|
ALTEPLASE 100 MG IV INFUSION FOR STROKE
|
Facility
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150807
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,185.20
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALTEPLASE 100MG IV SOLUTION FOR PE
|
Facility
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,185.20
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION
|
Facility
IP
|
$582.24
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$366.81 |
| Max. Negotiated Rate |
$524.02 |
| Rate for Payer: Aetna Commercial |
$494.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$378.46
|
| Rate for Payer: Cash Price |
$465.79
|
| Rate for Payer: Cofinity Commercial |
$407.57
|
| Rate for Payer: Cofinity Commercial |
$500.73
|
| Rate for Payer: Healthscope Commercial |
$524.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$494.90
|
| Rate for Payer: PHP Commercial |
$494.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$407.57
|
| Rate for Payer: Priority Health SBD |
$366.81
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION
|
Facility
OP
|
$582.24
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.67 |
| Max. Negotiated Rate |
$524.02 |
| Rate for Payer: Aetna Commercial |
$494.90
|
| Rate for Payer: Aetna Medicare |
$92.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$378.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$111.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$111.22
|
| Rate for Payer: BCBS Complete |
$51.11
|
| Rate for Payer: BCBS MAPPO |
$88.97
|
| Rate for Payer: BCBS Trust/PPO |
$263.40
|
| Rate for Payer: BCN Medicare Advantage |
$88.97
|
| Rate for Payer: Cash Price |
$465.79
|
| Rate for Payer: Cash Price |
$465.79
|
| Rate for Payer: Cofinity Commercial |
$407.57
|
| Rate for Payer: Cofinity Commercial |
$500.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$88.97
|
| Rate for Payer: Healthscope Commercial |
$524.02
|
| Rate for Payer: Mclaren Medicaid |
$48.67
|
| Rate for Payer: Mclaren Medicare |
$88.97
|
| Rate for Payer: Meridian Medicaid |
$51.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$93.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$494.90
|
| Rate for Payer: PACE Medicare |
$84.53
|
| Rate for Payer: PACE SWMI |
$88.97
|
| Rate for Payer: PHP Commercial |
$494.90
|
| Rate for Payer: PHP Medicare Advantage |
$88.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$48.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$407.57
|
| Rate for Payer: Priority Health Medicare |
$88.97
|
| Rate for Payer: Priority Health SBD |
$366.81
|
| Rate for Payer: Railroad Medicare Medicare |
$88.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$88.97
|
| Rate for Payer: UHC Medicare Advantage |
$91.64
|
| Rate for Payer: VA VA |
$88.97
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,083.34 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,371.70
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$10,092.60
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,255.30
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,092.60
|
| Rate for Payer: Priority Health SBD |
$9,083.34
|
|
|
ALTEPLASE INFUSION FOR CARDIAC ARREST
|
Facility
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
300766
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,185.20
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION
|
Facility
IP
|
$14.45
|
|
|
Service Code
|
NDC 0904-7727-14
|
| Hospital Charge Code |
24314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$10.12
|
| Rate for Payer: Healthscope Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.28
|
| Rate for Payer: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.12
|
| Rate for Payer: Priority Health SBD |
$9.10
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION
|
Facility
IP
|
$28.90
|
|
|
Service Code
|
NDC 0088-1171-12
|
| Hospital Charge Code |
24314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$26.01 |
| Rate for Payer: Aetna Commercial |
$24.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.78
|
| Rate for Payer: Cash Price |
$23.12
|
| Rate for Payer: Cofinity Commercial |
$20.23
|
| Rate for Payer: Cofinity Commercial |
$24.85
|
| Rate for Payer: Healthscope Commercial |
$26.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.56
|
| Rate for Payer: PHP Commercial |
$24.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.23
|
| Rate for Payer: Priority Health SBD |
$18.21
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
OP
|
$13.23
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.60
|
| Rate for Payer: BCBS Complete |
$5.29
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$11.38
|
| Rate for Payer: Cofinity Commercial |
$9.26
|
| Rate for Payer: Healthscope Commercial |
$11.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.25
|
| Rate for Payer: PHP Commercial |
$11.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.26
