|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$371.45
|
|
|
Service Code
|
NDC 00228257111
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.01 |
| Max. Negotiated Rate |
$334.31 |
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.44
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Advantage |
$260.01
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$278.59
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health SBD |
$234.01
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$371.45
|
|
|
Service Code
|
NDC 00228257111
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.98 |
| Max. Negotiated Rate |
$334.31 |
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna Medicare |
$185.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.44
|
| Rate for Payer: BCBS Complete |
$148.58
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Advantage |
$260.01
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$297.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$278.59
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health SBD |
$234.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.44
|
| Rate for Payer: UHC Core |
$193.53
|
| Rate for Payer: UHC Exchange |
$145.98
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$350.15
|
|
|
Service Code
|
NDC 43975030410
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.61 |
| Max. Negotiated Rate |
$315.13 |
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: Aetna Medicare |
$175.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.60
|
| Rate for Payer: BCBS Complete |
$140.06
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Advantage |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$315.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$280.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.61
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health SBD |
$220.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.60
|
| Rate for Payer: UHC Core |
$182.43
|
| Rate for Payer: UHC Exchange |
$137.61
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 43975030410
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.59 |
| Max. Negotiated Rate |
$315.13 |
| 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 Advantage |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$315.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.61
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health SBD |
$220.59
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$299.36 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$336.95
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cofinity Advantage |
$332.62
|
| Rate for Payer: Cofinity Advantage |
$362.87
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$388.79
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: Priority Health SBD |
$326.58
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: Aetna Medicare |
$9.67
|
| Rate for Payer: Aetna Medicare |
$9.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$336.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.62
|
| Rate for Payer: BCBS Complete |
$5.11
|
| Rate for Payer: BCBS Complete |
$5.11
|
| Rate for Payer: BCBS MAPPO |
$9.30
|
| Rate for Payer: BCBS MAPPO |
$9.30
|
| Rate for Payer: BCBS Trust/PPO |
$24.23
|
| Rate for Payer: BCBS Trust/PPO |
$24.23
|
| Rate for Payer: BCN Commercial |
$24.23
|
| Rate for Payer: BCN Commercial |
$24.23
|
| Rate for Payer: BCN Medicare Advantage |
$9.30
|
| Rate for Payer: BCN Medicare Advantage |
$9.30
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Advantage |
$362.87
|
| Rate for Payer: Cofinity Advantage |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.30
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicare |
$9.30
|
| Rate for Payer: Mclaren Medicare |
$9.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.77
|
| Rate for Payer: Meridian Medicaid |
$9.77
|
| Rate for Payer: Meridian Medicaid |
$9.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.23
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.62
|
| Rate for Payer: Nomi Health Commercial |
$27.90
|
| Rate for Payer: Nomi Health Commercial |
$27.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$388.79
|
| Rate for Payer: PACE Medicare |
$8.84
|
| Rate for Payer: PACE Medicare |
$8.84
|
| Rate for Payer: PACE SWMI |
$9.30
|
| Rate for Payer: PACE SWMI |
$9.30
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: PHP Medicare Advantage |
$9.30
|
| Rate for Payer: PHP Medicare Advantage |
$9.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31.40
|
| Rate for Payer: Priority Health Medicare |
$9.30
|
| Rate for Payer: Priority Health Medicare |
$9.30
|
| Rate for Payer: Priority Health SBD |
$326.58
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: Priority Health Tiered Network |
$25.12
|
| Rate for Payer: Priority Health Tiered Network |
$25.12
|
| Rate for Payer: Railroad Medicare Medicare |
$9.30
|
| Rate for Payer: Railroad Medicare Medicare |
$9.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.35
|
| Rate for Payer: UHC Core |
$15.35
|
| Rate for Payer: UHC Core |
$15.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.30
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.30
|
| Rate for Payer: UHC Exchange |
$15.35
|
| Rate for Payer: UHC Exchange |
$15.35
|
| Rate for Payer: UHC Medicaid |
$4.86
|
| Rate for Payer: UHC Medicaid |
$4.86
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
| Rate for Payer: VA VA |
$9.30
|
| Rate for Payer: VA VA |
$9.30
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$9.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.62
|
| Rate for Payer: BCBS Complete |
$5.11
|
| Rate for Payer: BCBS MAPPO |
