|
BARIUM SULFATE (BULK) POWDER
|
Facility
|
OP
|
$681.00
|
|
|
Service Code
|
NDC 00395020001
|
| Hospital Charge Code |
916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$272.40 |
| Max. Negotiated Rate |
$612.90 |
| Rate for Payer: Aetna Commercial |
$578.85
|
| Rate for Payer: Aetna Medicare |
$340.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.65
|
| Rate for Payer: BCBS Complete |
$272.40
|
| Rate for Payer: Cash Price |
$544.80
|
| Rate for Payer: Cofinity Commercial |
$476.70
|
| Rate for Payer: Cofinity Commercial |
$585.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$476.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$544.80
|
| Rate for Payer: Healthscope Commercial |
$612.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$578.85
|
| Rate for Payer: PHP Commercial |
$578.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$442.65
|
| Rate for Payer: Priority Health SBD |
$429.03
|
|
|
BARIUM SULFATE (BULK) POWDER
|
Facility
|
IP
|
$681.00
|
|
|
Service Code
|
NDC 00395020001
|
| Hospital Charge Code |
916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$429.03 |
| Max. Negotiated Rate |
$612.90 |
| Rate for Payer: Aetna Commercial |
$578.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.65
|
| Rate for Payer: Cash Price |
$544.80
|
| Rate for Payer: Cofinity Commercial |
$476.70
|
| Rate for Payer: Cofinity Commercial |
$585.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$476.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$544.80
|
| Rate for Payer: Healthscope Commercial |
$612.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$578.85
|
| Rate for Payer: PHP Commercial |
$578.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$442.65
|
| Rate for Payer: Priority Health SBD |
$429.03
|
|
|
BBC JOINT COCKTAIL COMPOUND (INTRA-OP)
|
Facility
|
OP
|
$283.83
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
300231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$241.26
|
| Rate for Payer: Aetna Medicare |
$141.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.49
|
| Rate for Payer: BCBS Complete |
$113.53
|
| Rate for Payer: BCBS Trust/PPO |
$0.17
|
| Rate for Payer: BCN Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cofinity Commercial |
$198.68
|
| Rate for Payer: Cofinity Commercial |
$244.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.06
|
| Rate for Payer: Healthscope Commercial |
$255.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.26
|
| Rate for Payer: PHP Commercial |
$241.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.49
|
| Rate for Payer: Priority Health SBD |
$178.81
|
|
|
BBC JOINT COCKTAIL COMPOUND (INTRA-OP)
|
Facility
|
IP
|
$283.83
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
300231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.81 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$241.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.49
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cofinity Commercial |
$198.68
|
| Rate for Payer: Cofinity Commercial |
$244.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.06
|
| Rate for Payer: Healthscope Commercial |
$255.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.26
|
| Rate for Payer: PHP Commercial |
$241.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.49
|
| Rate for Payer: Priority Health SBD |
$178.81
|
|
|
BBC JOINT COCKTAIL COMPOUND WITHOUT KETOROLAC (INTRA-OP)
|
Facility
|
OP
|
$283.83
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
300230
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$241.26
|
| Rate for Payer: Aetna Medicare |
$141.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.49
|
| Rate for Payer: BCBS Complete |
$113.53
|
| Rate for Payer: BCBS Trust/PPO |
$0.17
|
| Rate for Payer: BCN Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cofinity Commercial |
$198.68
|
| Rate for Payer: Cofinity Commercial |
$244.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.06
|
| Rate for Payer: Healthscope Commercial |
$255.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.26
|
| Rate for Payer: PHP Commercial |
$241.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.49
|
| Rate for Payer: Priority Health SBD |
$178.81
|
|
|
BBC JOINT COCKTAIL COMPOUND WITHOUT KETOROLAC (INTRA-OP)
|
Facility
|
IP
|
$283.83
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
300230
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.81 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$241.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.49
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cofinity Commercial |
$198.68
|
| Rate for Payer: Cofinity Commercial |
$244.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.06
|
| Rate for Payer: Healthscope Commercial |
