|
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 56700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$201.38 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,893.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,477.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,477.26
|
| Rate for Payer: BCBS Complete |
$1,597.87
|
| Rate for Payer: BCBS MAPPO |
$2,781.81
|
| Rate for Payer: BCBS Trust/PPO |
$1,362.12
|
| Rate for Payer: BCN Medicare Advantage |
$2,781.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,781.81
|
| Rate for Payer: Mclaren Medicaid |
$1,521.65
|
| Rate for Payer: Mclaren Medicare |
$2,781.81
|
| Rate for Payer: Meridian Medicaid |
$1,597.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,920.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,199.08
|
| Rate for Payer: PACE Medicare |
$2,642.72
|
| Rate for Payer: PACE SWMI |
$2,781.81
|
| Rate for Payer: PHP Medicare Advantage |
$2,781.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,521.65
|
| Rate for Payer: Priority Health Medicare |
$2,781.81
|
| Rate for Payer: Railroad Medicare Medicare |
$2,781.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$221.52
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,781.81
|
| Rate for Payer: UHC Exchange |
$201.38
|
| Rate for Payer: UHC Medicare Advantage |
$2,865.26
|
| Rate for Payer: VA VA |
$2,781.81
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC
|
Facility
|
IP
|
$22,020.49
|
|
|
Service Code
|
MS-DRG 543
|
| Min. Negotiated Rate |
$7,930.33 |
| Max. Negotiated Rate |
$22,020.49 |
| Rate for Payer: Aetna Medicare |
$8,681.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,434.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,434.65
|
| Rate for Payer: BCBS MAPPO |
$8,347.72
|
| Rate for Payer: BCBS Trust/PPO |
$22,020.49
|
| Rate for Payer: BCN Medicare Advantage |
$8,347.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,347.72
|
| Rate for Payer: Mclaren Medicare |
$8,347.72
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,765.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,599.88
|
| Rate for Payer: PACE Medicare |
$7,930.33
|
| Rate for Payer: PACE SWMI |
$8,347.72
|
| Rate for Payer: PHP Medicare Advantage |
$8,347.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,651.46
|
| Rate for Payer: Priority Health Medicare |
$8,347.72
|
| Rate for Payer: Priority Health Narrow Network |
$12,521.17
|
| Rate for Payer: Railroad Medicare Medicare |
$8,347.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,637.54
|
| Rate for Payer: UHC Core |
$10,208.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,347.72
|
| Rate for Payer: UHC Exchange |
$10,934.27
|
| Rate for Payer: UHC Medicare Advantage |
$8,598.15
|
| Rate for Payer: VA VA |
$8,347.72
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$42,044.90
|
|
|
Service Code
|
MS-DRG 542
|
| Min. Negotiated Rate |
$12,945.30 |
| Max. Negotiated Rate |
$42,044.90 |
| Rate for Payer: Aetna Medicare |
$14,171.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,033.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,033.29
|
| Rate for Payer: BCBS MAPPO |
$13,626.63
|
| Rate for Payer: BCBS Trust/PPO |
$42,044.90
|
| Rate for Payer: BCN Medicare Advantage |
$13,626.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,626.63
|
| Rate for Payer: Mclaren Medicare |
$13,626.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,307.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,670.62
|
| Rate for Payer: PACE Medicare |
$12,945.30
|
| Rate for Payer: PACE SWMI |
$13,626.63
|
| Rate for Payer: PHP Medicare Advantage |
$13,626.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,169.95
|
| Rate for Payer: Priority Health Medicare |
$13,626.63
|
| Rate for Payer: Priority Health Narrow Network |
$20,935.96
|
| Rate for Payer: Railroad Medicare Medicare |
$13,626.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27,818.72
|
| Rate for Payer: UHC Core |
$17,069.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$13,626.63
|
| Rate for Payer: UHC Exchange |
$18,282.59
|
| Rate for Payer: UHC Medicare Advantage |
$14,035.43
|
| Rate for Payer: VA VA |
$13,626.63
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$16,359.46
|
|
|
Service Code
|
MS-DRG 544
|
| Min. Negotiated Rate |
$5,719.10 |
| Max. Negotiated Rate |
$16,359.46 |
| Rate for Payer: Aetna Medicare |
$6,260.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,525.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,525.14
|
| Rate for Payer: BCBS MAPPO |
$6,020.11
|
| Rate for Payer: BCBS Trust/PPO |
$16,359.46
|
| Rate for Payer: BCN Medicare Advantage |
$6,020.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,020.11
|
| Rate for Payer: Mclaren Medicare |