$9.30
|
| Rate for Payer: BCBS Trust/PPO |
$24.23
|
| Rate for Payer: BCN Commercial |
$24.23
|
| Rate for Payer: BCN Medicare Advantage |
$9.30
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Advantage |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.30
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicare |
$9.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.77
|
| Rate for Payer: Meridian Medicaid |
$9.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Nomi Health Commercial |
$27.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.38
|
| Rate for Payer: PACE Medicare |
$8.84
|
| Rate for Payer: PACE SWMI |
$9.30
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: PHP Medicare Advantage |
$9.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31.40
|
| Rate for Payer: Priority Health Medicare |
$9.30
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: Priority Health Tiered Network |
$25.12
|
| Rate for Payer: Railroad Medicare Medicare |
$9.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.35
|
| Rate for Payer: UHC Core |
$15.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.30
|
| Rate for Payer: UHC Exchange |
$15.35
|
| Rate for Payer: UHC Medicaid |
$4.86
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
| Rate for Payer: VA VA |
$9.30
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
636
|
| 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 Advantage |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.38
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.92 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$419.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.57
|
| Rate for Payer: UHC Core |
$272.98
|
| Rate for Payer: UHC Exchange |
$205.92
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.92 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$419.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.57
|
| Rate for Payer: UHC Core |
$272.98
|
| Rate for Payer: UHC Exchange |
$205.92
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.98 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Advantage |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.23
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$211.67
|
| Rate for Payer: UHC Core |
$169.66
|
| Rate for Payer: UHC Exchange |
$127.98
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| 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 Advantage |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.23
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health SBD |
$205.15
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$330.09 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$330.09 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$128.73
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.10 |
| Max. Negotiated Rate |
$115.86 |
| Rate for Payer: Aetna Commercial |
$109.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.67
|
| Rate for Payer: Cash Price |
$102.98
|
| Rate for Payer: Cofinity Advantage |
$90.11
|
| Rate for Payer: Cofinity Commercial |
$110.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.98
|
| Rate for Payer: Healthscope Commercial |
$115.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.55
|
| Rate for Payer: PHP Commercial |
$109.42
|
| Rate for Payer: Priority Health SBD |
$81.10
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.32 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna Medicare |
$210.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.42
|
| Rate for Payer: BCBS Complete |
$168.26
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Advantage |
$294.45
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$336.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.49
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health SBD |
$265.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.42
|
| Rate for Payer: UHC Core |
$219.16
|
| Rate for Payer: UHC Exchange |
$165.32
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$2.58
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.19
|
| Rate for Payer: Aetna Medicare |
$1.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.68
|
| Rate for Payer: BCBS Complete |
$1.03
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.81
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.94
|
| Rate for Payer: PHP Commercial |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.68
|
| Rate for Payer: UHC Core |
$1.34
|
| Rate for Payer: UHC Exchange |
$1.01
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.58
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.68
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.81
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.94
|
| Rate for Payer: PHP Commercial |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.63
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| 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 Advantage |
$294.45
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.49
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health SBD |
$265.01
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$128.73
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.59 |
| Max. Negotiated Rate |
$115.86 |
| Rate for Payer: Aetna Commercial |
$109.42
|
| Rate for Payer: Aetna Medicare |
$64.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.67
|
| Rate for Payer: BCBS Complete |
$51.49
|
| Rate for Payer: Cash Price |
$102.98
|
| Rate for Payer: Cofinity Advantage |
$90.11
|
| Rate for Payer: Cofinity Commercial |
$110.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.98
|
| Rate for Payer: Healthscope Commercial |
