|
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;
|
Facility
|
OP
|
$12,013.78
|
|
|
Service Code
|
CPT 31256
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,493.02 |
| Max. Negotiated Rate |
$12,013.78 |
| Rate for Payer: Aetna Medicare |
$3,863.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,643.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,643.68
|
| Rate for Payer: BCBS Complete |
$2,040.25
|
| Rate for Payer: BCBS MAPPO |
$3,714.94
|
| Rate for Payer: BCBS Trust/PPO |
$1,493.02
|
| Rate for Payer: BCN Commercial |
$1,493.02
|
| Rate for Payer: BCN Medicare Advantage |
$3,714.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,714.94
|
| Rate for Payer: Mclaren Medicaid |
$1,942.91
|
| Rate for Payer: Mclaren Medicare |
$3,714.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,900.69
|
| Rate for Payer: Meridian Medicaid |
$3,900.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,272.18
|
| Rate for Payer: Molina Medicare/Medicaid |
$4,086.43
|
| Rate for Payer: Nomi Health Commercial |
$11,144.82
|
| Rate for Payer: PACE Medicare |
$3,529.19
|
| Rate for Payer: PACE SWMI |
$3,714.94
|
| Rate for Payer: PHP Medicare Advantage |
$3,714.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,942.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,013.78
|
| Rate for Payer: Priority Health Medicare |
$3,714.94
|
| Rate for Payer: Priority Health Tiered Network |
$9,611.02
|
| Rate for Payer: Railroad Medicare Medicare |
$3,714.94
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,714.94
|
| Rate for Payer: UHC Medicaid |
$1,942.91
|
| Rate for Payer: UHCCP Medicaid |
$1,942.91
|
| Rate for Payer: VA VA |
$3,714.94
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS
|
Facility
|
OP
|
$22,741.12
|
|
|
Service Code
|
CPT 31267
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,090.37 |
| Max. Negotiated Rate |
$22,741.12 |
| Rate for Payer: Aetna Medicare |
$7,313.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,790.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,790.10
|
| Rate for Payer: BCBS Complete |
$3,862.02
|
| Rate for Payer: BCBS MAPPO |
$7,032.08
|
| Rate for Payer: BCBS Trust/PPO |
$3,090.37
|
| Rate for Payer: BCN Commercial |
$3,090.37
|
| Rate for Payer: BCN Medicare Advantage |
$7,032.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,032.08
|
| Rate for Payer: Mclaren Medicaid |
$3,677.78
|
| Rate for Payer: Mclaren Medicare |
$7,032.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,383.68
|
| Rate for Payer: Meridian Medicaid |
$7,383.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,086.89
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,735.29
|
| Rate for Payer: Nomi Health Commercial |
$21,096.24
|
| Rate for Payer: PACE Medicare |
$6,680.48
|
| Rate for Payer: PACE SWMI |
$7,032.08
|
| Rate for Payer: PHP Medicare Advantage |
$7,032.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,677.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$22,741.12
|
| Rate for Payer: Priority Health Medicare |
$7,032.08
|
| Rate for Payer: Priority Health Tiered Network |
$18,192.90
|
| Rate for Payer: Railroad Medicare Medicare |
$7,032.08
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,032.08
|
| Rate for Payer: UHC Medicaid |
$3,677.78
|
| Rate for Payer: UHCCP Medicaid |
$3,677.78
|
| Rate for Payer: VA VA |
$7,032.08
|
|
|
NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23,085.98
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
40120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$20,777.38 |
| Rate for Payer: Aetna Commercial |
$19,623.08
|
| Rate for Payer: Aetna Medicare |
$25.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,005.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30.40
|
| Rate for Payer: BCBS Complete |
$13.36
|
| Rate for Payer: BCBS MAPPO |
$24.32
|
| Rate for Payer: BCBS Trust/PPO |
$61.49
|
| Rate for Payer: BCN Commercial |
$61.49
|
| Rate for Payer: BCN Medicare Advantage |
$24.32
|
| Rate for Payer: Cash Price |
$18,468.78
|
| Rate for Payer: Cash Price |
$18,468.78
|
| Rate for Payer: Cofinity Advantage |
$16,160.19
|
| Rate for Payer: Cofinity Commercial |
$19,853.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,468.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.32
|
| Rate for Payer: Healthscope Commercial |
$20,777.38
|
| Rate for Payer: Mclaren Medicaid |
$12.72
|
| Rate for Payer: Mclaren Medicare |
$24.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.54
|
| Rate for Payer: Meridian Medicaid |
$25.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.97
|
| Rate for Payer: Molina Medicare/Medicaid |
$26.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,623.08
|
| Rate for Payer: Nomi Health Commercial |
$72.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17,314.49
|
| Rate for Payer: PACE Medicare |
$23.10
|
| Rate for Payer: PACE SWMI |
$24.32
|
| Rate for Payer: PHP Commercial |
$19,623.08
|
| Rate for Payer: PHP Medicare Advantage |