$6,020.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,321.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,923.13
|
| Rate for Payer: PACE Medicare |
$5,719.10
|
| Rate for Payer: PACE SWMI |
$6,020.11
|
| Rate for Payer: PHP Medicare Advantage |
$6,020.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,013.56
|
| Rate for Payer: Priority Health Medicare |
$6,020.11
|
| Rate for Payer: Priority Health Narrow Network |
$8,810.85
|
| Rate for Payer: Railroad Medicare Medicare |
$6,020.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,707.45
|
| Rate for Payer: UHC Core |
$7,183.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,020.11
|
| Rate for Payer: UHC Exchange |
$7,694.19
|
| Rate for Payer: UHC Medicare Advantage |
$6,200.71
|
| Rate for Payer: VA VA |
$6,020.11
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
OP
|
$1,356.97
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$389.70 |
| Max. Negotiated Rate |
$1,997.47 |
| Rate for Payer: Aetna Commercial |
$1,153.42
|
| Rate for Payer: Aetna Medicare |
$740.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$882.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$890.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$890.55
|
| Rate for Payer: BCBS Complete |
$409.23
|
| Rate for Payer: BCBS MAPPO |
$712.44
|
| Rate for Payer: BCBS Trust/PPO |
$773.42
|
| Rate for Payer: BCN Medicare Advantage |
$712.44
|
| Rate for Payer: Cash Price |
$1,085.58
|
| Rate for Payer: Cash Price |
$1,085.58
|
| Rate for Payer: Cofinity Commercial |
$949.88
|
| Rate for Payer: Cofinity Commercial |
$1,166.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$712.44
|
| Rate for Payer: Healthscope Commercial |
$1,221.27
|
| Rate for Payer: Mclaren Medicaid |
$389.70
|
| Rate for Payer: Mclaren Medicare |
$712.44
|
| Rate for Payer: Meridian Medicaid |
$409.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$748.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$819.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,153.42
|
| Rate for Payer: PACE Medicare |
$676.82
|
| Rate for Payer: PACE SWMI |
$712.44
|
| Rate for Payer: PHP Commercial |
$1,153.42
|
| Rate for Payer: PHP Medicare Advantage |
$712.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$389.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$949.88
|
| Rate for Payer: Priority Health Medicare |
$712.44
|
| Rate for Payer: Priority Health SBD |
$854.89
|
| Rate for Payer: Railroad Medicare Medicare |
$712.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,997.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$712.44
|
| Rate for Payer: UHC Exchange |
$1,361.54
|
| Rate for Payer: UHC Medicare Advantage |
$733.81
|
| Rate for Payer: VA VA |
$712.44
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
IP
|
$1,356.97
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$854.89 |
| Max. Negotiated Rate |
$1,221.27 |
| Rate for Payer: Aetna Commercial |
$1,153.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$882.03
|
| Rate for Payer: Cash Price |
$1,085.58
|
| Rate for Payer: Cofinity Commercial |
$1,166.99
|
| Rate for Payer: Cofinity Commercial |
$949.88
|
| Rate for Payer: Healthscope Commercial |
$1,221.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,153.42
|
| Rate for Payer: PHP Commercial |
$1,153.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$949.88
|
| Rate for Payer: Priority Health SBD |
$854.89
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 43386-090-19
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.40
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.60
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.20
|
| Rate for Payer: Priority Health SBD |
$35.28
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 52268-100-01
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.00
|
| Rate for Payer: Priority Health SBD |
$44.10
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS
|
Facility
|
IP
|
$9.52
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$8.19
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Healthscope Commercial |
$8.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.09
|
| Rate for Payer: PHP Commercial |
$8.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.66
|
| Rate for Payer: Priority Health SBD |
$6.00
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION
|
Facility
|
OP
|
$114,666.70
|
|
|
Service Code
|
HCPCS J9266
|
| Hospital Charge Code |
12519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,102.46 |
| Max. Negotiated Rate |
$103,200.03 |
| Rate for Payer: Aetna Commercial |
$97,466.70
|
| Rate for Payer: Aetna Medicare |
$26,812.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74,533.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$32,226.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$32,226.82