$255.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.26
|
| Rate for Payer: PHP Commercial |
$241.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.49
|
| Rate for Payer: Priority Health SBD |
$178.81
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION
|
Facility
|
OP
|
$488.06
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
116210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$439.25 |
| Rate for Payer: Aetna Commercial |
$414.85
|
| Rate for Payer: Aetna Medicare |
$244.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$317.24
|
| Rate for Payer: BCBS Complete |
$195.22
|
| Rate for Payer: BCBS Trust/PPO |
$8.46
|
| Rate for Payer: BCN Commercial |
$8.46
|
| Rate for Payer: Cash Price |
$390.45
|
| Rate for Payer: Cash Price |
$390.45
|
| Rate for Payer: Cofinity Commercial |
$341.64
|
| Rate for Payer: Cofinity Commercial |
$419.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$341.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.45
|
| Rate for Payer: Healthscope Commercial |
$439.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$414.85
|
| Rate for Payer: PHP Commercial |
$414.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.24
|
| Rate for Payer: Priority Health SBD |
$307.48
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION
|
Facility
|
IP
|
$488.06
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
116210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$307.48 |
| Max. Negotiated Rate |
$439.25 |
| Rate for Payer: Aetna Commercial |
$414.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$317.24
|
| Rate for Payer: Cash Price |
$390.45
|
| Rate for Payer: Cofinity Commercial |
$341.64
|
| Rate for Payer: Cofinity Commercial |
$419.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$341.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.45
|
| Rate for Payer: Healthscope Commercial |
$439.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$414.85
|
| Rate for Payer: PHP Commercial |
$414.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.24
|
| Rate for Payer: Priority Health SBD |
$307.48
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,948.45
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
152968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,857.52 |
| Max. Negotiated Rate |
$2,653.60 |
| Rate for Payer: Aetna Commercial |
$2,506.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,916.49
|
| Rate for Payer: Cash Price |
$2,358.76
|
| Rate for Payer: Cofinity Commercial |
$2,063.92
|
| Rate for Payer: Cofinity Commercial |
$2,535.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,063.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,358.76
|
| Rate for Payer: Healthscope Commercial |
$2,653.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,506.18
|
| Rate for Payer: PHP Commercial |
$2,506.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,916.49
|
| Rate for Payer: Priority Health SBD |
$1,857.52
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,948.45
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
152968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$2,653.60 |
| Rate for Payer: Aetna Commercial |
$2,506.18
|
| Rate for Payer: Aetna Medicare |
$4.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,916.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.91
|
| Rate for Payer: BCBS Complete |
$2.21
|
| Rate for Payer: BCBS MAPPO |
$3.93
|
| Rate for Payer: BCBS Trust/PPO |
$11.09
|
| Rate for Payer: BCN Commercial |
$11.09
|
| Rate for Payer: BCN Medicare Advantage |
$3.93
|
| Rate for Payer: Cash Price |
$2,358.76
|
| Rate for Payer: Cash Price |
$2,358.76
|
| Rate for Payer: Cofinity Commercial |
$2,535.67
|
| Rate for Payer: Cofinity Commercial |
$2,063.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,063.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,358.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.93
|
| Rate for Payer: Healthscope Commercial |
$2,653.60
|
| Rate for Payer: Mclaren Medicaid |
$2.11
|
| Rate for Payer: Mclaren Medicare |
$3.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.13
|
| Rate for Payer: Meridian Medicaid |
$2.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,506.18
|
| Rate for Payer: Nomi Health Commercial |
$11.79
|
| Rate for Payer: PACE Medicare |
$3.73
|
| Rate for Payer: PACE SWMI |
$3.93
|
| Rate for Payer: PHP Commercial |
$2,506.18
|
| Rate for Payer: PHP Medicare Advantage |
$3.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,916.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.98
|
| Rate for Payer: Priority Health Medicare |
$3.93
|
| Rate for Payer: Priority Health Narrow Network |
$8.78
|
| Rate for Payer: Priority Health SBD |
$1,857.52
|
