|
INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
|
Facility
|
OP
|
$63,755.98
|
|
|
Service Code
|
CPT 64590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$289.13 |
| Max. Negotiated Rate |
$63,755.98 |
| Rate for Payer: Aetna Medicare |
$20,243.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,330.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,330.89
|
| Rate for Payer: BCBS Complete |
$11,180.53
|
| Rate for Payer: BCBS MAPPO |
$19,464.71
|
| Rate for Payer: BCBS Trust/PPO |
$14,237.89
|
| Rate for Payer: BCN Medicare Advantage |
$19,464.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,464.71
|
| Rate for Payer: Mclaren Medicaid |
$10,647.20
|
| Rate for Payer: Mclaren Medicare |
$19,464.71
|
| Rate for Payer: Meridian Medicaid |
$11,180.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,437.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,384.42
|
| Rate for Payer: PACE Medicare |
$18,491.47
|
| Rate for Payer: PACE SWMI |
$19,464.71
|
| Rate for Payer: PHP Medicare Advantage |
$19,464.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,647.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$63,755.98
|
| Rate for Payer: Priority Health Medicare |
$19,464.71
|
| Rate for Payer: Priority Health Narrow Network |
$51,004.78
|
| Rate for Payer: Railroad Medicare Medicare |
$19,464.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$318.04
|
| Rate for Payer: UHC Core |
$11,194.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$19,464.71
|
| Rate for Payer: UHC Exchange |
$289.13
|
| Rate for Payer: UHC Medicare Advantage |
$20,048.65
|
| Rate for Payer: VA VA |
$19,464.71
|
|
|
INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
|
Facility
|
OP
|
$34,537.55
|
|
|
Service Code
|
CPT 63685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$336.61 |
| Max. Negotiated Rate |
$34,537.55 |
| Rate for Payer: Aetna Medicare |
$28,735.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34,537.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34,537.55
|
| Rate for Payer: BCBS Complete |
$15,870.69
|
| Rate for Payer: BCBS MAPPO |
$27,630.04
|
| Rate for Payer: BCBS Trust/PPO |
$18,696.27
|
| Rate for Payer: BCN Medicare Advantage |
$27,630.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27,630.04
|
| Rate for Payer: Mclaren Medicaid |
$15,113.63
|
| Rate for Payer: Mclaren Medicare |
$27,630.04
|
| Rate for Payer: Meridian Medicaid |
$15,870.69
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$29,011.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31,774.55
|
| Rate for Payer: PACE Medicare |
$26,248.54
|
| Rate for Payer: PACE SWMI |
$27,630.04
|
| Rate for Payer: PHP Medicare Advantage |
$27,630.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$15,113.63
|
| Rate for Payer: Priority Health Medicare |
$27,630.04
|
| Rate for Payer: Railroad Medicare Medicare |
$27,630.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$370.27
|
| Rate for Payer: UHC Core |
$11,194.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$27,630.04
|
| Rate for Payer: UHC Exchange |
$336.61
|
| Rate for Payer: UHC Medicare Advantage |
$28,458.94
|
| Rate for Payer: VA VA |
$27,630.04
|
|
|
INSULIN 1 UNIT/ ML INFUSION 100 ML (IV PREMIX)
|
Facility
|
IP
|
$77.40
|
|
|
Service Code
|
NDC 9900-0018-34
|
| Hospital Charge Code |
300906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.76 |
| Max. Negotiated Rate |
$69.66 |
| Rate for Payer: Aetna Commercial |
$65.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.31
|
| Rate for Payer: Cash Price |
$61.92
|
| Rate for Payer: Cofinity Commercial |
$66.56
|
| Rate for Payer: Cofinity Commercial |
$54.18
|
| Rate for Payer: Healthscope Commercial |
$69.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.79
|
| Rate for Payer: PHP Commercial |
$65.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.18
|
| Rate for Payer: Priority Health SBD |
$48.76
|
|
|
INSULIN 5 UNIT/5 ML IV PUSH 5 ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 9900-0011-38
|
| Hospital Charge Code |
300205
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna Commercial |
$17.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Cofinity Commercial |
$17.20
|
| Rate for Payer: Healthscope Commercial |
$18.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.00
|
| Rate for Payer: PHP Commercial |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.00
|
| Rate for Payer: Priority Health SBD |
$12.60
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
300798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM OB
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
301084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) LOW DOSE SUBCUTANEOUS PEN CUSTOM
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
300796
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) LOW DOSE SUBCUTANEOUS PEN CUSTOM OB
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
301082
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) MEDIUM DOSE SUBCUTANEOUS PEN CUSTOM
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
300797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) MEDIUM DOSE SUBCUTANEOUS PEN CUSTOM OB
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
301083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN
|
Facility
|
IP
|
$115.64
|
|
|
Service Code
|
NDC 0169-6339-10
|
| Hospital Charge Code |
112756
