|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML SQ FOR INSULIN PUMP REFILL
|
Facility
|
IP
|
$141.16
|
|
|
Service Code
|
NDC 00169183311
|
| Hospital Charge Code |
301806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.93 |
| Max. Negotiated Rate |
$127.04 |
| Rate for Payer: Aetna Commercial |
$119.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.75
|
| Rate for Payer: Cash Price |
$112.93
|
| Rate for Payer: Cofinity Commercial |
$121.40
|
| Rate for Payer: Cofinity Commercial |
$98.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.93
|
| Rate for Payer: Healthscope Commercial |
$127.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.99
|
| Rate for Payer: PHP Commercial |
$119.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.75
|
| Rate for Payer: Priority Health SBD |
$88.93
|
|
|
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$2,747.08
|
|
|
Service Code
|
NDC 44087004403
|
| Hospital Charge Code |
22532
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,098.83 |
| Max. Negotiated Rate |
$2,472.37 |
| Rate for Payer: Aetna Commercial |
$2,335.02
|
| Rate for Payer: Aetna Medicare |
$1,373.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,785.60
|
| Rate for Payer: BCBS Complete |
$1,098.83
|
| Rate for Payer: Cash Price |
$2,197.66
|
| Rate for Payer: Cofinity Commercial |
$1,922.96
|
| Rate for Payer: Cofinity Commercial |
$2,362.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,922.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,197.66
|
| Rate for Payer: Healthscope Commercial |
$2,472.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,335.02
|
| Rate for Payer: PHP Commercial |
$2,335.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,785.60
|
| Rate for Payer: Priority Health SBD |
$1,730.66
|
|
|
INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$2,747.08
|
|
|
Service Code
|
NDC 44087004403
|
| Hospital Charge Code |
22532
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,730.66 |
| Max. Negotiated Rate |
$2,472.37 |
| Rate for Payer: Aetna Commercial |
$2,335.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,785.60
|
| Rate for Payer: Cash Price |
$2,197.66
|
| Rate for Payer: Cofinity Commercial |
$1,922.96
|
| Rate for Payer: Cofinity Commercial |
$2,362.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,922.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,197.66
|
| Rate for Payer: Healthscope Commercial |
$2,472.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,335.02
|
| Rate for Payer: PHP Commercial |
$2,335.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,785.60
|
| Rate for Payer: Priority Health SBD |
$1,730.66
|
|
|
INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;
|
Facility
|
OP
|
$4,264.69
|
|
|
Service Code
|
CPT 36901
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$812.06 |
| Max. Negotiated Rate |
$4,264.69 |
| Rate for Payer: Aetna Medicare |
$1,575.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,893.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,893.80
|
| Rate for Payer: BCBS Complete |
$852.66
|
| Rate for Payer: BCBS MAPPO |
$1,515.04
|
| Rate for Payer: BCN Medicare Advantage |
$1,515.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,515.04
|
| Rate for Payer: Mclaren Medicaid |
$812.06
|
| Rate for Payer: Mclaren Medicare |
$1,515.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,590.79
|
| Rate for Payer: Meridian Medicaid |
$852.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,742.30
|
| Rate for Payer: PACE Medicare |
$1,439.29
|
| Rate for Payer: PACE SWMI |
$1,515.04
|
| Rate for Payer: PHP Medicare Advantage |
$1,515.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$812.06
|
| Rate for Payer: Priority Health Medicare |
$1,515.04
|
| Rate for Payer: Railroad Medicare Medicare |
$1,515.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,264.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,515.04
|
| Rate for Payer: UHC Medicare Advantage |
$1,515.04
|
| Rate for Payer: UHCCP Medicaid |
$852.97
|
| Rate for Payer: VA VA |
$1,515.04
|
|
|
INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT
|
Facility
|
OP
|
$31,133.44
|
|
|
Service Code
|
CPT 36903
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,928.28 |
| Max. Negotiated Rate |
$31,133.44 |
| Rate for Payer: Aetna Medicare |
$11,502.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,825.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,825.29
|
| Rate for Payer: BCBS Complete |
$6,224.70
|
| Rate for Payer: BCBS MAPPO |
$11,060.23
|
| Rate for Payer: BCN Medicare Advantage |
$11,060.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,060.23
|
| Rate for Payer: Mclaren Medicaid |
$5,928.28
|
| Rate for Payer: Mclaren Medicare |
$11,060.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11,613.24
|
| Rate for Payer: Meridian Medicaid |
$6,224.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,719.26
|
| Rate for Payer: PACE Medicare |
$10,507.22
|
| Rate for Payer: PACE SWMI |
$11,060.23
|
| Rate for Payer: PHP Medicare Advantage |
$11,060.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,928.28
|
| Rate for Payer: Priority Health Medicare |
$11,060.23
|
| Rate for Payer: Railroad Medicare Medicare |
$11,060.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,133.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,060.23
|
| Rate for Payer: UHC Medicare Advantage |
$11,060.23
|
| Rate for Payer: UHCCP Medicaid |
