|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.97
|
|
|
Service Code
|
NDC 65219-257-01
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.62
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.28
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$34.71
|
|
|
Service Code
|
NDC 70121-1637-5
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.87 |
| Max. Negotiated Rate |
$31.24 |
| Rate for Payer: Aetna Commercial |
$29.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.56
|
| Rate for Payer: Cash Price |
$27.77
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Commercial |
$29.85
|
| Rate for Payer: Healthscope Commercial |
$31.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.50
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.30
|
| Rate for Payer: Priority Health SBD |
$21.87
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.97
|
|
|
Service Code
|
NDC 65219-257-00
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.62
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.28
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.11
|
|
|
Service Code
|
NDC 55150-373-01
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$25.30 |
| Rate for Payer: Aetna Commercial |
$23.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.27
|
| Rate for Payer: Cash Price |
$22.49
|
| Rate for Payer: Cofinity Commercial |
$19.68
|
| Rate for Payer: Cofinity Commercial |
$24.17
|
| Rate for Payer: Healthscope Commercial |
$25.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.89
|
| Rate for Payer: PHP Commercial |
$23.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.68
|
| Rate for Payer: Priority Health SBD |
$17.71
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$41.39
|
|
|
Service Code
|
NDC 0641-6238-01
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cofinity Commercial |
$28.97
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.18
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.97
|
| Rate for Payer: Priority Health SBD |
$26.08
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$41.39
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
179024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna Commercial |
$23.89
|
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cash Price |
$22.49
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$28.97
|
| Rate for Payer: Cofinity Commercial |
$19.68
|
| Rate for Payer: Cofinity Commercial |
$24.17
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Healthscope Commercial |
$25.30
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.18
|
| Rate for Payer: PHP Commercial |
$23.89
|
| Rate for Payer: PHP Commercial |
$15.94
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.97
|
| Rate for Payer: Priority Health SBD |
$17.71
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: Priority Health SBD |
$18.25
|
| Rate for Payer: Priority Health SBD |
$26.08
|
|
|
EPIDIDYMECTOMY; UNILATERAL
|
Facility
|
OP
|
$9,573.02
|
|
|
Service Code
|
CPT 54860
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$412.90 |
| Max. Negotiated Rate |
$9,573.02 |
| Rate for Payer: Aetna Medicare |
$3,226.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,877.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,877.45
|
| Rate for Payer: BCBS Complete |
$1,781.77
|
| Rate for Payer: BCBS MAPPO |
$3,101.96
|
| Rate for Payer: BCBS Trust/PPO |
$888.39
|
| Rate for Payer: BCN Medicare Advantage |
$3,101.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,101.96
|
| Rate for Payer: Mclaren Medicaid |
$1,696.77
|
| Rate for Payer: Mclaren Medicare |
$3,101.96
|
| Rate for Payer: Meridian Medicaid |
$1,781.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,257.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,567.25
|
| Rate for Payer: PACE Medicare |
$2,946.86
|
| Rate for Payer: PACE SWMI |
$3,101.96
|
| Rate for Payer: PHP Medicare Advantage |
$3,101.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,573.02
|
| Rate for Payer: Priority Health Medicare |
$3,101.96
|
| Rate for Payer: Priority Health Narrow Network |
$7,658.42
|
| Rate for Payer: Railroad Medicare Medicare |
$3,101.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$454.19
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,101.96
|
| Rate for Payer: UHC Exchange |
$412.90
|
| Rate for Payer: UHC Medicare Advantage |
