|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$120.86
|
|
|
Service Code
|
NDC 69315050447
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.14 |
| Max. Negotiated Rate |
$108.77 |
| Rate for Payer: Aetna Commercial |
$102.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.56
|
| Rate for Payer: Cash Price |
$96.69
|
| Rate for Payer: Cofinity Commercial |
$103.94
|
| Rate for Payer: Cofinity Commercial |
$84.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$84.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.69
|
| Rate for Payer: Healthscope Commercial |
$108.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.73
|
| Rate for Payer: PHP Commercial |
$102.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.56
|
| Rate for Payer: Priority Health SBD |
$76.14
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$18.03
|
|
|
Service Code
|
NDC 68462031417
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.21 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Aetna Commercial |
$15.33
|
| Rate for Payer: Aetna Medicare |
$9.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.72
|
| Rate for Payer: BCBS Complete |
$7.21
|
| Rate for Payer: Cash Price |
$14.42
|
| Rate for Payer: Cofinity Commercial |
$12.62
|
| Rate for Payer: Cofinity Commercial |
$15.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.42
|
| Rate for Payer: Healthscope Commercial |
$16.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.33
|
| Rate for Payer: PHP Commercial |
$15.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.72
|
| Rate for Payer: Priority Health SBD |
$11.36
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$68.20
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.28 |
| Max. Negotiated Rate |
$61.38 |
| Rate for Payer: Aetna Commercial |
$57.97
|
| Rate for Payer: Aetna Medicare |
$34.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.33
|
| Rate for Payer: BCBS Complete |
$27.28
|
| Rate for Payer: Cash Price |
$54.56
|
| Rate for Payer: Cofinity Commercial |
$47.74
|
| Rate for Payer: Cofinity Commercial |
$58.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.56
|
| Rate for Payer: Healthscope Commercial |
$61.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.97
|
| Rate for Payer: PHP Commercial |
$57.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.33
|
| Rate for Payer: Priority Health SBD |
$42.97
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$18.03
|
|
|
Service Code
|
NDC 68462031417
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Aetna Commercial |
$15.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.72
|
| Rate for Payer: Cash Price |
$14.42
|
| Rate for Payer: Cofinity Commercial |
$12.62
|
| Rate for Payer: Cofinity Commercial |
$15.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.42
|
| Rate for Payer: Healthscope Commercial |
$16.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.33
|
| Rate for Payer: PHP Commercial |
$15.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.72
|
| Rate for Payer: Priority Health SBD |
$11.36
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$68.20
|
|
|
Service Code
|
NDC 51672126301
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.97 |
| Max. Negotiated Rate |
$61.38 |
| Rate for Payer: Aetna Commercial |
$57.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.33
|
| Rate for Payer: Cash Price |
$54.56
|
| Rate for Payer: Cofinity Commercial |
$47.74
|
| Rate for Payer: Cofinity Commercial |
$58.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.56
|
| Rate for Payer: Healthscope Commercial |
$61.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.97
|
| Rate for Payer: PHP Commercial |
$57.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.33
|
| Rate for Payer: Priority Health SBD |
$42.97
|
|
|
OB/GYN SPEC KZOO ONLY - NITROUS OXIDE ADMIN
|
Professional
|
Both
|
$61.00
|
|
|
Service Code
|
HCPCS 00563
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$24.40 |
| Max. Negotiated Rate |
$39.65 |
| Rate for Payer: Aetna Medicare |
$30.50
|
| Rate for Payer: BCBS Complete |
$24.40
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.65
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$38,671.12
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
168805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.34 |
| Max. Negotiated Rate |
$34,804.01 |
| Rate for Payer: Aetna Commercial |
$32,870.45
|
| Rate for Payer: Aetna Medicare |
$82.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25,136.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$98.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$98.75
|