$6,226.91
|
| Rate for Payer: VA VA |
$11,060.23
|
|
|
INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY
|
Facility
|
OP
|
$15,652.48
|
|
|
Service Code
|
CPT 36902
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,980.47 |
| Max. Negotiated Rate |
$15,652.48 |
| Rate for Payer: Aetna Medicare |
$5,783.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,950.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,950.73
|
| Rate for Payer: BCBS Complete |
$3,129.49
|
| Rate for Payer: BCBS MAPPO |
$5,560.58
|
| Rate for Payer: BCN Medicare Advantage |
$5,560.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,560.58
|
| Rate for Payer: Mclaren Medicaid |
$2,980.47
|
| Rate for Payer: Mclaren Medicare |
$5,560.58
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,838.61
|
| Rate for Payer: Meridian Medicaid |
$3,129.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,394.67
|
| Rate for Payer: PACE Medicare |
$5,282.55
|
| Rate for Payer: PACE SWMI |
$5,560.58
|
| Rate for Payer: PHP Medicare Advantage |
$5,560.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,980.47
|
| Rate for Payer: Priority Health Medicare |
$5,560.58
|
| Rate for Payer: Railroad Medicare Medicare |
$5,560.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,652.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,560.58
|
| Rate for Payer: UHC Medicare Advantage |
$5,560.58
|
| Rate for Payer: UHCCP Medicaid |
$3,130.61
|
| Rate for Payer: VA VA |
$5,560.58
|
|
|
INVESTIGATIONAL PLACEBO OR PEMBROLIZUMAB (MK-3475) 25 MG/ML INTRAVENOUS SOLUTION NRG-GY018 STUDY SUPPLIED
|
Facility
|
OP
|
$169.71
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
300991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.32 |
| Max. Negotiated Rate |
$169.71 |
| Rate for Payer: Aetna Medicare |
$62.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$75.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$75.36
|
| Rate for Payer: BCBS Complete |
$33.93
|
| Rate for Payer: BCBS MAPPO |
$60.29
|
| Rate for Payer: BCN Medicare Advantage |
$60.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$60.29
|
| Rate for Payer: Mclaren Medicaid |
$32.32
|
| Rate for Payer: Mclaren Medicare |
$60.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$63.30
|
| Rate for Payer: Meridian Medicaid |
$33.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$69.33
|
| Rate for Payer: PACE Medicare |
$57.28
|
| Rate for Payer: PACE SWMI |
$60.29
|
| Rate for Payer: PHP Medicare Advantage |
$60.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$32.32
|
| Rate for Payer: Priority Health Medicare |
$60.29
|
| Rate for Payer: Railroad Medicare Medicare |
$60.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$60.29
|
| Rate for Payer: UHC Medicare Advantage |
$60.29
|
| Rate for Payer: UHCCP Medicaid |
$33.94
|
| Rate for Payer: VA VA |
$60.29
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION
|
Facility
|
OP
|
$116.55
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
108150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.62 |
| Max. Negotiated Rate |
$104.89 |
| Rate for Payer: Aetna Commercial |
$99.07
|
| Rate for Payer: Aetna Medicare |
$58.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.76
|
| Rate for Payer: BCBS Complete |
$46.62
|
| Rate for Payer: Cash Price |
$93.24
|
| Rate for Payer: Cofinity Commercial |
$100.23
|
| Rate for Payer: Cofinity Commercial |
$81.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.24
|
| Rate for Payer: Healthscope Commercial |
$104.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.07
|
| Rate for Payer: PHP Commercial |
$99.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.76
|
| Rate for Payer: Priority Health SBD |
$73.43
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION
|
Facility
|
IP
|
$116.55
|
|
|
Service Code
|
NDC 48433023015
|
| Hospital Charge Code |
108150
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.43 |
| Max. Negotiated Rate |
$104.89 |
| Rate for Payer: Aetna Commercial |
$99.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.76
|
| Rate for Payer: Cash Price |
$93.24
|
| Rate for Payer: Cofinity Commercial |
$100.23
|
| Rate for Payer: Cofinity Commercial |
$81.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.24
|
| Rate for Payer: Healthscope Commercial |
$104.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.07
|
| Rate for Payer: PHP Commercial |
$99.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.76
|
| Rate for Payer: Priority Health SBD |
$73.43
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$61.88
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.98 |
| Max. Negotiated Rate |
$55.69 |
| Rate for Payer: Aetna Commercial |
$52.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.22
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cofinity Commercial |
$43.32
|
| Rate for Payer: Cofinity Commercial |
$53.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.50
|
| Rate for Payer: Healthscope Commercial |
$55.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.60
|
| Rate for Payer: PHP Commercial |
$52.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.22
|
| Rate for Payer: Priority Health SBD |
$38.98
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$61.88
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$55.69 |
| Rate for Payer: Aetna Commercial |
$52.60
|
| Rate for Payer: Aetna Medicare |
$30.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.22