$3,195.02
|
| Rate for Payer: VA VA |
$3,101.96
|
|
|
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE
|
Facility
|
IP
|
$39.16
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
2848
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.67 |
| Max. Negotiated Rate |
$35.24 |
| Rate for Payer: Aetna Commercial |
$33.29
|
| Rate for Payer: Aetna Commercial |
$27.77
|
| Rate for Payer: Aetna Commercial |
$30.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.24
|
| Rate for Payer: Cash Price |
$26.14
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cash Price |
$31.33
|
| Rate for Payer: Cofinity Commercial |
$28.10
|
| Rate for Payer: Cofinity Commercial |
$33.68
|
| Rate for Payer: Cofinity Commercial |
$22.87
|
| Rate for Payer: Cofinity Commercial |
$27.41
|
| Rate for Payer: Cofinity Commercial |
$24.92
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Healthscope Commercial |
$35.24
|
| Rate for Payer: Healthscope Commercial |
$29.40
|
| Rate for Payer: Healthscope Commercial |
$32.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.29
|
| Rate for Payer: PHP Commercial |
$30.26
|
| Rate for Payer: PHP Commercial |
$27.77
|
| Rate for Payer: PHP Commercial |
$33.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.92
|
| Rate for Payer: Priority Health SBD |
$24.67
|
| Rate for Payer: Priority Health SBD |
$20.58
|
| Rate for Payer: Priority Health SBD |
$22.43
|
|
|
EPINEPHRINE 0.1MG/ML-LIDOCAINE 1% (1:3) TOPICAL ENT SYRINGE
|
Facility
|
IP
|
$20.30
|
|
|
Service Code
|
NDC 9900-0009-74
|
| Hospital Charge Code |
180619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.79 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Aetna Commercial |
$17.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.20
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cofinity Commercial |
$14.21
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Healthscope Commercial |
$18.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.26
|
| Rate for Payer: PHP Commercial |
$17.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.21
|
| Rate for Payer: Priority Health SBD |
$12.79
|
|
|
EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR
|
Facility
|
IP
|
$403.09
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
100491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$253.95 |
| Max. Negotiated Rate |
$362.78 |
| Rate for Payer: Aetna Commercial |
$342.63
|
| Rate for Payer: Aetna Commercial |
$399.90
|
| Rate for Payer: Aetna Commercial |
$685.24
|
| Rate for Payer: Aetna Commercial |
$799.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$611.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$524.01
|
| Rate for Payer: Cash Price |
$644.94
|
| Rate for Payer: Cash Price |
$322.47
|
| Rate for Payer: Cash Price |
$376.38
|
| Rate for Payer: Cash Price |
$752.74
|
| Rate for Payer: Cofinity Commercial |
$693.31
|
| Rate for Payer: Cofinity Commercial |
$564.32
|
| Rate for Payer: Cofinity Commercial |
$809.20
|
| Rate for Payer: Cofinity Commercial |
$658.65
|
| Rate for Payer: Cofinity Commercial |
$346.66
|
| Rate for Payer: Cofinity Commercial |
$404.60
|
| Rate for Payer: Cofinity Commercial |
$282.16
|
| Rate for Payer: Cofinity Commercial |
$329.33
|
| Rate for Payer: Healthscope Commercial |
$846.84
|
| Rate for Payer: Healthscope Commercial |
$423.42
|
| Rate for Payer: Healthscope Commercial |
$725.55
|
| Rate for Payer: Healthscope Commercial |
$362.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$685.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$799.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$399.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$342.63
|
| Rate for Payer: PHP Commercial |
$399.90
|
| Rate for Payer: PHP Commercial |
$685.24
|
| Rate for Payer: PHP Commercial |
$342.63
|
| Rate for Payer: PHP Commercial |
$799.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$564.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$658.65
|
| Rate for Payer: Priority Health SBD |
$507.89
|
| Rate for Payer: Priority Health SBD |
$592.79
|
| Rate for Payer: Priority Health SBD |
$296.40
|
| Rate for Payer: Priority Health SBD |
$253.95
|
|
|
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION
|
Facility
|
OP
|
$57.94
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