| Rate for Payer: BCBS Complete |
$44.46
|
| Rate for Payer: BCBS MAPPO |
$79.00
|
| Rate for Payer: BCN Medicare Advantage |
$79.00
|
| Rate for Payer: Cash Price |
$30,936.90
|
| Rate for Payer: Cash Price |
$30,936.90
|
| Rate for Payer: Cofinity Commercial |
$33,257.16
|
| Rate for Payer: Cofinity Commercial |
$27,069.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$27,069.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30,936.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$79.00
|
| Rate for Payer: Healthscope Commercial |
$34,804.01
|
| Rate for Payer: Mclaren Medicaid |
$42.34
|
| Rate for Payer: Mclaren Medicare |
$79.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.95
|
| Rate for Payer: Meridian Medicaid |
$44.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$90.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32,870.45
|
| Rate for Payer: PACE Medicare |
$75.05
|
| Rate for Payer: PACE SWMI |
$79.00
|
| Rate for Payer: PHP Commercial |
$32,870.45
|
| Rate for Payer: PHP Medicare Advantage |
$79.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$42.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25,136.23
|
| Rate for Payer: Priority Health Medicare |
$79.00
|
| Rate for Payer: Priority Health SBD |
$24,362.81
|
| Rate for Payer: Railroad Medicare Medicare |
$79.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$222.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$79.00
|
| Rate for Payer: UHC Medicare Advantage |
$79.00
|
| Rate for Payer: UHCCP Medicaid |
$44.48
|
| Rate for Payer: VA VA |
$79.00
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$38,671.12
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
168805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24,362.81 |
| Max. Negotiated Rate |
$34,804.01 |
| Rate for Payer: Aetna Commercial |
$32,870.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25,136.23
|
| Rate for Payer: Cash Price |
$30,936.90
|
| Rate for Payer: Cofinity Commercial |
$27,069.78
|
| Rate for Payer: Cofinity Commercial |
$33,257.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$27,069.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30,936.90
|
| Rate for Payer: Healthscope Commercial |
$34,804.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32,870.45
|
| Rate for Payer: PHP Commercial |
$32,870.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25,136.23
|
| Rate for Payer: Priority Health SBD |
$24,362.81
|
|
|
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$53,666.50
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
182454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33,809.89 |
| Max. Negotiated Rate |
$48,299.85 |
| Rate for Payer: Aetna Commercial |
$45,616.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34,883.22
|
| Rate for Payer: Cash Price |
$42,933.20
|
| Rate for Payer: Cofinity Commercial |
$37,566.55
|
| Rate for Payer: Cofinity Commercial |
$46,153.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$37,566.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42,933.20
|
| Rate for Payer: Healthscope Commercial |
$48,299.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45,616.53
|
| Rate for Payer: PHP Commercial |
$45,616.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34,883.22
|
| Rate for Payer: Priority Health SBD |
$33,809.89
|
|
|
OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$53,666.50
|
|
|
Service Code
|
HCPCS J2350
|
| Hospital Charge Code |
182454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.84 |
| Max. Negotiated Rate |
$48,299.85 |
| Rate for Payer: Aetna Commercial |
$45,616.53
|
| Rate for Payer: Aetna Medicare |
$61.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34,883.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$74.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$74.26
|
| Rate for Payer: BCBS Complete |
$33.44
|
| Rate for Payer: BCBS MAPPO |
$59.41
|
| Rate for Payer: BCN Medicare Advantage |
$59.41
|
| Rate for Payer: Cash Price |
$42,933.20
|
| Rate for Payer: Cash Price |
$42,933.20
|
| Rate for Payer: Cofinity Commercial |
$46,153.19
|
| Rate for Payer: Cofinity Commercial |
$37,566.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$37,566.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42,933.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.41
|
| Rate for Payer: Healthscope Commercial |
$48,299.85
|
| Rate for Payer: Mclaren Medicaid |
$31.84
|
| Rate for Payer: Mclaren Medicare |
$59.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.38
|
| Rate for Payer: Meridian Medicaid |
$33.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45,616.53
|
