for Payer: PHP Commercial |
$2.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.48
|
|