152715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$52.15 |
| Rate for Payer: Aetna Commercial |
$49.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.66
|
| Rate for Payer: BCBS Complete |
$23.18
|
| Rate for Payer: BCBS Trust/PPO |
$2.21
|
| Rate for Payer: Cash Price |
$46.35
|
| Rate for Payer: Cash Price |
$46.35
|
| Rate for Payer: Cofinity Commercial |
$40.56
|
| Rate for Payer: Cofinity Commercial |
$49.83
|
| Rate for Payer: Healthscope Commercial |
$52.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.25
|
| Rate for Payer: PHP Commercial |
$49.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.56
|
| Rate for Payer: Priority Health SBD |
$36.50
|
|
|
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION
|
Facility
|
IP
|
$57.94
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
152715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.50 |
| Max. Negotiated Rate |
$52.15 |
| Rate for Payer: Aetna Commercial |
$49.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.66
|
| Rate for Payer: Cash Price |
$46.35
|
| Rate for Payer: Cofinity Commercial |
$40.56
|
| Rate for Payer: Cofinity Commercial |
$49.83
|
| Rate for Payer: Healthscope Commercial |
$52.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.25
|
| Rate for Payer: PHP Commercial |
$49.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.56
|
| Rate for Payer: Priority Health SBD |
$36.50
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$561.26
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
2850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$353.59 |
| Max. Negotiated Rate |
$505.13 |
| Rate for Payer: Aetna Commercial |
$477.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$364.82
|
| Rate for Payer: Cash Price |
$449.01
|
| Rate for Payer: Cofinity Commercial |
$392.88
|
| Rate for Payer: Cofinity Commercial |
$482.68
|
| Rate for Payer: Healthscope Commercial |
$505.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$477.07
|
| Rate for Payer: PHP Commercial |
$477.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$392.88
|
| Rate for Payer: Priority Health SBD |
$353.59
|
|
|
EPINEPHRINE 1 MG/ML NASAL SOLUTION
|
Facility
|
IP
|
$812.49
|
|
|
Service Code
|
NDC 42023-103-01
|
| Hospital Charge Code |
19604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$511.87 |
| Max. Negotiated Rate |
$731.24 |
| Rate for Payer: Aetna Commercial |
$690.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$528.12
|
| Rate for Payer: Cash Price |
$649.99
|
| Rate for Payer: Cofinity Commercial |
$568.74
|
| Rate for Payer: Cofinity Commercial |
$698.74
|
| Rate for Payer: Healthscope Commercial |
$731.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$690.62
|
| Rate for Payer: PHP Commercial |
$690.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$568.74
|
| Rate for Payer: Priority Health SBD |
$511.87
|
|
|
EPINEPHRINE 2 MG IN OXYMETAZOLINE SOLN 32 ML
|
Facility
|
IP
|
$37.60
|
|
|
Service Code
|
NDC 9900-0007-92
|
| Hospital Charge Code |
180291
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$33.84 |
| Rate for Payer: Aetna Commercial |
$31.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.44
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cofinity Commercial |
$32.34
|
| Rate for Payer: Cofinity Commercial |
$26.32
|
| Rate for Payer: Healthscope Commercial |
$33.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.96
|
| Rate for Payer: PHP Commercial |
$31.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.32
|
| Rate for Payer: Priority Health SBD |
$23.69
|
|
|
EPINEPHRINE ANAPHYLAXIS KIT
|
Facility
|
IP
|
$62.31
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
181607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.26 |
| Max. Negotiated Rate |
$56.08 |
| Rate for Payer: Aetna Commercial |
$52.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.50
|
| Rate for Payer: Cash Price |
$49.85
|
| Rate for Payer: Cofinity Commercial |
$43.62
|
| Rate for Payer: Cofinity Commercial |
$53.59
|
| Rate for Payer: Healthscope Commercial |
$56.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.96
|
| Rate for Payer: PHP Commercial |
$52.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.62
|
| Rate for Payer: Priority Health SBD |
$39.26
|
|
|
EPINEPHRINE HCL 0.1 MG/ML SYRINGE (CODE)
|
Facility
|
IP
|
$35.60