$24.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$75.68
|
| Rate for Payer: Priority Health Medicare |
$24.32
|
| Rate for Payer: Priority Health SBD |
$14,544.17
|
| Rate for Payer: Priority Health Tiered Network |
$60.54
|
| Rate for Payer: Railroad Medicare Medicare |
$24.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.44
|
| Rate for Payer: UHC Core |
$40.44
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$24.32
|
| Rate for Payer: UHC Exchange |
$40.44
|
| Rate for Payer: UHC Medicaid |
$12.72
|
| Rate for Payer: UHCCP Medicaid |
$12.72
|
| Rate for Payer: VA VA |
$24.32
|
|
|
NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23,085.98
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
40120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,544.17 |
| Max. Negotiated Rate |
$20,777.38 |
| Rate for Payer: Aetna Commercial |
$19,623.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,005.89
|
| Rate for Payer: Cash Price |
$18,468.78
|
| Rate for Payer: Cofinity Advantage |
$16,160.19
|
| Rate for Payer: Cofinity Commercial |
$19,853.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,468.78
|
| Rate for Payer: Healthscope Commercial |
$20,777.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,623.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17,314.49
|
| Rate for Payer: PHP Commercial |
$19,623.08
|
| Rate for Payer: Priority Health SBD |
$14,544.17
|
|
|
NECITUMUMAB 800 MG/50 ML (16 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19,440.58
|
|
|
Service Code
|
HCPCS J9295
|
| Hospital Charge Code |
176602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,247.57 |
| Max. Negotiated Rate |
$17,496.52 |
| Rate for Payer: Aetna Commercial |
$16,524.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,636.38
|
| Rate for Payer: Cash Price |
$15,552.46
|
| Rate for Payer: Cofinity Advantage |
$13,608.41
|
| Rate for Payer: Cofinity Commercial |
$16,718.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,552.46
|
| Rate for Payer: Healthscope Commercial |
$17,496.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,524.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,580.43
|
| Rate for Payer: PHP Commercial |
$16,524.49
|
| Rate for Payer: Priority Health SBD |
$12,247.57
|
|
|
NECITUMUMAB 800 MG/50 ML (16 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19,440.58
|
|
|
Service Code
|
HCPCS J9295
|
| Hospital Charge Code |
176602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$17,496.52 |
| Rate for Payer: Aetna Commercial |
$16,524.49
|
| Rate for Payer: Aetna Medicare |
$5.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,636.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.16
|
| Rate for Payer: BCBS Complete |
$3.15
|
| Rate for Payer: BCBS MAPPO |
$5.73
|
| Rate for Payer: BCBS Trust/PPO |
$14.36
|
| Rate for Payer: BCN Commercial |
$14.36
|
| Rate for Payer: BCN Medicare Advantage |
$5.73
|
| Rate for Payer: Cash Price |
$15,552.46
|
| Rate for Payer: Cash Price |
$15,552.46
|
| Rate for Payer: Cofinity Advantage |
$13,608.41
|
| Rate for Payer: Cofinity Commercial |
$16,718.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,552.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.73
|
| Rate for Payer: Healthscope Commercial |
$17,496.52
|
| Rate for Payer: Mclaren Medicaid |
$3.00
|
| Rate for Payer: Mclaren Medicare |
$5.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.02
|
| Rate for Payer: Meridian Medicaid |
$6.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.59
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,524.49
|
| Rate for Payer: Nomi Health Commercial |
$17.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,580.43
|
| Rate for Payer: PACE Medicare |
$5.44
|
| Rate for Payer: PACE SWMI |
$5.73
|
| Rate for Payer: PHP Commercial |
$16,524.49
|
| Rate for Payer: PHP Medicare Advantage |
$5.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$18.08
|
| Rate for Payer: Priority Health Medicare |
$5.73
|
| Rate for Payer: Priority Health SBD |
$12,247.57
|
| Rate for Payer: Priority Health Tiered Network |
$14.46
|
| Rate for Payer: Railroad Medicare Medicare |
$5.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.45
|
| Rate for Payer: UHC Core |
$9.45
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.73
|
| Rate for Payer: UHC Exchange |
$9.45
|
| Rate for Payer: UHC Medicaid |
$3.00
|
| Rate for Payer: UHCCP Medicaid |
$3.00
|
| Rate for Payer: VA VA |
$5.73
|
|
|
NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS
|
Facility
|
OP
|
$1,309.90
|
|
|
Service Code
|
CPT 97607
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$211.84 |
| Max. Negotiated Rate |
$1,309.90 |
| Rate for Payer: Aetna Medicare |
$421.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$506.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$506.31
|
| Rate for Payer: BCBS Complete |
$222.45
|
| Rate for Payer: BCBS MAPPO |
$405.05
|
| Rate for Payer: BCBS Trust/PPO |
$438.69
|
| Rate for Payer: BCN Commercial |
$438.69
|