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$104.08 |
| Rate for Payer: Aetna Commercial |
$98.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.17
|
| Rate for Payer: Cash Price |
$92.51
|
| Rate for Payer: Cofinity Commercial |
$80.95
|
| Rate for Payer: Cofinity Commercial |
$99.45
|
| Rate for Payer: Healthscope Commercial |
$104.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.29
|
| Rate for Payer: PHP Commercial |
$98.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.95
|
| Rate for Payer: Priority Health SBD |
$72.85
|
|
|
INSULIN DETEMIR 100 UNIT/ML SUBCUTANEOUS (HOSPITAL USE BULK)
|
Facility
|
IP
|
$311.77
|
|
|
Service Code
|
NDC 0169-3687-12
|
| Hospital Charge Code |
180051
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.42 |
| Max. Negotiated Rate |
$280.59 |
| Rate for Payer: Aetna Commercial |
$265.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.65
|
| Rate for Payer: Cash Price |
$249.42
|
| Rate for Payer: Cofinity Commercial |
$218.24
|
| Rate for Payer: Cofinity Commercial |
$268.12
|
| Rate for Payer: Healthscope Commercial |
$280.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$265.00
|
| Rate for Payer: PHP Commercial |
$265.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.24
|
| Rate for Payer: Priority Health SBD |
$196.42
|
|
|
INSULIN DETEMIR (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN
|
Facility
|
IP
|
$97.49
|
|
|
Service Code
|
NDC 0169-6438-10
|
| Hospital Charge Code |
116361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.42 |
| Max. Negotiated Rate |
$87.74 |
| Rate for Payer: Aetna Commercial |
$82.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.37
|
| Rate for Payer: Cash Price |
$77.99
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$83.84
|
| Rate for Payer: Healthscope Commercial |
$87.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.87
|
| Rate for Payer: PHP Commercial |
$82.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.24
|
| Rate for Payer: Priority Health SBD |
$61.42
|
|
|
INSULIN DETEMIR (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN
|
Facility
|
IP
|
$97.49
|
|
|
Service Code
|
NDC 0169-6438-90
|
| Hospital Charge Code |
116361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.42 |
| Max. Negotiated Rate |
$87.74 |
| Rate for Payer: Aetna Commercial |
$82.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.37
|
| Rate for Payer: Cash Price |
$77.99
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$83.84
|
| Rate for Payer: Healthscope Commercial |
$87.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.87
|
| Rate for Payer: PHP Commercial |
$82.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.24
|
| Rate for Payer: Priority Health SBD |
$61.42
|
|
|
INSULIN DETEMIR (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$311.77
|
|
|
Service Code
|
NDC 0169-3687-12
|
| Hospital Charge Code |
70261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.71 |
| Max. Negotiated Rate |
$280.59 |
| Rate for Payer: Aetna Commercial |
$265.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.65
|
| Rate for Payer: BCBS Complete |
$124.71
|
| Rate for Payer: Cash Price |
$249.42
|
| Rate for Payer: Cofinity Commercial |
$218.24
|
| Rate for Payer: Cofinity Commercial |
$268.12
|
| Rate for Payer: Healthscope Commercial |
$280.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$265.00
|
| Rate for Payer: PHP Commercial |
$265.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.24
|
| Rate for Payer: Priority Health SBD |
$196.42
|
|
|
INSULIN DETEMIR (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$311.77
|
|
|
Service Code
|
NDC 0169-3687-12
|
| Hospital Charge Code |
70261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.42 |
| Max. Negotiated Rate |
$280.59 |
| Rate for Payer: Aetna Commercial |
$265.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.65
|
| Rate for Payer: Cash Price |
$249.42
|
| Rate for Payer: Cofinity Commercial |
$218.24
|
| Rate for Payer: Cofinity Commercial |
$268.12
|
| Rate for Payer: Healthscope Commercial |
$280.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$265.00
|
| Rate for Payer: PHP Commercial |
$265.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.24
|
| Rate for Payer: Priority Health SBD |
$196.42
|
|
|
INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$211.05
|
|
|
Service Code
|
NDC 0088-2220-33
|
| Hospital Charge Code |
28282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.96 |
| Max. Negotiated Rate |
$189.94 |
| Rate for Payer: Aetna Commercial |
$179.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.18
|
| Rate for Payer: Cash Price |
$168.84
|
| Rate for Payer: Cofinity Commercial |
$147.74
|
| Rate for Payer: Cofinity Commercial |
$181.50
|
| Rate for Payer: Healthscope Commercial |
$189.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.39
|
| Rate for Payer: PHP Commercial |
$179.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.74
|
| Rate for Payer: Priority Health SBD |
$132.96
|
|
|
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN
|
Facility
|
IP
|
$80.59
|
|
|
Service Code
|
NDC 0002-8799-59
|
| Hospital Charge Code |
111377
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.77 |
| Max. Negotiated Rate |
$72.53 |
| Rate for Payer: Aetna Commercial |
$68.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.38
|
| Rate for Payer: Cash Price |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$69.31
