|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE
|
Facility
|
OP
|
$1,096.83
|
|
|
Service Code
|
CPT 10120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$208.85 |
| Max. Negotiated Rate |
$1,096.83 |
| Rate for Payer: Aetna Medicare |
$405.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$487.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$487.06
|
| Rate for Payer: BCBS Complete |
$219.30
|
| Rate for Payer: BCBS MAPPO |
$389.65
|
| Rate for Payer: BCN Medicare Advantage |
$389.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$389.65
|
| Rate for Payer: Mclaren Medicaid |
$208.85
|
| Rate for Payer: Mclaren Medicare |
$389.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$409.13
|
| Rate for Payer: Meridian Medicaid |
$219.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$448.10
|
| Rate for Payer: PACE Medicare |
$370.17
|
| Rate for Payer: PACE SWMI |
$389.65
|
| Rate for Payer: PHP Medicare Advantage |
$389.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$208.85
|
| Rate for Payer: Priority Health Medicare |
$389.65
|
| Rate for Payer: Railroad Medicare Medicare |
$389.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,096.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$389.65
|
| Rate for Payer: UHC Medicare Advantage |
$389.65
|
| Rate for Payer: UHCCP Medicaid |
$219.37
|
| Rate for Payer: VA VA |
$389.65
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$878.76
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
INCISION OF LABIAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$1,398.05
|
|
|
Service Code
|
CPT 40806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$266.21 |
| Max. Negotiated Rate |
$1,398.05 |
| Rate for Payer: Aetna Medicare |
$516.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$620.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$620.83
|
| Rate for Payer: BCBS Complete |
$279.52
|
| Rate for Payer: BCBS MAPPO |
$496.66
|
| Rate for Payer: BCN Medicare Advantage |
$496.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$496.66
|
| Rate for Payer: Mclaren Medicaid |
$266.21
|
| Rate for Payer: Mclaren Medicare |
$496.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$521.49
|
| Rate for Payer: Meridian Medicaid |
$279.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$571.16
|
| Rate for Payer: PACE Medicare |
$471.83
|
| Rate for Payer: PACE SWMI |
$496.66
|
| Rate for Payer: PHP Medicare Advantage |
$496.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$266.21
|
| Rate for Payer: Priority Health Medicare |
$496.66
|
| Rate for Payer: Railroad Medicare Medicare |
$496.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,398.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$496.66
|
| Rate for Payer: UHC Medicare Advantage |
$496.66
|
| Rate for Payer: UHCCP Medicaid |
$279.62
|
| Rate for Payer: VA VA |
$496.66
|
|
|
INCISION OF LINGUAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$4,066.57
|
|
|
Service Code
|
CPT 41010
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$774.34 |
| Max. Negotiated Rate |
$4,066.57 |
| Rate for Payer: Aetna Medicare |
$1,502.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,805.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,805.83
|
| Rate for Payer: BCBS Complete |
$813.05
|
| Rate for Payer: BCBS MAPPO |
$1,444.66
|
| Rate for Payer: BCN Medicare Advantage |
$1,444.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,444.66
|
| Rate for Payer: Mclaren Medicaid |
$774.34
|
| Rate for Payer: Mclaren Medicare |
$1,444.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,516.89
|
| Rate for Payer: Meridian Medicaid |
$813.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,661.36
|
| Rate for Payer: PACE Medicare |
$1,372.43
|
| Rate for Payer: PACE SWMI |
$1,444.66
|
| Rate for Payer: PHP Medicare Advantage |
$1,444.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$774.34
|
| Rate for Payer: Priority Health Medicare |
$1,444.66
|
| Rate for Payer: Railroad Medicare Medicare |
$1,444.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,066.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,444.66
|
| Rate for Payer: UHC Medicare Advantage |
$1,444.66
|
| Rate for Payer: UHCCP Medicaid |
$813.34
|
| Rate for Payer: VA VA |
$1,444.66
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$8,791.70
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,538.77 |
| Max. Negotiated Rate |
$7,912.53 |
| Rate for Payer: Aetna Commercial |
$7,472.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,714.60
|
| Rate for Payer: Cash Price |
$7,033.36
|
| Rate for Payer: Cofinity Commercial |
$6,154.19
|
| Rate for Payer: Cofinity Commercial |
$7,560.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,154.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,033.36
|
| Rate for Payer: Healthscope Commercial |
$7,912.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,472.94
|
| Rate for Payer: PHP Commercial |
$7,472.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,714.60
|
| Rate for Payer: Priority Health SBD |
$5,538.77
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$8,791.70
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$7,912.53 |
| Rate for Payer: Aetna Commercial |
$7,472.94
|
| Rate for Payer: Aetna Medicare |
$12.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,714.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.40
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: BCBS MAPPO |
$12.32
|
| Rate for Payer: BCN Medicare Advantage |
$12.32
|
| Rate for Payer: Cash Price |
$7,033.36
|
| Rate for Payer: Cash Price |
$7,033.36
|
| Rate for Payer: Cofinity Commercial |
$7,560.86
|
| Rate for Payer: Cofinity Commercial |
$6,154.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,154.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,033.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.32
|
| Rate for Payer: Healthscope Commercial |
$7,912.53
|
| Rate for Payer: Mclaren Medicaid |
$6.60
|
| Rate for Payer: Mclaren Medicare |
$12.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.94
|
| Rate for Payer: Meridian Medicaid |
$6.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,472.94
|
| Rate for Payer: PACE Medicare |
$11.70
|
| Rate for Payer: PACE SWMI |