|
| Rate for Payer: BCBS Complete |
$14,808.87
|
| Rate for Payer: BCBS MAPPO |
$25,781.46
|
| Rate for Payer: BCBS Trust/PPO |
$76,326.64
|
| Rate for Payer: BCN Medicare Advantage |
$25,781.46
|
| Rate for Payer: Cash Price |
$91,733.36
|
| Rate for Payer: Cash Price |
$91,733.36
|
| Rate for Payer: Cofinity Commercial |
$98,613.36
|
| Rate for Payer: Cofinity Commercial |
$80,266.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25,781.46
|
| Rate for Payer: Healthscope Commercial |
$103,200.03
|
| Rate for Payer: Mclaren Medicaid |
$14,102.46
|
| Rate for Payer: Mclaren Medicare |
$25,781.46
|
| Rate for Payer: Meridian Medicaid |
$14,808.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$27,070.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29,648.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97,466.70
|
| Rate for Payer: PACE Medicare |
$24,492.39
|
| Rate for Payer: PACE SWMI |
$25,781.46
|
| Rate for Payer: PHP Commercial |
$97,466.70
|
| Rate for Payer: PHP Medicare Advantage |
$25,781.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$14,102.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80,266.69
|
| Rate for Payer: Priority Health Medicare |
$25,781.46
|
| Rate for Payer: Priority Health SBD |
$72,240.02
|
| Rate for Payer: Railroad Medicare Medicare |
$25,781.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$25,781.46
|
| Rate for Payer: UHC Medicare Advantage |
$26,554.90
|
| Rate for Payer: VA VA |
$25,781.46
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION
|
Facility
|
IP
|
$114,666.70
|
|
|
Service Code
|
HCPCS J9266
|
| Hospital Charge Code |
12519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72,240.02 |
| Max. Negotiated Rate |
$103,200.03 |
| Rate for Payer: Aetna Commercial |
$97,466.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74,533.36
|
| Rate for Payer: Cash Price |
$91,733.36
|
| Rate for Payer: Cofinity Commercial |
$80,266.69
|
| Rate for Payer: Cofinity Commercial |
$98,613.36
|
| Rate for Payer: Healthscope Commercial |
$103,200.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97,466.70
|
| Rate for Payer: PHP Commercial |
$97,466.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80,266.69
|
| Rate for Payer: Priority Health SBD |
$72,240.02
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR
|
Facility
|
OP
|
$11,749.74
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
173747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$10,574.77 |
| Rate for Payer: Aetna Commercial |
$9,987.28
|
| Rate for Payer: Aetna Medicare |
$52.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,637.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$63.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$63.35
|
| Rate for Payer: BCBS Complete |
$29.11
|
| Rate for Payer: BCBS MAPPO |
$50.68
|
| Rate for Payer: BCBS Trust/PPO |
$653.78
|
| Rate for Payer: BCN Medicare Advantage |
$50.68
|
| Rate for Payer: Cash Price |
$9,399.79
|
| Rate for Payer: Cash Price |
$9,399.79
|
| Rate for Payer: Cofinity Commercial |
$8,224.82
|
| Rate for Payer: Cofinity Commercial |
$10,104.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$50.68
|
| Rate for Payer: Healthscope Commercial |
$10,574.77
|
| Rate for Payer: Mclaren Medicaid |
$27.72
|
| Rate for Payer: Mclaren Medicare |
$50.68
|
| Rate for Payer: Meridian Medicaid |
$29.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$53.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,987.28
|
| Rate for Payer: PACE Medicare |
$48.14
|
| Rate for Payer: PACE SWMI |
$50.68
|
| Rate for Payer: PHP Commercial |
$9,987.28
|
| Rate for Payer: PHP Medicare Advantage |
$50.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$27.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,224.82
|
| Rate for Payer: Priority Health Medicare |
$50.68
|
| Rate for Payer: Priority Health SBD |
$7,402.34
|
| Rate for Payer: Railroad Medicare Medicare |
$50.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$50.68
|
| Rate for Payer: UHC Medicare Advantage |
$52.20
|
| Rate for Payer: VA VA |
$50.68
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR
|
Facility
|
IP
|
$11,749.74
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
173747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,402.34 |
| Max. Negotiated Rate |
$10,574.77 |
| Rate for Payer: Aetna Commercial |
$9,987.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,637.33
|
| Rate for Payer: Cash Price |
$9,399.79
|
| Rate for Payer: Cofinity Commercial |
$8,224.82
|
| Rate for Payer: Cofinity Commercial |
$10,104.78
|
| Rate for Payer: Healthscope Commercial |
$10,574.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,987.28
|
| Rate for Payer: PHP Commercial |