|
| Rate for Payer: Cofinity Commercial |
$56.41
|
| Rate for Payer: Healthscope Commercial |
$72.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.50
|
| Rate for Payer: PHP Commercial |
$68.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.41
|
| Rate for Payer: Priority Health SBD |
$50.77
|
|
|
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN
|
Facility
|
IP
|
$80.59
|
|
|
Service Code
|
NDC 0002-8222-59
|
| Hospital Charge Code |
111377
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.77 |
| Max. Negotiated Rate |
$72.53 |
| Rate for Payer: Aetna Commercial |
$68.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.38
|
| Rate for Payer: Cash Price |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$56.41
|
| Rate for Payer: Cofinity Commercial |
$69.31
|
| Rate for Payer: Healthscope Commercial |
$72.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.50
|
| Rate for Payer: PHP Commercial |
$68.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.41
|
| Rate for Payer: Priority Health SBD |
$50.77
|
|
|
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN
|
Facility
|
IP
|
$80.59
|
|
|
Service Code
|
NDC 0002-8222-01
|
| Hospital Charge Code |
111377
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.77 |
| Max. Negotiated Rate |
$72.53 |
| Rate for Payer: Aetna Commercial |
$68.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.38
|
| Rate for Payer: Cash Price |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$56.41
|
| Rate for Payer: Cofinity Commercial |
$69.31
|
| Rate for Payer: Healthscope Commercial |
$72.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.50
|
| Rate for Payer: PHP Commercial |
$68.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.41
|
| Rate for Payer: Priority Health SBD |
$50.77
|
|
|
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN
|
Facility
|
IP
|
$80.59
|
|
|
Service Code
|
NDC 0002-8799-01
|
| Hospital Charge Code |
111377
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.77 |
| Max. Negotiated Rate |
$72.53 |
| Rate for Payer: Aetna Commercial |
$68.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.38
|
| Rate for Payer: Cash Price |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$56.41
|
| Rate for Payer: Cofinity Commercial |
$69.31
|
| Rate for Payer: Healthscope Commercial |
$72.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.50
|
| Rate for Payer: PHP Commercial |
$68.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.41
|
| Rate for Payer: Priority Health SBD |
$50.77
|
|
|
INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$44.03
|
|
|
Service Code
|
NDC 0002-7510-17
|
| Hospital Charge Code |
17405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.74 |
| Max. Negotiated Rate |
$39.63 |
| Rate for Payer: Aetna Commercial |
$37.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.62
|
| Rate for Payer: Cash Price |
$35.22
|
| Rate for Payer: Cofinity Commercial |
$30.82
|
| Rate for Payer: Cofinity Commercial |
$37.87
|
| Rate for Payer: Healthscope Commercial |
$39.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.43
|
| Rate for Payer: PHP Commercial |
$37.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.82
|
| Rate for Payer: Priority Health SBD |
$27.74
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION
|
Facility
|
IP
|
$60.35
|
|
|
Service Code
|
NDC 0002-8315-01
|
| Hospital Charge Code |
10284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.02 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.23
|
| Rate for Payer: Cash Price |
$48.28
|
| Rate for Payer: Cofinity Commercial |
$42.24
|
| Rate for Payer: Cofinity Commercial |
$51.90
|
| Rate for Payer: Healthscope Commercial |
$54.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.30
|
| Rate for Payer: PHP Commercial |
$51.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.24
|
| Rate for Payer: Priority Health SBD |
$38.02
|
|
|
INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION
|
Facility
|
IP
|
$56.95
|
|
|
Service Code
|
NDC 0169-1834-11
|
| Hospital Charge Code |
10284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$51.26 |
| Rate for Payer: Aetna Commercial |
$48.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.02
|
| Rate for Payer: Cash Price |
$45.56
|
| Rate for Payer: Cofinity Commercial |
$39.86
|
| Rate for Payer: Cofinity Commercial |
$48.98
|
| Rate for Payer: Healthscope Commercial |
$51.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.41
|
| Rate for Payer: PHP Commercial |
$48.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.86
|
| Rate for Payer: Priority Health SBD |
$35.88
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN
|
Facility
|
IP
|
$938.40
|
|
|
Service Code
|
NDC 0002-8824-27
|
| Hospital Charge Code |
178095
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$591.19 |
| Max. Negotiated Rate |
$844.56 |
| Rate for Payer: Aetna Commercial |
$797.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$609.96
|
| Rate for Payer: Cash Price |
$750.72
|
| Rate for Payer: Cofinity Commercial |
$656.88
|
| Rate for Payer: Cofinity Commercial |
$807.02
|
| Rate for Payer: Healthscope Commercial |
$844.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$797.64
|
| Rate for Payer: PHP Commercial |
$797.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$656.88
|
| Rate for Payer: Priority Health SBD |
$591.19
|
|