| Rate for Payer: Railroad Medicare Medicare |
$3.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.93
|
| Rate for Payer: UHC Medicare Advantage |
$3.93
|
| Rate for Payer: UHCCP Medicaid |
$2.21
|
| Rate for Payer: VA VA |
$3.93
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,031.20
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
152250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,279.66 |
| Max. Negotiated Rate |
$1,828.08 |
| Rate for Payer: Aetna Commercial |
$1,726.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,320.28
|
| Rate for Payer: Cash Price |
$1,624.96
|
| Rate for Payer: Cofinity Commercial |
$1,421.84
|
| Rate for Payer: Cofinity Commercial |
$1,746.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,421.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,624.96
|
| Rate for Payer: Healthscope Commercial |
$1,828.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,726.52
|
| Rate for Payer: PHP Commercial |
$1,726.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,320.28
|
| Rate for Payer: Priority Health SBD |
$1,279.66
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,031.20
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
152250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$1,828.08 |
| Rate for Payer: Aetna Commercial |
$1,726.52
|
| Rate for Payer: Aetna Medicare |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,320.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$68.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$68.64
|
| Rate for Payer: BCBS Complete |
$30.90
|
| Rate for Payer: BCBS MAPPO |
$54.91
|
| Rate for Payer: BCBS Trust/PPO |
$155.09
|
| Rate for Payer: BCN Commercial |
$155.09
|
| Rate for Payer: BCN Medicare Advantage |
$54.91
|
| Rate for Payer: Cash Price |
$1,624.96
|
| Rate for Payer: Cash Price |
$1,624.96
|
| Rate for Payer: Cofinity Commercial |
$1,746.83
|
| Rate for Payer: Cofinity Commercial |
$1,421.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,421.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,624.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.91
|
| Rate for Payer: Healthscope Commercial |
$1,828.08
|
| Rate for Payer: Mclaren Medicaid |
$29.43
|
| Rate for Payer: Mclaren Medicare |
$54.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$57.66
|
| Rate for Payer: Meridian Medicaid |
$30.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,726.52
|
| Rate for Payer: Nomi Health Commercial |
$164.73
|
| Rate for Payer: PACE Medicare |
$52.16
|
| Rate for Payer: PACE SWMI |
$54.91
|
| Rate for Payer: PHP Commercial |
$1,726.52
|
| Rate for Payer: PHP Medicare Advantage |
$54.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,320.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$155.85
|
| Rate for Payer: Priority Health Medicare |
$54.91
|
| Rate for Payer: Priority Health Narrow Network |
$124.68
|
| Rate for Payer: Priority Health SBD |
$1,279.66
|
| Rate for Payer: Railroad Medicare Medicare |
$54.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$54.91
|
| Rate for Payer: UHC Medicare Advantage |
$54.91
|
| Rate for Payer: UHCCP Medicaid |
$30.91
|
| Rate for Payer: VA VA |
$54.91
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,500.82
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
152251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,465.52 |
| Max. Negotiated Rate |
$4,950.74 |
| Rate for Payer: Aetna Commercial |
$4,675.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,575.53
|
| Rate for Payer: Cash Price |
$4,400.66
|
| Rate for Payer: Cofinity Commercial |
$3,850.57
|
| Rate for Payer: Cofinity Commercial |
$4,730.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,850.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,400.66
|
| Rate for Payer: Healthscope Commercial |
$4,950.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,675.70
|
| Rate for Payer: PHP Commercial |
$4,675.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,575.53
|
| Rate for Payer: Priority Health SBD |
$3,465.52
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,500.82
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
152251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$4,950.74 |
| Rate for Payer: Aetna Commercial |
$4,675.70
|
| Rate for Payer: Aetna Medicare |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,575.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$68.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$68.64
|
| Rate for Payer: BCBS Complete |
$30.90
|
| Rate for Payer: BCBS MAPPO |
$54.91
|
| Rate for Payer: BCBS Trust/PPO |
$155.09
|
| Rate for Payer: BCN Commercial |
$155.09
|
| Rate for Payer: BCN Medicare Advantage |
$54.91
|
| Rate for Payer: Cash Price |
$4,400.66
|