$115.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.55
|
| Rate for Payer: PHP Commercial |
$109.42
|
| Rate for Payer: Priority Health SBD |
$81.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$83.67
|
| Rate for Payer: UHC Core |
$67.07
|
| Rate for Payer: UHC Exchange |
$50.59
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC
|
Facility
|
IP
|
$15,957.70
|
|
|
Service Code
|
MSDRG 758
|
| Min. Negotiated Rate |
$7,737.69 |
| Max. Negotiated Rate |
$15,957.70 |
| Rate for Payer: Aetna Medicare |
$8,470.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,181.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,181.17
|
| Rate for Payer: BCBS MAPPO |
$8,144.94
|
| Rate for Payer: BCBS Trust/PPO |
$13,309.79
|
| Rate for Payer: BCN Commercial |
$13,309.79
|
| Rate for Payer: BCN Medicare Advantage |
$8,144.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,144.94
|
| Rate for Payer: Mclaren Medicare |
$8,144.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,552.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,366.68
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,959.43
|
| Rate for Payer: Nomi Health Commercial |
$12,629.10
|
| Rate for Payer: PACE Medicare |
$7,737.69
|
| Rate for Payer: PACE SWMI |
$8,144.94
|
| Rate for Payer: PHP Medicare Advantage |
$8,144.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$15,783.58
|
| Rate for Payer: Priority Health Medicare |
$8,144.94
|
| Rate for Payer: Priority Health Tiered Network |
$12,626.86
|
| Rate for Payer: Railroad Medicare Medicare |
$8,144.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,957.70
|
| Rate for Payer: UHC Core |
$13,350.62
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,144.94
|
| Rate for Payer: UHC Exchange |
$10,903.12
|
| Rate for Payer: VA VA |
$8,144.94
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$23,339.97
|
|
|
Service Code
|
MSDRG 757
|
| Min. Negotiated Rate |
$11,062.79 |
| Max. Negotiated Rate |
$23,339.97 |
| Rate for Payer: Aetna Medicare |
$12,110.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,556.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,556.30
|
| Rate for Payer: BCBS MAPPO |
$11,645.04
|
| Rate for Payer: BCBS Trust/PPO |
$19,487.16
|
| Rate for Payer: BCN Commercial |
$19,487.16
|
| Rate for Payer: BCN Medicare Advantage |
$11,645.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,645.04
|
| Rate for Payer: Mclaren Medicare |
$11,645.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,227.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,391.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$12,809.54
|
| Rate for Payer: Nomi Health Commercial |
$18,471.51
|
| Rate for Payer: PACE Medicare |
$11,062.79
|
| Rate for Payer: PACE SWMI |
$11,645.04
|
| Rate for Payer: PHP Medicare Advantage |
$11,645.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,085.29
|
| Rate for Payer: Priority Health Medicare |
$11,645.04
|
| Rate for Payer: Priority Health Tiered Network |
$18,468.23
|
| Rate for Payer: Railroad Medicare Medicare |
$11,645.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23,339.97
|
| Rate for Payer: UHC Core |
$19,526.82
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,645.04
|
| Rate for Payer: UHC Exchange |
$15,947.07
|
| Rate for Payer: VA VA |
$11,645.04
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$12,427.31
|
|
|
Service Code
|
MSDRG 759
|
| Min. Negotiated Rate |
$5,422.08 |
| Max. Negotiated Rate |
$12,427.31 |
| Rate for Payer: Aetna Medicare |
$5,935.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,134.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,134.31
|
| Rate for Payer: BCBS MAPPO |
$5,707.45
|
| Rate for Payer: BCBS Trust/PPO |
$12,427.31
|
| Rate for Payer: BCN Commercial |
$12,427.31
|
| Rate for Payer: BCN Medicare Advantage |
$5,707.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,707.45
|
| Rate for Payer: Mclaren Medicare |
$5,707.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,992.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,563.57
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,278.19
|
| Rate for Payer: Nomi Health Commercial |
$8,560.44
|
| Rate for Payer: PACE Medicare |
$5,422.08
|
| Rate for Payer: PACE SWMI |
$5,707.45
|
| Rate for Payer: PHP Medicare Advantage |
$5,707.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,698.65
|
| Rate for Payer: Priority Health Medicare |
$5,707.45
|
| Rate for Payer: Priority Health Tiered Network |
$8,558.92
|
| Rate for Payer: Railroad Medicare Medicare |
$5,707.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,816.68
|
| Rate for Payer: UHC Core |
$9,049.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,707.45
|
| Rate for Payer: UHC Exchange |
$7,390.51
|
| Rate for Payer: VA VA |
$5,707.45
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$2,363.72
|
|
|
Service Code
|
APR-DRG 1131
|
| Min. Negotiated Rate |
$2,251.16 |
| Max. Negotiated Rate |
$2,363.72 |
| Rate for Payer: BCBS Complete |
$2,363.72
|
| Rate for Payer: Mclaren Medicaid |
$2,251.16
|
| Rate for Payer: Meridian Medicaid |
$2,363.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,251.16
|
| Rate for Payer: UHC Medicaid |
$2,251.16
|
| Rate for Payer: UHCCP Medicaid |
$2,251.16
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$3,130.22
|
|
|
Service Code
|
APR-DRG 1132
|
| Min. Negotiated Rate |
$2,981.16 |
| Max. Negotiated Rate |
$3,130.22 |
| Rate for Payer: BCBS Complete |
$3,130.22
|
| Rate for Payer: Mclaren Medicaid |
$2,981.16
|
| Rate for Payer: Meridian Medicaid |
$3,130.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,981.16
|
| Rate for Payer: UHC Medicaid |
$2,981.16
|
| Rate for Payer: UHCCP Medicaid |
$2,981.16
|
|