| Rate for Payer: BCN Medicare Advantage |
$405.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$405.05
|
| Rate for Payer: Mclaren Medicaid |
$211.84
|
| Rate for Payer: Mclaren Medicare |
$405.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$425.30
|
| Rate for Payer: Meridian Medicaid |
$425.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$465.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$445.56
|
| Rate for Payer: Nomi Health Commercial |
$1,215.15
|
| Rate for Payer: PACE Medicare |
$384.80
|
| Rate for Payer: PACE SWMI |
$405.05
|
| Rate for Payer: PHP Medicare Advantage |
$405.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$211.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,309.90
|
| Rate for Payer: Priority Health Medicare |
$405.05
|
| Rate for Payer: Priority Health Tiered Network |
$1,047.92
|
| Rate for Payer: Railroad Medicare Medicare |
$405.05
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$405.05
|
| Rate for Payer: UHC Medicaid |
$211.84
|
| Rate for Payer: UHCCP Medicaid |
$211.84
|
| Rate for Payer: VA VA |
$405.05
|
|
|
NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 97605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$62.78 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$62.78
|
| Rate for Payer: BCN Commercial |
$62.78
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS
|
Facility
|
OP
|
$167.13
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
5474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.68 |
| Max. Negotiated Rate |
$150.42 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Aetna Medicare |
$83.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.63
|
| Rate for Payer: BCBS Complete |
$66.85
|
| Rate for Payer: Cash Price |
$133.70
|
| Rate for Payer: Cofinity Advantage |
$116.99
|
| Rate for Payer: Cofinity Commercial |
$143.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.70
|
| Rate for Payer: Healthscope Commercial |
$150.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$133.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.35
|
| Rate for Payer: PHP Commercial |
$142.06
|
| Rate for Payer: Priority Health SBD |
$105.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.63
|
| Rate for Payer: UHC Core |
$87.07
|
| Rate for Payer: UHC Exchange |
$65.68
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS
|
Facility
|
IP
|
$167.13
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
5474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.29 |
| Max. Negotiated Rate |
$150.42 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.63
|
| Rate for Payer: Cash Price |
$133.70
|
| Rate for Payer: Cofinity Advantage |
$116.99
|
| Rate for Payer: Cofinity Commercial |
$143.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.70
|
| Rate for Payer: Healthscope Commercial |
$150.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.35
|
| Rate for Payer: PHP Commercial |
$142.06
|
| Rate for Payer: Priority Health SBD |
$105.29
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
OP
|
$58.60
|
|
|
Service Code
|
NDC 61314063136
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.03 |
| Max. Negotiated Rate |
$52.74 |
| Rate for Payer: Aetna Commercial |
$49.81
|
| Rate for Payer: Aetna Medicare |
$29.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.09
|
| Rate for Payer: BCBS Complete |
$23.44
|
| Rate for Payer: Cash Price |
$46.88
|
| Rate for Payer: Cofinity Advantage |
$41.02
|
| Rate for Payer: Cofinity Commercial |
$50.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.88
|
| Rate for Payer: Healthscope Commercial |
$52.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$46.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.95
|
| Rate for Payer: PHP Commercial |
$49.81
|
| Rate for Payer: Priority Health SBD |
$36.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.09
|
| Rate for Payer: UHC Core |
$30.53
|
| Rate for Payer: UHC Exchange |
$23.03
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$43.05
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.12 |
| Max. Negotiated Rate |
$38.74 |
| Rate for Payer: Aetna Commercial |
$36.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.98
|
| Rate for Payer: Cash Price |
$34.44
|
| Rate for Payer: Cofinity Advantage |
$30.14
|
| Rate for Payer: Cofinity Commercial |
$37.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.44
|
| Rate for Payer: Healthscope Commercial |
$38.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.29
|
| Rate for Payer: PHP Commercial |
$36.59
|
| Rate for Payer: Priority Health SBD |
$27.12
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$58.60
|
|
|
Service Code
|
NDC 61314063136
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$52.74 |
| Rate for Payer: Aetna Commercial |
$49.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.09
|
| Rate for Payer: Cash Price |
$46.88
|
| Rate for Payer: Cofinity Advantage |
$41.02
|
| Rate for Payer: Cofinity Commercial |
$50.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.88