| Rate for Payer: Cash Price |
$4,400.66
|
| Rate for Payer: Cofinity Commercial |
$4,730.71
|
| Rate for Payer: Cofinity Commercial |
$3,850.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,850.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,400.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.91
|
| Rate for Payer: Healthscope Commercial |
$4,950.74
|
| Rate for Payer: Mclaren Medicaid |
$29.43
|
| Rate for Payer: Mclaren Medicare |
$54.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$57.66
|
| Rate for Payer: Meridian Medicaid |
$30.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,675.70
|
| Rate for Payer: Nomi Health Commercial |
$164.73
|
| Rate for Payer: PACE Medicare |
$52.16
|
| Rate for Payer: PACE SWMI |
$54.91
|
| Rate for Payer: PHP Commercial |
$4,675.70
|
| Rate for Payer: PHP Medicare Advantage |
$54.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,575.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$155.85
|
| Rate for Payer: Priority Health Medicare |
$54.91
|
| Rate for Payer: Priority Health Narrow Network |
$124.68
|
| Rate for Payer: Priority Health SBD |
$3,465.52
|
| Rate for Payer: Railroad Medicare Medicare |
$54.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$54.91
|
| Rate for Payer: UHC Medicare Advantage |
$54.91
|
| Rate for Payer: UHCCP Medicaid |
$30.91
|
| Rate for Payer: VA VA |
$54.91
|
|
|
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$9,530.12
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
176654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,003.98 |
| Max. Negotiated Rate |
$8,577.11 |
| Rate for Payer: Aetna Commercial |
$8,100.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,194.58
|
| Rate for Payer: Cash Price |
$7,624.10
|
| Rate for Payer: Cofinity Commercial |
$6,671.08
|
| Rate for Payer: Cofinity Commercial |
$8,195.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,671.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,624.10
|
| Rate for Payer: Healthscope Commercial |
$8,577.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,100.60
|
| Rate for Payer: PHP Commercial |
$8,100.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,194.58
|
| Rate for Payer: Priority Health SBD |
$6,003.98
|
|
|
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$9,269.97
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
176654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.21 |
| Max. Negotiated Rate |
$8,342.97 |
| Rate for Payer: Aetna Commercial |
$7,879.47
|
| Rate for Payer: Aetna Commercial |
$8,100.60
|
| Rate for Payer: Aetna Medicare |
$13.99
|
| Rate for Payer: Aetna Medicare |
$13.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,194.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,025.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.81
|
| Rate for Payer: BCBS Complete |
$7.57
|
| Rate for Payer: BCBS Complete |
$7.57
|
| Rate for Payer: BCBS MAPPO |
$13.45
|
| Rate for Payer: BCBS MAPPO |
$13.45
|
| Rate for Payer: BCBS Trust/PPO |
$37.29
|
| Rate for Payer: BCBS Trust/PPO |
$37.29
|
| Rate for Payer: BCN Commercial |
$37.29
|
| Rate for Payer: BCN Commercial |
$37.29
|
| Rate for Payer: BCN Medicare Advantage |
$13.45
|
| Rate for Payer: BCN Medicare Advantage |
$13.45
|
| Rate for Payer: Cash Price |
$7,624.10
|
| Rate for Payer: Cash Price |
$7,624.10
|
| Rate for Payer: Cash Price |
$7,415.98
|
| Rate for Payer: Cash Price |
$7,415.98
|
| Rate for Payer: Cofinity Commercial |
$8,195.90
|
| Rate for Payer: Cofinity Commercial |
$6,671.08
|
| Rate for Payer: Cofinity Commercial |
$6,488.98
|
| Rate for Payer: Cofinity Commercial |
$7,972.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,488.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,671.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,624.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,415.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.45
|
| Rate for Payer: Healthscope Commercial |
$8,342.97
|
| Rate for Payer: Healthscope Commercial |
$8,577.11
|
| Rate for Payer: Mclaren Medicaid |
$7.21
|
| Rate for Payer: Mclaren Medicaid |
$7.21
|
| Rate for Payer: Mclaren Medicare |
$13.45
|
| Rate for Payer: Mclaren Medicare |
$13.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.12
|
| Rate for Payer: Meridian Medicaid |
$7.57
|
| Rate for Payer: Meridian Medicaid |
$7.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,100.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,879.47
|
| Rate for Payer: Nomi Health Commercial |
$40.35
|
| Rate for Payer: Nomi Health Commercial |
$40.35
|
| Rate for Payer: PACE Medicare |
$12.78
|
| Rate for Payer: PACE Medicare |
$12.78
|
| Rate for Payer: PACE SWMI |
$13.45
|
| Rate for Payer: PACE SWMI |
$13.45
|
| Rate for Payer: PHP Commercial |