$9,987.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,224.82
|
| Rate for Payer: Priority Health SBD |
$7,402.34
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$9,392.27
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$8,453.04 |
| Rate for Payer: Aetna Commercial |
$7,983.43
|
| Rate for Payer: Aetna Medicare |
$52.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,104.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$63.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$63.35
|
| Rate for Payer: BCBS Complete |
$29.11
|
| Rate for Payer: BCBS MAPPO |
$50.68
|
| Rate for Payer: BCBS Trust/PPO |
$653.78
|
| Rate for Payer: BCN Medicare Advantage |
$50.68
|
| Rate for Payer: Cash Price |
$7,513.82
|
| Rate for Payer: Cash Price |
$7,513.82
|
| Rate for Payer: Cofinity Commercial |
$8,077.35
|
| Rate for Payer: Cofinity Commercial |
$6,574.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$50.68
|
| Rate for Payer: Healthscope Commercial |
$8,453.04
|
| Rate for Payer: Mclaren Medicaid |
$27.72
|
| Rate for Payer: Mclaren Medicare |
$50.68
|
| Rate for Payer: Meridian Medicaid |
$29.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$53.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,983.43
|
| Rate for Payer: PACE Medicare |
$48.14
|
| Rate for Payer: PACE SWMI |
$50.68
|
| Rate for Payer: PHP Commercial |
$7,983.43
|
| Rate for Payer: PHP Medicare Advantage |
$50.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$27.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,574.59
|
| Rate for Payer: Priority Health Medicare |
$50.68
|
| Rate for Payer: Priority Health SBD |
$5,917.13
|
| Rate for Payer: Railroad Medicare Medicare |
$50.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$50.68
|
| Rate for Payer: UHC Medicare Advantage |
$52.20
|
| Rate for Payer: VA VA |
$50.68
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$9,392.27
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,917.13 |
| Max. Negotiated Rate |
$8,453.04 |
| Rate for Payer: Aetna Commercial |
$7,983.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,104.98
|
| Rate for Payer: Cash Price |
$7,513.82
|
| Rate for Payer: Cofinity Commercial |
$6,574.59
|
| Rate for Payer: Cofinity Commercial |
$8,077.35
|
| Rate for Payer: Healthscope Commercial |
$8,453.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,983.43
|
| Rate for Payer: PHP Commercial |
$7,983.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,574.59
|
| Rate for Payer: Priority Health SBD |
$5,917.13
|
|
|
PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$6,396.10
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
195654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,029.54 |
| Max. Negotiated Rate |
$5,756.49 |
| Rate for Payer: Aetna Commercial |
$5,436.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,157.46
|
| Rate for Payer: Cash Price |
$5,116.88
|
| Rate for Payer: Cofinity Commercial |
$4,477.27
|
| Rate for Payer: Cofinity Commercial |
$5,500.65
|
| Rate for Payer: Healthscope Commercial |
$5,756.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,436.68
|
| Rate for Payer: PHP Commercial |
$5,436.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,477.27
|
| Rate for Payer: Priority Health SBD |
$4,029.54
|
|
|
PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$6,396.10
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
195654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$5,756.49 |
| Rate for Payer: Aetna Commercial |
$5,436.68
|
| Rate for Payer: Aetna Medicare |
$64.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,157.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$77.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$77.97
|
| Rate for Payer: BCBS Complete |
$35.83
|
| Rate for Payer: BCBS MAPPO |
$62.38
|
| Rate for Payer: BCBS Trust/PPO |
$376.35
|
| Rate for Payer: BCN Medicare Advantage |
$62.38
|
| Rate for Payer: Cash Price |
$5,116.88
|
| Rate for Payer: Cash Price |
$5,116.88
|
| Rate for Payer: Cofinity Commercial |
$4,477.27
|
| Rate for Payer: Cofinity Commercial |
$5,500.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.38
|
| Rate for Payer: Healthscope Commercial |
$5,756.49
|
| Rate for Payer: Mclaren Medicaid |
$34.12
|
| Rate for Payer: Mclaren Medicare |
$62.38
|
| Rate for Payer: Meridian Medicaid |
$35.83
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$65.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,436.68
|
| Rate for Payer: PACE Medicare |
$59.26
|
| Rate for Payer: PACE SWMI |
$62.38
|
| Rate for Payer: PHP Commercial |
$5,436.68
|
| Rate for Payer: PHP Medicare Advantage |
$62.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$34.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,477.27
|