| Rate for Payer: PACE Medicare |
$56.44
|
| Rate for Payer: PACE SWMI |
$59.41
|
| Rate for Payer: PHP Commercial |
$45,616.53
|
| Rate for Payer: PHP Medicare Advantage |
$59.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34,883.22
|
| Rate for Payer: Priority Health Medicare |
$59.41
|
| Rate for Payer: Priority Health SBD |
$33,809.89
|
| Rate for Payer: Railroad Medicare Medicare |
$59.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$59.41
|
| Rate for Payer: UHC Medicare Advantage |
$59.41
|
| Rate for Payer: UHCCP Medicaid |
$33.45
|
| Rate for Payer: VA VA |
$59.41
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$17.21
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$15.49 |
| Rate for Payer: Aetna Commercial |
$14.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.19
|
| Rate for Payer: Cash Price |
$13.77
|
| Rate for Payer: Cofinity Commercial |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$14.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.77
|
| Rate for Payer: Healthscope Commercial |
$15.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.63
|
| Rate for Payer: PHP Commercial |
$14.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.19
|
| Rate for Payer: Priority Health SBD |
$10.84
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$17.21
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$15.49 |
| Rate for Payer: Aetna Commercial |
$14.63
|
| Rate for Payer: Aetna Medicare |
$8.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.19
|
| Rate for Payer: BCBS Complete |
$6.88
|
| Rate for Payer: Cash Price |
$13.77
|
| Rate for Payer: Cofinity Commercial |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$14.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.77
|
| Rate for Payer: Healthscope Commercial |
$15.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.63
|
| Rate for Payer: PHP Commercial |
$14.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.19
|
| Rate for Payer: Priority Health SBD |
$10.84
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$144.85
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.26 |
| Max. Negotiated Rate |
$130.37 |
| Rate for Payer: Aetna Commercial |
$123.12
|
| Rate for Payer: Aetna Commercial |
$39.80
|
| Rate for Payer: Aetna Commercial |
$41.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.58
|
| Rate for Payer: Cash Price |
$115.88
|
| Rate for Payer: Cash Price |
$37.46
|
| Rate for Payer: Cash Price |
$38.87
|
| Rate for Payer: Cofinity Commercial |
$34.01
|
| Rate for Payer: Cofinity Commercial |
$101.39
|
| Rate for Payer: Cofinity Commercial |
$124.57
|
| Rate for Payer: Cofinity Commercial |
$41.79
|
| Rate for Payer: Cofinity Commercial |
$32.77
|
| Rate for Payer: Cofinity Commercial |
$40.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.87
|
| Rate for Payer: Healthscope Commercial |
$42.14
|
| Rate for Payer: Healthscope Commercial |
$43.73
|
| Rate for Payer: Healthscope Commercial |
$130.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.30
|
| Rate for Payer: PHP Commercial |
$41.30
|
| Rate for Payer: PHP Commercial |
$123.12
|
| Rate for Payer: PHP Commercial |
$39.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.43
|
| Rate for Payer: Priority Health SBD |
$30.61
|
| Rate for Payer: Priority Health SBD |
$91.26
|
| Rate for Payer: Priority Health SBD |
$29.50
|
|
|
OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$144.85
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.94 |
| Max. Negotiated Rate |
$130.37 |
| Rate for Payer: Aetna Commercial |
$123.12
|
| Rate for Payer: Aetna Commercial |
$41.30
|
| Rate for Payer: Aetna Commercial |
$39.80
|
| Rate for Payer: Aetna Medicare |
$24.30
|
| Rate for Payer: Aetna Medicare |
$72.42
|
| Rate for Payer: Aetna Medicare |
$23.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.43
|
| Rate for Payer: BCBS Complete |
$18.73
|
| Rate for Payer: BCBS Complete |
$57.94
|
| Rate for Payer: BCBS Complete |
$19.44
|
| Rate for Payer: Cash Price |
$38.87
|
| Rate for Payer: Cash Price |
$115.88
|
| Rate for Payer: Cash Price |
$37.46
|
| Rate for Payer: Cofinity Commercial |
$41.79
|
| Rate for Payer: Cofinity Commercial |
$124.57
|
| Rate for Payer: Cofinity Commercial |
$101.39
|
| Rate for Payer: Cofinity Commercial |
$40.27
|
| Rate for Payer: Cofinity Commercial |
$32.77
|
| Rate for Payer: Cofinity Commercial |
$34.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.88
|
| Rate for Payer: Healthscope Commercial |
$42.14
|
| Rate for Payer: Healthscope Commercial |
$130.37
|
| Rate for Payer: Healthscope Commercial |
$43.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.12
|