|
| Rate for Payer: Healthscope Commercial |
$52.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.95
|
| Rate for Payer: PHP Commercial |
$49.81
|
| Rate for Payer: Priority Health SBD |
$36.92
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
OP
|
$43.05
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.92 |
| Max. Negotiated Rate |
$38.74 |
| Rate for Payer: Aetna Commercial |
$36.59
|
| Rate for Payer: Aetna Medicare |
$21.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.98
|
| Rate for Payer: BCBS Complete |
$17.22
|
| Rate for Payer: Cash Price |
$34.44
|
| Rate for Payer: Cofinity Advantage |
$30.14
|
| Rate for Payer: Cofinity Commercial |
$37.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.44
|
| Rate for Payer: Healthscope Commercial |
$38.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.29
|
| Rate for Payer: PHP Commercial |
$36.59
|
| Rate for Payer: Priority Health SBD |
$27.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.98
|
| Rate for Payer: UHC Core |
$22.43
|
| Rate for Payer: UHC Exchange |
$16.92
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
OP
|
$605.76
|
|
|
Service Code
|
NDC 39822031005
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.06 |
| Max. Negotiated Rate |
$545.18 |
| Rate for Payer: Aetna Commercial |
$514.90
|
| Rate for Payer: Aetna Medicare |
$302.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.74
|
| Rate for Payer: BCBS Complete |
$242.30
|
| Rate for Payer: Cash Price |
$484.61
|
| Rate for Payer: Cofinity Advantage |
$424.03
|
| Rate for Payer: Cofinity Commercial |
$520.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.61
|
| Rate for Payer: Healthscope Commercial |
$545.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$484.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$454.32
|
| Rate for Payer: PHP Commercial |
$514.90
|
| Rate for Payer: Priority Health SBD |
$381.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$393.74
|
| Rate for Payer: UHC Core |
$315.60
|
| Rate for Payer: UHC Exchange |
$238.06
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$605.76
|
|
|
Service Code
|
NDC 39822031005
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$381.63 |
| Max. Negotiated Rate |
$545.18 |
| Rate for Payer: Aetna Commercial |
$514.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.74
|
| Rate for Payer: Cash Price |
$484.61
|
| Rate for Payer: Cofinity Advantage |
$424.03
|
| Rate for Payer: Cofinity Commercial |
$520.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.61
|
| Rate for Payer: Healthscope Commercial |
$545.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$454.32
|
| Rate for Payer: PHP Commercial |
$514.90
|
| Rate for Payer: Priority Health SBD |
$381.63
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
OP
|
$474.72
|
|
|
Service Code
|
NDC 00093117701
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.56 |
| Max. Negotiated Rate |
$427.25 |
| Rate for Payer: Aetna Commercial |
$403.51
|
| Rate for Payer: Aetna Medicare |
$237.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.57
|
| Rate for Payer: BCBS Complete |
$189.89
|
| Rate for Payer: Cash Price |
$379.78
|
| Rate for Payer: Cofinity Advantage |
$332.30
|
| Rate for Payer: Cofinity Commercial |
$408.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.78
|
| Rate for Payer: Healthscope Commercial |
$427.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$379.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.04
|
| Rate for Payer: PHP Commercial |
$403.51
|
| Rate for Payer: Priority Health SBD |
$299.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$308.57
|
| Rate for Payer: UHC Core |
$247.33
|
| Rate for Payer: UHC Exchange |
$186.56
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$454.56
|
|
|
Service Code
|
NDC 50383056510
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.37 |
| Max. Negotiated Rate |
$409.10 |
| Rate for Payer: Aetna Commercial |
$386.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.46
|
| Rate for Payer: Cash Price |
$363.65
|
| Rate for Payer: Cofinity Advantage |
$318.19
|
| Rate for Payer: Cofinity Commercial |
$390.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$363.65
|
| Rate for Payer: Healthscope Commercial |
$409.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$386.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$340.92
|
| Rate for Payer: PHP Commercial |
$386.38
|
| Rate for Payer: Priority Health SBD |
$286.37
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$6.06
|
|
|
Service Code
|
NDC 39822031007
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$5.45 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.94
|
| Rate for Payer: Cash Price |
$4.85
|
| Rate for Payer: Cofinity Advantage |
$4.24
|
| Rate for Payer: Cofinity Commercial |
$5.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.85
|
| Rate for Payer: Healthscope Commercial |
$5.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.54