|
| Rate for Payer: Priority Health SBD |
$8.33
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$15.98
|
|
|
Service Code
|
NDC 0536-1293-83
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.39
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Commercial |
$11.19
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.58
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.19
|
| Rate for Payer: Priority Health SBD |
$10.07
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$14.38
|
|
|
Service Code
|
NDC 0536-1317-83
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.35
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Cofinity Commercial |
$12.37
|
| Rate for Payer: Healthscope Commercial |
$12.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.22
|
| Rate for Payer: PHP Commercial |
$12.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.07
|
| Rate for Payer: Priority Health SBD |
$9.06
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$13.23
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.60
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$11.38
|
| Rate for Payer: Cofinity Commercial |
$9.26
|
| Rate for Payer: Healthscope Commercial |
$11.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.25
|
| Rate for Payer: PHP Commercial |
$11.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.26
|
| Rate for Payer: Priority Health SBD |
$8.33
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$10.26
|
|
|
Service Code
|
NDC 0904-6838-73
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$14.38
|
|
|
Service Code
|
NDC 57896-629-12
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.35
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Cofinity Commercial |
$12.37
|
| Rate for Payer: Healthscope Commercial |
$12.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.22
|
| Rate for Payer: PHP Commercial |
$12.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.07
|
| Rate for Payer: Priority Health SBD |
$9.06
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
IP
|
$515.54
|
|
|
Service Code
|
NDC 0591-2312-45
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$324.79 |
| Max. Negotiated Rate |
$463.99 |
| Rate for Payer: Aetna Commercial |
$438.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$335.10
|
| Rate for Payer: Cash Price |
$412.43
|
| Rate for Payer: Cofinity Commercial |
$360.88
|
| Rate for Payer: Cofinity Commercial |
$443.36
|
| Rate for Payer: Healthscope Commercial |
$463.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$438.21
|
| Rate for Payer: PHP Commercial |
$438.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$360.88
|
| Rate for Payer: Priority Health SBD |
$324.79
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
IP
|
$15,465.97
|
|
|
Service Code
|
NDC 0591-2312-15
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9,743.56 |
| Max. Negotiated Rate |
$13,919.37 |
| Rate for Payer: Aetna Commercial |
$13,146.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,052.88
|
| Rate for Payer: Cash Price |
$12,372.78
|
| Rate for Payer: Cofinity Commercial |
$10,826.18
|
| Rate for Payer: Cofinity Commercial |
$13,300.73
|
| Rate for Payer: Healthscope Commercial |
$13,919.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13,146.07
|
| Rate for Payer: PHP Commercial |
$13,146.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,826.18
|
| Rate for Payer: Priority Health SBD |
$9,743.56
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
IP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12,716.07 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,119.76
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$14,128.97
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17,156.60
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14,128.97
|
| Rate for Payer: Priority Health SBD |
$12,716.07
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
IP
|
$468.00
|
|
|
Service Code
|
NDC 0904-6630-61
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.84 |
| Max. Negotiated Rate |
$421.20 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$304.20
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cofinity Commercial |
$327.60
|
| Rate for Payer: Cofinity Commercial |
$402.48
|
| Rate for Payer: Healthscope Commercial |
$421.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$397.80
|
| Rate for Payer: PHP Commercial |
$397.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.60
|
| Rate for Payer: Priority Health SBD |
$294.84
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
IP
|
$524.16
|
|
|
Service Code
|
NDC 0904-7042-61
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$330.22 |
| Max. Negotiated Rate |
$471.74 |
| Rate for Payer: Aetna Commercial |
$445.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.70
|
| Rate for Payer: Cash Price |
$419.33