$8,100.60
|
| Rate for Payer: PHP Commercial |
$7,879.47
|
| Rate for Payer: PHP Medicare Advantage |
$13.45
|
| Rate for Payer: PHP Medicare Advantage |
$13.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,194.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,025.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.26
|
| Rate for Payer: Priority Health Medicare |
$13.45
|
| Rate for Payer: Priority Health Medicare |
$13.45
|
| Rate for Payer: Priority Health Narrow Network |
$29.81
|
| Rate for Payer: Priority Health Narrow Network |
$29.81
|
| Rate for Payer: Priority Health SBD |
$5,840.08
|
| Rate for Payer: Priority Health SBD |
$6,003.98
|
| Rate for Payer: Railroad Medicare Medicare |
$13.45
|
| Rate for Payer: Railroad Medicare Medicare |
$13.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.45
|
| Rate for Payer: UHC Medicare Advantage |
$13.45
|
| Rate for Payer: UHC Medicare Advantage |
$13.45
|
| Rate for Payer: UHCCP Medicaid |
$7.57
|
| Rate for Payer: UHCCP Medicaid |
$7.57
|
| Rate for Payer: VA VA |
$13.45
|
| Rate for Payer: VA VA |
$13.45
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$19,146.17
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,062.09 |
| Max. Negotiated Rate |
$17,231.55 |
| Rate for Payer: Aetna Commercial |
$16,274.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,445.01
|
| Rate for Payer: Cash Price |
$15,316.94
|
| Rate for Payer: Cofinity Commercial |
$13,402.32
|
| Rate for Payer: Cofinity Commercial |
$16,465.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,402.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,316.94
|
| Rate for Payer: Healthscope Commercial |
$17,231.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,274.24
|
| Rate for Payer: PHP Commercial |
$16,274.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,445.01
|
| Rate for Payer: Priority Health SBD |
$12,062.09
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$19,146.17
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$17,231.55 |
| Rate for Payer: Aetna Commercial |
$16,274.24
|
| Rate for Payer: Aetna Medicare |
$172.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,445.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$207.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$207.36
|
| Rate for Payer: BCBS Complete |
$93.36
|
| Rate for Payer: BCBS MAPPO |
$165.89
|
| Rate for Payer: BCBS Trust/PPO |
$472.57
|
| Rate for Payer: BCN Commercial |
$472.57
|
| Rate for Payer: BCN Medicare Advantage |
$165.89
|
| Rate for Payer: Cash Price |
$15,316.94
|
| Rate for Payer: Cash Price |
$15,316.94
|
| Rate for Payer: Cofinity Commercial |
$16,465.71
|
| Rate for Payer: Cofinity Commercial |
$13,402.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,402.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,316.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$165.89
|
| Rate for Payer: Healthscope Commercial |
$17,231.55
|
| Rate for Payer: Mclaren Medicaid |
$88.92
|
| Rate for Payer: Mclaren Medicare |
$165.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$174.18
|
| Rate for Payer: Meridian Medicaid |
$93.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,274.24
|
| Rate for Payer: Nomi Health Commercial |
$497.67
|
| Rate for Payer: PACE Medicare |
$157.60
|
| Rate for Payer: PACE SWMI |
$165.89
|
| Rate for Payer: PHP Commercial |
$16,274.24
|
| Rate for Payer: PHP Medicare Advantage |
$165.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$88.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,445.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$481.49
|
| Rate for Payer: Priority Health Medicare |
$165.89
|
| Rate for Payer: Priority Health Narrow Network |
$385.19
|
| Rate for Payer: Priority Health SBD |
$12,062.09
|
| Rate for Payer: Railroad Medicare Medicare |
$165.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$466.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$165.89
|
| Rate for Payer: UHC Medicare Advantage |
$165.89
|
| Rate for Payer: UHCCP Medicaid |
$93.40
|
| Rate for Payer: VA VA |
$165.89
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$129.14
|
|
|
Service Code
|
NDC 00283067960
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.66 |
| Max. Negotiated Rate |
$116.23 |
| Rate for Payer: Aetna Commercial |
$109.77
|
| Rate for Payer: Aetna Medicare |
$64.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.94
|
| Rate for Payer: BCBS Complete |
$51.66
|
| Rate for Payer: Cash Price |
$103.31
|
| Rate for Payer: Cofinity Commercial |
$111.06
|
| Rate for Payer: Cofinity Commercial |
$90.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.31
|
| Rate for Payer: Healthscope Commercial |
$116.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.77