| Rate for Payer: PHP Commercial |
$39.80
|
| Rate for Payer: PHP Commercial |
$123.12
|
| Rate for Payer: PHP Commercial |
$41.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.43
|
| Rate for Payer: Priority Health SBD |
$30.61
|
| Rate for Payer: Priority Health SBD |
$29.50
|
| Rate for Payer: Priority Health SBD |
$91.26
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE
|
Facility
|
IP
|
$11,585.32
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
161512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,298.75 |
| Max. Negotiated Rate |
$10,426.79 |
| Rate for Payer: Aetna Commercial |
$9,847.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,530.46
|
| Rate for Payer: Cash Price |
$9,268.26
|
| Rate for Payer: Cofinity Commercial |
$8,109.72
|
| Rate for Payer: Cofinity Commercial |
$9,963.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,109.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,268.26
|
| Rate for Payer: Healthscope Commercial |
$10,426.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,847.52
|
| Rate for Payer: PHP Commercial |
$9,847.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,530.46
|
| Rate for Payer: Priority Health SBD |
$7,298.75
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE
|
Facility
|
OP
|
$11,585.32
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
161512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.12 |
| Max. Negotiated Rate |
$10,426.79 |
| Rate for Payer: Aetna Commercial |
$9,847.52
|
| Rate for Payer: Aetna Medicare |
$211.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,530.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$254.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$254.47
|
| Rate for Payer: BCBS Complete |
$114.57
|
| Rate for Payer: BCBS MAPPO |
$203.58
|
| Rate for Payer: BCN Medicare Advantage |
$203.58
|
| Rate for Payer: Cash Price |
$9,268.26
|
| Rate for Payer: Cash Price |
$9,268.26
|
| Rate for Payer: Cofinity Commercial |
$9,963.38
|
| Rate for Payer: Cofinity Commercial |
$8,109.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,109.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,268.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$203.58
|
| Rate for Payer: Healthscope Commercial |
$10,426.79
|
| Rate for Payer: Mclaren Medicaid |
$109.12
|
| Rate for Payer: Mclaren Medicare |
$203.58
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$213.76
|
| Rate for Payer: Meridian Medicaid |
$114.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$234.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,847.52
|
| Rate for Payer: PACE Medicare |
$193.40
|
| Rate for Payer: PACE SWMI |
$203.58
|
| Rate for Payer: PHP Commercial |
$9,847.52
|
| Rate for Payer: PHP Medicare Advantage |
$203.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$109.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,530.46
|
| Rate for Payer: Priority Health Medicare |
$203.58
|
| Rate for Payer: Priority Health SBD |
$7,298.75
|
| Rate for Payer: Railroad Medicare Medicare |
$203.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$573.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$203.58
|
| Rate for Payer: UHC Medicare Advantage |
$203.58
|
| Rate for Payer: UHCCP Medicaid |
$114.62
|
| Rate for Payer: VA VA |
$203.58
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE
|
Facility
|
OP
|
$17,348.09
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
161514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.12 |
| Max. Negotiated Rate |
$15,613.28 |
| Rate for Payer: Aetna Commercial |
$14,745.88
|
| Rate for Payer: Aetna Medicare |
$211.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,276.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$254.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$254.47
|
| Rate for Payer: BCBS Complete |
$114.57
|
| Rate for Payer: BCBS MAPPO |
$203.58
|
| Rate for Payer: BCN Medicare Advantage |
$203.58
|
| Rate for Payer: Cash Price |
$13,878.47
|
| Rate for Payer: Cash Price |
$13,878.47
|
| Rate for Payer: Cofinity Commercial |
$14,919.36
|
| Rate for Payer: Cofinity Commercial |
$12,143.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,143.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,878.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$203.58
|
| Rate for Payer: Healthscope Commercial |
$15,613.28
|
| Rate for Payer: Mclaren Medicaid |
$109.12
|
| Rate for Payer: Mclaren Medicare |
$203.58
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$213.76
|
| Rate for Payer: Meridian Medicaid |
$114.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$234.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,745.88