|
| Rate for Payer: Cofinity Commercial |
$366.91
|
| Rate for Payer: Cofinity Commercial |
$450.78
|
| Rate for Payer: Healthscope Commercial |
$471.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$445.54
|
| Rate for Payer: PHP Commercial |
$445.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$366.91
|
| Rate for Payer: Priority Health SBD |
$330.22
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
IP
|
$725.76
|
|
|
Service Code
|
NDC 0781-2048-01
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$457.23 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$471.74
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$508.03
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$616.90
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$508.03
|
| Rate for Payer: Priority Health SBD |
$457.23
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION
|
Facility
IP
|
$50.73
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
119785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.96 |
| Max. Negotiated Rate |
$45.66 |
| Rate for Payer: Aetna Commercial |
$43.12
|
| Rate for Payer: Aetna Commercial |
$15.88
|
| Rate for Payer: Aetna Commercial |
$24.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.14
|
| Rate for Payer: Cash Price |
$23.26
|
| Rate for Payer: Cash Price |
$14.94
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Cofinity Commercial |
$16.06
|
| Rate for Payer: Cofinity Commercial |
$20.35
|
| Rate for Payer: Cofinity Commercial |
$25.00
|
| Rate for Payer: Cofinity Commercial |
$35.51
|
| Rate for Payer: Cofinity Commercial |
$43.63
|
| Rate for Payer: Healthscope Commercial |
$26.16
|
| Rate for Payer: Healthscope Commercial |
$16.81
|
| Rate for Payer: Healthscope Commercial |
$45.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.12
|
| Rate for Payer: PHP Commercial |
$24.71
|
| Rate for Payer: PHP Commercial |
$15.88
|
| Rate for Payer: PHP Commercial |
$43.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.51
|
| Rate for Payer: Priority Health SBD |
$11.77
|
| Rate for Payer: Priority Health SBD |
$18.31
|
| Rate for Payer: Priority Health SBD |
$31.96
|
|
|
AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION
|
Facility
IP
|
$120.15
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
27928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.69 |
| Max. Negotiated Rate |
$108.14 |
| Rate for Payer: Aetna Commercial |
$102.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.10
|
| Rate for Payer: Cash Price |
$96.12
|
| Rate for Payer: Cofinity Commercial |
$103.33
|
| Rate for Payer: Cofinity Commercial |
$84.10
|
| Rate for Payer: Healthscope Commercial |
$108.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.13
|
| Rate for Payer: PHP Commercial |
$102.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.10
|
| Rate for Payer: Priority Health SBD |
$75.69
|
|
|
AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D10W INTRAVENOUS SOLUTION
|
Facility
IP
|
$137.95
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
27951
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.91 |
| Max. Negotiated Rate |
$124.16 |
| Rate for Payer: Aetna Commercial |
$117.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.67
|
| Rate for Payer: Cash Price |
$110.36
|
| Rate for Payer: Cofinity Commercial |
$118.64
|
| Rate for Payer: Cofinity Commercial |
$96.56
|
| Rate for Payer: Healthscope Commercial |
$124.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.26
|
| Rate for Payer: PHP Commercial |
$117.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.56
|
| Rate for Payer: Priority Health SBD |
$86.91
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$157.33
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$141.60 |
| Rate for Payer: Aetna Commercial |
$133.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.26
|
| Rate for Payer: Cash Price |
$125.86
|
| Rate for Payer: Cofinity Commercial |
$110.13
|
| Rate for Payer: Cofinity Commercial |
$135.30
|
| Rate for Payer: Healthscope Commercial |
$141.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.73
|
| Rate for Payer: PHP Commercial |
$133.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.13
|
| Rate for Payer: Priority Health SBD |
$99.12
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$31.15
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
113386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.62 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$26.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.25
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: Cofinity Commercial |
$21.80
|
| Rate for Payer: Cofinity Commercial |
$26.79
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.48
|
| Rate for Payer: PHP Commercial |
$26.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.80
|
| Rate for Payer: Priority Health SBD |
$19.62
|
|