| Rate for Payer: Priority Health Medicare |
$62.38
|
| Rate for Payer: Priority Health SBD |
$4,029.54
|
| Rate for Payer: Railroad Medicare Medicare |
$62.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.38
|
| Rate for Payer: UHC Medicare Advantage |
$64.25
|
| Rate for Payer: VA VA |
$62.38
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$6,368.78
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
192102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,012.33 |
| Max. Negotiated Rate |
$5,731.90 |
| Rate for Payer: Aetna Commercial |
$5,413.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,139.71
|
| Rate for Payer: Cash Price |
$5,095.02
|
| Rate for Payer: Cofinity Commercial |
$4,458.15
|
| Rate for Payer: Cofinity Commercial |
$5,477.15
|
| Rate for Payer: Healthscope Commercial |
$5,731.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,413.46
|
| Rate for Payer: PHP Commercial |
$5,413.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,458.15
|
| Rate for Payer: Priority Health SBD |
$4,012.33
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$6,368.78
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
192102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.67 |
| Max. Negotiated Rate |
$5,731.90 |
| Rate for Payer: Aetna Commercial |
$5,413.46
|
| Rate for Payer: Aetna Medicare |
$360.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,139.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$433.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$433.44
|
| Rate for Payer: BCBS Complete |
$199.18
|
| Rate for Payer: BCBS MAPPO |
$346.76
|
| Rate for Payer: BCBS Trust/PPO |
$237.02
|
| Rate for Payer: BCN Medicare Advantage |
$346.76
|
| Rate for Payer: Cash Price |
$5,095.02
|
| Rate for Payer: Cash Price |
$5,095.02
|
| Rate for Payer: Cofinity Commercial |
$4,458.15
|
| Rate for Payer: Cofinity Commercial |
$5,477.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$346.76
|
| Rate for Payer: Healthscope Commercial |
$5,731.90
|
| Rate for Payer: Mclaren Medicaid |
$189.67
|
| Rate for Payer: Mclaren Medicare |
$346.76
|
| Rate for Payer: Meridian Medicaid |
$199.18
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$364.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$398.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,413.46
|
| Rate for Payer: PACE Medicare |
$329.42
|
| Rate for Payer: PACE SWMI |
$346.76
|
| Rate for Payer: PHP Commercial |
$5,413.46
|
| Rate for Payer: PHP Medicare Advantage |
$346.76
|
| Rate for Payer: Priority Health Choice Medicaid |
$189.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,458.15
|
| Rate for Payer: Priority Health Medicare |
$346.76
|
| Rate for Payer: Priority Health SBD |
$4,012.33
|
| Rate for Payer: Railroad Medicare Medicare |
$346.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$346.76
|
| Rate for Payer: UHC Medicare Advantage |
$357.16
|
| Rate for Payer: VA VA |
$346.76
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR
|
Facility
|
IP
|
$5,304.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
203866
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,341.52 |
| Max. Negotiated Rate |
$4,773.60 |
| Rate for Payer: Aetna Commercial |
$4,508.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,447.60
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cofinity Commercial |
$3,712.80
|
| Rate for Payer: Cofinity Commercial |
$4,561.44
|
| Rate for Payer: Healthscope Commercial |
$4,773.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,508.40
|
| Rate for Payer: PHP Commercial |
$4,508.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,712.80
|
| Rate for Payer: Priority Health SBD |
$3,341.52
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,304.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
189200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,341.52 |
| Max. Negotiated Rate |
$4,773.60 |
| Rate for Payer: Aetna Commercial |
$4,508.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,447.60
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cofinity Commercial |
$3,712.80
|
| Rate for Payer: Cofinity Commercial |
$4,561.44
|
| Rate for Payer: Healthscope Commercial |
$4,773.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,508.40
|
| Rate for Payer: PHP Commercial |
$4,508.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,712.80
|
| Rate for Payer: Priority Health SBD |
$3,341.52
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,304.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
189200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.79 |
| Max. Negotiated Rate |
$4,773.60 |
| Rate for Payer: Aetna Commercial |
$4,508.40
|
| Rate for Payer: Aetna Medicare |