|
| Rate for Payer: PACE Medicare |
$193.40
|
| Rate for Payer: PACE SWMI |
$203.58
|
| Rate for Payer: PHP Commercial |
$14,745.88
|
| Rate for Payer: PHP Medicare Advantage |
$203.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$109.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,276.26
|
| Rate for Payer: Priority Health Medicare |
$203.58
|
| Rate for Payer: Priority Health SBD |
$10,929.30
|
| Rate for Payer: Railroad Medicare Medicare |
$203.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$573.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$203.58
|
| Rate for Payer: UHC Medicare Advantage |
$203.58
|
| Rate for Payer: UHCCP Medicaid |
$114.62
|
| Rate for Payer: VA VA |
$203.58
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE
|
Facility
|
IP
|
$17,348.09
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
161514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,929.30 |
| Max. Negotiated Rate |
$15,613.28 |
| Rate for Payer: Aetna Commercial |
$14,745.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,276.26
|
| Rate for Payer: Cash Price |
$13,878.47
|
| Rate for Payer: Cofinity Commercial |
$12,143.66
|
| Rate for Payer: Cofinity Commercial |
$14,919.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,143.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,878.47
|
| Rate for Payer: Healthscope Commercial |
$15,613.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,745.88
|
| Rate for Payer: PHP Commercial |
$14,745.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,276.26
|
| Rate for Payer: Priority Health SBD |
$10,929.30
|
|
|
OFATUMUMAB 1,000 MG/50 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26,414.00
|
|
|
Service Code
|
HCPCS J9302
|
| Hospital Charge Code |
153045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.36 |
| Max. Negotiated Rate |
$23,772.60 |
| Rate for Payer: Aetna Commercial |
$22,451.90
|
| Rate for Payer: Aetna Medicare |
$64.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17,169.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$77.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$77.79
|
| Rate for Payer: BCBS Complete |
$35.02
|
| Rate for Payer: BCBS MAPPO |
$62.23
|
| Rate for Payer: BCN Medicare Advantage |
$62.23
|
| Rate for Payer: Cash Price |
$21,131.20
|
| Rate for Payer: Cash Price |
$21,131.20
|
| Rate for Payer: Cofinity Commercial |
$18,489.80
|
| Rate for Payer: Cofinity Commercial |
$22,716.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$18,489.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21,131.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.23
|
| Rate for Payer: Healthscope Commercial |
$23,772.60
|
| Rate for Payer: Mclaren Medicaid |
$33.36
|
| Rate for Payer: Mclaren Medicare |
$62.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.34
|
| Rate for Payer: Meridian Medicaid |
$35.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22,451.90
|
| Rate for Payer: PACE Medicare |
$59.12
|
| Rate for Payer: PACE SWMI |
$62.23
|
| Rate for Payer: PHP Commercial |
$22,451.90
|
| Rate for Payer: PHP Medicare Advantage |
$62.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$33.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17,169.10
|
| Rate for Payer: Priority Health Medicare |
$62.23
|
| Rate for Payer: Priority Health SBD |
$16,640.82
|
| Rate for Payer: Railroad Medicare Medicare |
$62.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.23
|
| Rate for Payer: UHC Medicare Advantage |
$62.23
|
| Rate for Payer: UHCCP Medicaid |
$35.04
|
| Rate for Payer: VA VA |
$62.23
|
|
|
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,641.40
|
|
|
Service Code
|
HCPCS J9302
|
| Hospital Charge Code |
100265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,664.08 |
| Max. Negotiated Rate |
$2,377.26 |
| Rate for Payer: Aetna Commercial |
$2,245.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,716.91
|
| Rate for Payer: Cash Price |
$2,113.12
|
| Rate for Payer: Cofinity Commercial |
$1,848.98
|
| Rate for Payer: Cofinity Commercial |
$2,271.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,848.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,113.12
|
| Rate for Payer: Healthscope Commercial |
$2,377.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,245.19
|
| Rate for Payer: PHP Commercial |
$2,245.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,716.91
|
| Rate for Payer: Priority Health SBD |
$1,664.08
|
|
|
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,641.40
|
|
|
Service Code
|
HCPCS J9302
|
| Hospital Charge Code |
100265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.36 |