|
| Rate for Payer: BCBS Complete |
$24.75
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cofinity Commercial |
$43.32
|
| Rate for Payer: Cofinity Commercial |
$53.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.50
|
| Rate for Payer: Healthscope Commercial |
$55.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.60
|
| Rate for Payer: PHP Commercial |
$52.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.22
|
| Rate for Payer: Priority Health SBD |
$38.98
|
|
|
IOPAMIDOL 250 MG IODINE/ML (51 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$4.85
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$4.12
|
| Rate for Payer: Aetna Medicare |
$2.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.15
|
| Rate for Payer: BCBS Complete |
$1.94
|
| Rate for Payer: Cash Price |
$3.88
|
| Rate for Payer: Cofinity Commercial |
$3.40
|
| Rate for Payer: Cofinity Commercial |
$4.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.88
|
| Rate for Payer: Healthscope Commercial |
$4.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.12
|
| Rate for Payer: PHP Commercial |
$4.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.15
|
| Rate for Payer: Priority Health SBD |
$3.06
|
|
|
IOPAMIDOL 250 MG IODINE/ML (51 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$4.85
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$4.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.15
|
| Rate for Payer: Cash Price |
$3.88
|
| Rate for Payer: Cofinity Commercial |
$3.40
|
| Rate for Payer: Cofinity Commercial |
$4.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.88
|
| Rate for Payer: Healthscope Commercial |
$4.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.12
|
| Rate for Payer: PHP Commercial |
$4.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.15
|
| Rate for Payer: Priority Health SBD |
$3.06
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$72.90
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.16 |
| Max. Negotiated Rate |
$65.61 |
| Rate for Payer: Aetna Commercial |
$61.97
|
| Rate for Payer: Aetna Medicare |
$36.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.38
|
| Rate for Payer: BCBS Complete |
$29.16
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cofinity Commercial |
$51.03
|
| Rate for Payer: Cofinity Commercial |
$62.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.32
|
| Rate for Payer: Healthscope Commercial |
$65.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.97
|
| Rate for Payer: PHP Commercial |
$61.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health SBD |
$45.93
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$72.90
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.93 |
| Max. Negotiated Rate |
$65.61 |
| Rate for Payer: Aetna Commercial |
$61.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.38
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cofinity Commercial |
$51.03
|
| Rate for Payer: Cofinity Commercial |
$62.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.32
|
| Rate for Payer: Healthscope Commercial |
$65.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.97
|
| Rate for Payer: PHP Commercial |
$61.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health SBD |
$45.93
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna Commercial |
$35.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.30
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$29.40
|
| Rate for Payer: Cofinity Commercial |
$36.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$37.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: PHP Commercial |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$26.46
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna Commercial |
$35.70
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.30
|
| Rate for Payer: BCBS Complete |
$16.80
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$29.40
|
| Rate for Payer: Cofinity Commercial |
$36.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$37.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: PHP Commercial |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$26.46
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna Commercial |
$119.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$120.40
|
| Rate for Payer: Cofinity Commercial |
$98.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Healthscope Commercial |
$126.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.00
|
| Rate for Payer: PHP Commercial |
$119.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.00
|
| Rate for Payer: Priority Health SBD |
$88.20
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna Commercial |
$119.00
|
| Rate for Payer: Aetna Medicare |
$70.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.00
|
| Rate for Payer: BCBS Complete |
$56.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$120.40
|
| Rate for Payer: Cofinity Commercial |
$98.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Healthscope Commercial |
$126.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.00
|
| Rate for Payer: PHP Commercial |
$119.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.00
|
| Rate for Payer: Priority Health SBD |
$88.20
|
|
|
IOPAMIDOL 61 % ORAL SOLUTION
|
Facility
|
IP
|
$11.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
180462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.52
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health SBD |