$126.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,447.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$152.63
|
| Rate for Payer: Amish Plain Church Group Commercial |
$152.63
|
| Rate for Payer: BCBS Complete |
$70.14
|
| Rate for Payer: BCBS MAPPO |
$122.10
|
| Rate for Payer: BCBS Trust/PPO |
$361.47
|
| Rate for Payer: BCN Medicare Advantage |
$122.10
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cofinity Commercial |
$4,561.44
|
| Rate for Payer: Cofinity Commercial |
$3,712.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$122.10
|
| Rate for Payer: Healthscope Commercial |
$4,773.60
|
| Rate for Payer: Mclaren Medicaid |
$66.79
|
| Rate for Payer: Mclaren Medicare |
$122.10
|
| Rate for Payer: Meridian Medicaid |
$70.14
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$128.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$140.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,508.40
|
| Rate for Payer: PACE Medicare |
$116.00
|
| Rate for Payer: PACE SWMI |
$122.10
|
| Rate for Payer: PHP Commercial |
$4,508.40
|
| Rate for Payer: PHP Medicare Advantage |
$122.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$66.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,712.80
|
| Rate for Payer: Priority Health Medicare |
$122.10
|
| Rate for Payer: Priority Health SBD |
$3,341.52
|
| Rate for Payer: Railroad Medicare Medicare |
$122.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$122.10
|
| Rate for Payer: UHC Medicare Advantage |
$125.77
|
| Rate for Payer: VA VA |
$122.10
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,616.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
187520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.03 |
| Max. Negotiated Rate |
$5,054.40 |
| Rate for Payer: Aetna Commercial |
$4,773.60
|
| Rate for Payer: Aetna Medicare |
$127.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,650.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$153.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$153.18
|
| Rate for Payer: BCBS Complete |
$70.39
|
| Rate for Payer: BCBS MAPPO |
$122.54
|
| Rate for Payer: BCBS Trust/PPO |
$362.78
|
| Rate for Payer: BCN Medicare Advantage |
$122.54
|
| Rate for Payer: Cash Price |
$4,492.80
|
| Rate for Payer: Cash Price |
$4,492.80
|
| Rate for Payer: Cofinity Commercial |
$4,829.76
|
| Rate for Payer: Cofinity Commercial |
$3,931.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$122.54
|
| Rate for Payer: Healthscope Commercial |
$5,054.40
|
| Rate for Payer: Mclaren Medicaid |
$67.03
|
| Rate for Payer: Mclaren Medicare |
$122.54
|
| Rate for Payer: Meridian Medicaid |
$70.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$128.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$140.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,773.60
|
| Rate for Payer: PACE Medicare |
$116.41
|
| Rate for Payer: PACE SWMI |
$122.54
|
| Rate for Payer: PHP Commercial |
$4,773.60
|
| Rate for Payer: PHP Medicare Advantage |
$122.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,931.20
|
| Rate for Payer: Priority Health Medicare |
$122.54
|
| Rate for Payer: Priority Health SBD |
$3,538.08
|
| Rate for Payer: Railroad Medicare Medicare |
$122.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$122.54
|
| Rate for Payer: UHC Medicare Advantage |
$126.22
|
| Rate for Payer: VA VA |
$122.54
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,616.00
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
187520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,538.08 |
| Max. Negotiated Rate |
$5,054.40 |
| Rate for Payer: Aetna Commercial |
$4,773.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,650.40
|
| Rate for Payer: Cash Price |
$4,492.80
|
| Rate for Payer: Cofinity Commercial |
$4,829.76
|
| Rate for Payer: Cofinity Commercial |
$3,931.20
|
| Rate for Payer: Healthscope Commercial |
$5,054.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,773.60
|
| Rate for Payer: PHP Commercial |
$4,773.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,931.20
|
| Rate for Payer: Priority Health SBD |
$3,538.08
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$72,697.46
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45,799.40 |
| Max. Negotiated Rate |
$65,427.71 |
| Rate for Payer: Aetna Commercial |
$61,792.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47,253.35
|
| Rate for Payer: Cash Price |
$58,157.97
|
| Rate for Payer: Cofinity Commercial |
$50,888.22
|
| Rate for Payer: Cofinity Commercial |
$62,519.82
|
| Rate for Payer: Healthscope Commercial |
$65,427.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$61,792.84
|
| Rate for Payer: PHP Commercial |
$61,792.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50,888.22
|
| Rate for Payer: Priority Health SBD |
$45,799.40
|
|