| Max. Negotiated Rate |
$2,377.26 |
| Rate for Payer: Aetna Commercial |
$2,245.19
|
| Rate for Payer: Aetna Medicare |
$64.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,716.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$77.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$77.79
|
| Rate for Payer: BCBS Complete |
$35.02
|
| Rate for Payer: BCBS MAPPO |
$62.23
|
| Rate for Payer: BCN Medicare Advantage |
$62.23
|
| Rate for Payer: Cash Price |
$2,113.12
|
| Rate for Payer: Cash Price |
$2,113.12
|
| Rate for Payer: Cofinity Commercial |
$1,848.98
|
| Rate for Payer: Cofinity Commercial |
$2,271.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,848.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,113.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.23
|
| Rate for Payer: Healthscope Commercial |
$2,377.26
|
| Rate for Payer: Mclaren Medicaid |
$33.36
|
| Rate for Payer: Mclaren Medicare |
$62.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.34
|
| Rate for Payer: Meridian Medicaid |
$35.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,245.19
|
| Rate for Payer: PACE Medicare |
$59.12
|
| Rate for Payer: PACE SWMI |
$62.23
|
| Rate for Payer: PHP Commercial |
$2,245.19
|
| Rate for Payer: PHP Medicare Advantage |
$62.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$33.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,716.91
|
| Rate for Payer: Priority Health Medicare |
$62.23
|
| Rate for Payer: Priority Health SBD |
$1,664.08
|
| Rate for Payer: Railroad Medicare Medicare |
$62.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.23
|
| Rate for Payer: UHC Medicare Advantage |
$62.23
|
| Rate for Payer: UHCCP Medicaid |
$35.04
|
| Rate for Payer: VA VA |
$62.23
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$403.83
|
|
|
Service Code
|
NDC 11980077905
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.41 |
| Max. Negotiated Rate |
$363.45 |
| Rate for Payer: Aetna Commercial |
$343.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.49
|
| Rate for Payer: Cash Price |
$323.06
|
| Rate for Payer: Cofinity Commercial |
$282.68
|
| Rate for Payer: Cofinity Commercial |
$347.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.06
|
| Rate for Payer: Healthscope Commercial |
$363.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.26
|
| Rate for Payer: PHP Commercial |
$343.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.49
|
| Rate for Payer: Priority Health SBD |
$254.41
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$31.75
|
|
|
Service Code
|
NDC 17478071310
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$28.57 |
| Rate for Payer: Aetna Commercial |
$26.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.64
|
| Rate for Payer: Cash Price |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$22.23
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.40
|
| Rate for Payer: Healthscope Commercial |
$28.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.99
|
| Rate for Payer: PHP Commercial |
$26.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.64
|
| Rate for Payer: Priority Health SBD |
$20.00
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$31.75
|
|
|
Service Code
|
NDC 17478071310
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$28.57 |
| Rate for Payer: Aetna Commercial |
$26.99
|
| Rate for Payer: Aetna Medicare |
$15.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.64
|
| Rate for Payer: BCBS Complete |
$12.70
|
| Rate for Payer: Cash Price |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$22.23
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.40
|
| Rate for Payer: Healthscope Commercial |
$28.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.99
|
| Rate for Payer: PHP Commercial |
$26.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.64
|
| Rate for Payer: Priority Health SBD |
$20.00
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$66.54
|
|
|
Service Code
|
NDC 24208043405
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.92 |
| Max. Negotiated Rate |
$59.89 |
| Rate for Payer: Aetna Commercial |
$56.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.25
|
| Rate for Payer: Cash Price |
$53.23
|
| Rate for Payer: Cofinity Commercial |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$57.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.23
|
| Rate for Payer: Healthscope Commercial |
$59.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.56
|
| Rate for Payer: PHP Commercial |
$56.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.25
|
| Rate for Payer: Priority Health SBD |
$41.92
|
|