$7.06
|
|
|
IOPAMIDOL 61 % ORAL SOLUTION
|
Facility
|
OP
|
$11.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
180462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.48 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Aetna Medicare |
$5.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: BCBS Complete |
$4.48
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.52
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health SBD |
$7.06
|
|
|
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$92,322.68
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$83,090.41 |
| Rate for Payer: Aetna Commercial |
$78,474.28
|
| Rate for Payer: Aetna Medicare |
$190.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60,009.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$229.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$229.35
|
| Rate for Payer: BCBS Complete |
$103.26
|
| Rate for Payer: BCBS MAPPO |
$183.48
|
| Rate for Payer: BCN Medicare Advantage |
$183.48
|
| Rate for Payer: Cash Price |
$73,858.14
|
| Rate for Payer: Cash Price |
$73,858.14
|
| Rate for Payer: Cofinity Commercial |
$64,625.88
|
| Rate for Payer: Cofinity Commercial |
$79,397.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$64,625.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73,858.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$183.48
|
| Rate for Payer: Healthscope Commercial |
$83,090.41
|
| Rate for Payer: Mclaren Medicaid |
$98.35
|
| Rate for Payer: Mclaren Medicare |
$183.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$192.65
|
| Rate for Payer: Meridian Medicaid |
$103.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78,474.28
|
| Rate for Payer: PACE Medicare |
$174.31
|
| Rate for Payer: PACE SWMI |
$183.48
|
| Rate for Payer: PHP Commercial |
$78,474.28
|
| Rate for Payer: PHP Medicare Advantage |
$183.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$98.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60,009.74
|
| Rate for Payer: Priority Health Medicare |
$183.48
|
| Rate for Payer: Priority Health SBD |
$58,163.29
|
| Rate for Payer: Railroad Medicare Medicare |
$183.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$516.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$183.48
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: UHCCP Medicaid |
$103.30
|
| Rate for Payer: VA VA |
$183.48
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23,080.72
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,540.85 |
| Max. Negotiated Rate |
$20,772.65 |
| Rate for Payer: Aetna Commercial |
$19,618.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,002.47
|
| Rate for Payer: Cash Price |
$18,464.58
|
| Rate for Payer: Cofinity Commercial |
$16,156.50
|
| Rate for Payer: Cofinity Commercial |
$19,849.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$16,156.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,464.58
|
| Rate for Payer: Healthscope Commercial |
$20,772.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,618.61
|
| Rate for Payer: PHP Commercial |
$19,618.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,002.47
|
| Rate for Payer: Priority Health SBD |
$14,540.85
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23,080.72
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$20,772.65 |
| Rate for Payer: Aetna Commercial |
$19,618.61
|
| Rate for Payer: Aetna Medicare |
$190.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,002.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$229.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$229.35
|
| Rate for Payer: BCBS Complete |
$103.26
|
| Rate for Payer: BCBS MAPPO |
$183.48
|
| Rate for Payer: BCN Medicare Advantage |
$183.48
|
| Rate for Payer: Cash Price |
$18,464.58
|
| Rate for Payer: Cash Price |
$18,464.58
|
| Rate for Payer: Cofinity Commercial |
$19,849.42
|
| Rate for Payer: Cofinity Commercial |
$16,156.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$16,156.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,464.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$183.48
|
| Rate for Payer: Healthscope Commercial |
$20,772.65
|
| Rate for Payer: Mclaren Medicaid |
$98.35
|
| Rate for Payer: Mclaren Medicare |
$183.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$192.65
|
| Rate for Payer: Meridian Medicaid |
$103.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,618.61
|
| Rate for Payer: PACE Medicare |
$174.31
|
| Rate for Payer: PACE SWMI |
$183.48
|
| Rate for Payer: PHP Commercial |
$19,618.61
|
| Rate for Payer: PHP Medicare Advantage |
$183.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$98.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,002.47
|
| Rate for Payer: Priority Health Medicare |
$183.48
|
| Rate for Payer: Priority Health SBD |
$14,540.85
|
| Rate for Payer: Railroad Medicare Medicare |
$183.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$516.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$183.48
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: UHCCP Medicaid |
$103.30
|
| Rate for Payer: VA VA |
$183.48
|
|
|
IPL CHEEKS FIRST
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
HCPCS 00126
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$83.20 |
| Rate for Payer: Aetna Medicare |
$64.00
|
| Rate for Payer: BCBS Complete |
$51.20
|
| Rate for Payer: Cash Price |
$102.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.20
|
|