|
| Rate for Payer: PHP Commercial |
$5.15
|
| Rate for Payer: Priority Health SBD |
$3.82
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$474.72
|
|
|
Service Code
|
NDC 00093117701
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.07 |
| Max. Negotiated Rate |
$427.25 |
| Rate for Payer: Aetna Commercial |
$403.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.57
|
| Rate for Payer: Cash Price |
$379.78
|
| Rate for Payer: Cofinity Advantage |
$332.30
|
| Rate for Payer: Cofinity Commercial |
$408.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.78
|
| Rate for Payer: Healthscope Commercial |
$427.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.04
|
| Rate for Payer: PHP Commercial |
$403.51
|
| Rate for Payer: Priority Health SBD |
$299.07
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
OP
|
$6.06
|
|
|
Service Code
|
NDC 39822031007
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$5.45 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: Aetna Medicare |
$3.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.94
|
| Rate for Payer: BCBS Complete |
$2.42
|
| Rate for Payer: Cash Price |
$4.85
|
| Rate for Payer: Cofinity Advantage |
$4.24
|
| Rate for Payer: Cofinity Commercial |
$5.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.85
|
| Rate for Payer: Healthscope Commercial |
$5.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.54
|
| Rate for Payer: PHP Commercial |
$5.15
|
| Rate for Payer: Priority Health SBD |
$3.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.94
|
| Rate for Payer: UHC Core |
$3.16
|
| Rate for Payer: UHC Exchange |
$2.38
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
OP
|
$454.56
|
|
|
Service Code
|
NDC 50383056510
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.64 |
| Max. Negotiated Rate |
$409.10 |
| Rate for Payer: Aetna Commercial |
$386.38
|
| Rate for Payer: Aetna Medicare |
$227.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.46
|
| Rate for Payer: BCBS Complete |
$181.82
|
| Rate for Payer: Cash Price |
$363.65
|
| Rate for Payer: Cofinity Advantage |
$318.19
|
| Rate for Payer: Cofinity Commercial |
$390.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$363.65
|
| Rate for Payer: Healthscope Commercial |
$409.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$363.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$386.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$340.92
|
| Rate for Payer: PHP Commercial |
$386.38
|
| Rate for Payer: Priority Health SBD |
$286.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.46
|
| Rate for Payer: UHC Core |
$236.83
|
| Rate for Payer: UHC Exchange |
$178.64
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT
|
Facility
|
OP
|
$69.38
|
|
|
Service Code
|
NDC 24208078555
|
| Hospital Charge Code |
849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.27 |
| Max. Negotiated Rate |
$62.44 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Medicare |
$34.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.10
|
| Rate for Payer: BCBS Complete |
$27.75
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cofinity Advantage |
$48.57
|
| Rate for Payer: Cofinity Commercial |
$59.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.50
|
| Rate for Payer: Healthscope Commercial |
$62.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.03
|
| Rate for Payer: PHP Commercial |
$58.97
|
| Rate for Payer: Priority Health SBD |
$43.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.10
|
| Rate for Payer: UHC Core |
$36.15
|
| Rate for Payer: UHC Exchange |
$27.27
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT
|
Facility
|
IP
|
$69.38
|
|
|
Service Code
|
NDC 24208078555
|
| Hospital Charge Code |
849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.71 |
| Max. Negotiated Rate |
$62.44 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.10
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cofinity Advantage |
$48.57
|
| Rate for Payer: Cofinity Commercial |
$59.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.50
|
| Rate for Payer: Healthscope Commercial |
$62.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.03
|
| Rate for Payer: PHP Commercial |
$58.97
|
| Rate for Payer: Priority Health SBD |
$43.71
|
|
|
NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT
|
Facility
|
IP
|
$67.42
|
|
|
Service Code
|
NDC 24208078055
|
| Hospital Charge Code |
38701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.47 |
| Max. Negotiated Rate |
$60.68 |
| Rate for Payer: Aetna Commercial |
$57.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.82
|
| Rate for Payer: Cash Price |
$53.94
|
| Rate for Payer: Cofinity Advantage |
$47.19
|
| Rate for Payer: Cofinity Commercial |
$57.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.94
|
| Rate for Payer: Healthscope Commercial |
$60.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.56
|
| Rate for Payer: PHP Commercial |
$57.31
|
| Rate for Payer: Priority Health SBD |
$42.47
|
|