|
| Rate for Payer: PHP Commercial |
$109.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.94
|
| Rate for Payer: Priority Health SBD |
$81.36
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$100.09
|
|
|
Service Code
|
NDC 00283067902
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.06 |
| Max. Negotiated Rate |
$90.08 |
| Rate for Payer: Aetna Commercial |
$85.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.06
|
| Rate for Payer: Cash Price |
$80.07
|
| Rate for Payer: Cofinity Commercial |
$70.06
|
| Rate for Payer: Cofinity Commercial |
$86.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.07
|
| Rate for Payer: Healthscope Commercial |
$90.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.08
|
| Rate for Payer: PHP Commercial |
$85.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.06
|
| Rate for Payer: Priority Health SBD |
$63.06
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$100.09
|
|
|
Service Code
|
NDC 00283067902
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.04 |
| Max. Negotiated Rate |
$90.08 |
| Rate for Payer: Aetna Commercial |
$85.08
|
| Rate for Payer: Aetna Medicare |
$50.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.06
|
| Rate for Payer: BCBS Complete |
$40.04
|
| Rate for Payer: Cash Price |
$80.07
|
| Rate for Payer: Cofinity Commercial |
$70.06
|
| Rate for Payer: Cofinity Commercial |
$86.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.07
|
| Rate for Payer: Healthscope Commercial |
$90.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.08
|
| Rate for Payer: PHP Commercial |
$85.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.06
|
| Rate for Payer: Priority Health SBD |
$63.06
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$129.14
|
|
|
Service Code
|
NDC 00283067960
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$116.23 |
| Rate for Payer: Aetna Commercial |
$109.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.94
|
| Rate for Payer: Cash Price |
$103.31
|
| Rate for Payer: Cofinity Commercial |
$111.06
|
| Rate for Payer: Cofinity Commercial |
$90.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.31
|
| Rate for Payer: Healthscope Commercial |
$116.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.77
|
| Rate for Payer: PHP Commercial |
$109.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.94
|
| Rate for Payer: Priority Health SBD |
$81.36
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$199.55
|
|
|
Service Code
|
NDC 00699310002
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.72 |
| Max. Negotiated Rate |
$179.60 |
| Rate for Payer: Aetna Commercial |
$169.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.71
|
| Rate for Payer: Cash Price |
$159.64
|
| Rate for Payer: Cofinity Commercial |
$139.68
|
| Rate for Payer: Cofinity Commercial |
$171.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.64
|
| Rate for Payer: Healthscope Commercial |
$179.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.62
|
| Rate for Payer: PHP Commercial |
$169.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.71
|
| Rate for Payer: Priority Health SBD |
$125.72
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$199.55
|
|
|
Service Code
|
NDC 00699310002
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.82 |
| Max. Negotiated Rate |
$179.60 |
| Rate for Payer: Aetna Commercial |
$169.62
|
| Rate for Payer: Aetna Medicare |
$99.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.71
|
| Rate for Payer: BCBS Complete |
$79.82
|
| Rate for Payer: Cash Price |
$159.64
|
| Rate for Payer: Cofinity Commercial |
$139.68
|
| Rate for Payer: Cofinity Commercial |
$171.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.64
|
| Rate for Payer: Healthscope Commercial |
$179.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.62
|
| Rate for Payer: PHP Commercial |
$169.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.71
|
| Rate for Payer: Priority Health SBD |
$125.72
|
|
|
BENZOCAINE 20 % TOPICAL AEROSOL
|
Facility
|
IP
|
$59.51
|
|
|
Service Code
|
NDC 63736037882
|
| Hospital Charge Code |
108881
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.49 |
| Max. Negotiated Rate |
$53.56 |
| Rate for Payer: Aetna Commercial |
$50.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.68
|
| Rate for Payer: Cash Price |
$47.61
|
| Rate for Payer: Cofinity Commercial |
$41.66
|
| Rate for Payer: Cofinity Commercial |
$51.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.61
|
| Rate for Payer: Healthscope Commercial |
$53.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.58
|
| Rate for Payer: PHP Commercial |
$50.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.68
|
| Rate for Payer: Priority Health SBD |
$37.49
|
|