$12.32
|
| Rate for Payer: PHP Commercial |
$7,472.94
|
| Rate for Payer: PHP Medicare Advantage |
$12.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,714.60
|
| Rate for Payer: Priority Health Medicare |
$12.32
|
| Rate for Payer: Priority Health SBD |
$5,538.77
|
| Rate for Payer: Railroad Medicare Medicare |
$12.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.32
|
| Rate for Payer: UHC Medicare Advantage |
$12.32
|
| Rate for Payer: UHCCP Medicaid |
$6.94
|
| Rate for Payer: VA VA |
$12.32
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$253.80
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna Medicare |
$126.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.97
|
| Rate for Payer: BCBS Complete |
$101.52
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Cofinity Commercial |
$218.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$228.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: PHP Commercial |
$215.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: Priority Health SBD |
$159.89
|
|
|
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 Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$245.10
|
| 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: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health SBD |
$220.59
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$350.15
|
|
|
Service Code
|
NDC 43975030410
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.06 |
| 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 Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$245.10
|
| 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: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health SBD |
$220.59
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$253.80
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.89 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.97
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Cofinity Commercial |
$218.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$228.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: PHP Commercial |
$215.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: Priority Health SBD |
$159.89
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| 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 |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| 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: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.07 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$237.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: BCBS Complete |
$190.07
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| 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: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$518.38
|
|
|
Service Code
|
NDC 00517037505
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$207.35 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: Aetna Medicare |
$259.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$336.95
|
| Rate for Payer: BCBS Complete |
$207.35
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cofinity Commercial |
$362.87
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$362.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.62
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.95
|
| Rate for Payer: Priority Health SBD |
$326.58
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 00517037505
|
| 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: Cofinity Medicare Advantage |
$362.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.62
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.95
|
| Rate for Payer: Priority Health SBD |
$326.58
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| 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: Cofinity Medicare Advantage |
$332.62
|
| 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: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.07 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$237.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: BCBS Complete |
$190.07
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| 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: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
|
|
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 |
$209.58 |
| 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 Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| 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: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238042406
|
| 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: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
|
|
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 Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| 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: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
|
|
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 |
$209.58 |
| 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 Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| 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: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| 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 Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| 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: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238042425
|
| 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: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$232.38
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.95 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna Medicare |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: BCBS Complete |
$92.95
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
|
|
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 Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| 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: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$232.38
|
|
|
Service Code
|
NDC 17238042425
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.95 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna Medicare |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: BCBS Complete |
$92.95
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
|