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
163700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.43 |
| Max. Negotiated Rate |
$32.04 |
| Rate for Payer: Aetna Commercial |
$30.26
|
| Rate for Payer: Aetna Commercial |
$27.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.24
|
| Rate for Payer: Cash Price |
$26.14
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Cofinity Commercial |
$22.87
|
| Rate for Payer: Cofinity Commercial |
$28.10
|
| Rate for Payer: Cofinity Commercial |
$24.92
|
| Rate for Payer: Healthscope Commercial |
$29.40
|
| Rate for Payer: Healthscope Commercial |
$32.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.77
|
| Rate for Payer: PHP Commercial |
$30.26
|
| Rate for Payer: PHP Commercial |
$27.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.87
|
| Rate for Payer: Priority Health SBD |
$22.43
|
| Rate for Payer: Priority Health SBD |
$20.58
|
|
|
EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR
|
Facility
|
IP
|
$1,019.25
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
29031
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$642.13 |
| Max. Negotiated Rate |
$917.32 |
| Rate for Payer: Aetna Commercial |
$866.36
|
| Rate for Payer: Aetna Commercial |
$399.90
|
| Rate for Payer: Aetna Commercial |
$799.79
|
| Rate for Payer: Aetna Commercial |
$433.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$662.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$331.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$611.60
|
| Rate for Payer: Cash Price |
$376.38
|
| Rate for Payer: Cash Price |
$752.74
|
| Rate for Payer: Cash Price |
$815.40
|
| Rate for Payer: Cash Price |
$407.70
|
| Rate for Payer: Cofinity Commercial |
$658.65
|
| Rate for Payer: Cofinity Commercial |
$329.33
|
| Rate for Payer: Cofinity Commercial |
$404.60
|
| Rate for Payer: Cofinity Commercial |
$713.48
|
| Rate for Payer: Cofinity Commercial |
$809.20
|
| Rate for Payer: Cofinity Commercial |
$356.74
|
| Rate for Payer: Cofinity Commercial |
$438.28
|
| Rate for Payer: Cofinity Commercial |
$876.56
|
| Rate for Payer: Healthscope Commercial |
$458.67
|
| Rate for Payer: Healthscope Commercial |
$917.32
|
| Rate for Payer: Healthscope Commercial |
$423.42
|
| Rate for Payer: Healthscope Commercial |
$846.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$399.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$433.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$866.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$799.79
|
| Rate for Payer: PHP Commercial |
$866.36
|
| Rate for Payer: PHP Commercial |
$399.90
|
| Rate for Payer: PHP Commercial |
$433.19
|
| Rate for Payer: PHP Commercial |
$799.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$713.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$658.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.74
|
| Rate for Payer: Priority Health SBD |
$321.07
|
| Rate for Payer: Priority Health SBD |
$296.40
|
| Rate for Payer: Priority Health SBD |
$592.79
|
| Rate for Payer: Priority Health SBD |
$642.13
|
|
|
EPISTAXIS WITH MCC
|
Facility
|
IP
|
$27,892.32
|
|
|
Service Code
|
MS-DRG 150
|
| Min. Negotiated Rate |
$9,461.52 |
| Max. Negotiated Rate |
$27,892.32 |
| Rate for Payer: Aetna Medicare |
$10,357.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,449.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,449.38
|
| Rate for Payer: BCBS MAPPO |
$9,959.50
|
| Rate for Payer: BCBS Trust/PPO |
$27,892.32
|
| Rate for Payer: BCN Medicare Advantage |
$9,959.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,959.50
|
| Rate for Payer: Mclaren Medicare |
$9,959.50
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,457.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,453.42
|
| Rate for Payer: PACE Medicare |
$9,461.52
|
| Rate for Payer: PACE SWMI |
$9,959.50
|
| Rate for Payer: PHP Medicare Advantage |
$9,959.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,862.97
|
| Rate for Payer: Priority Health Medicare |
$9,959.50
|
| Rate for Payer: Priority Health Narrow Network |
$15,090.38
|
| Rate for Payer: Railroad Medicare Medicare |
$9,959.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20,051.38
|
| Rate for Payer: UHC Core |
$12,303.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,959.50
|
| Rate for Payer: UHC Exchange |
$13,177.86
|
| Rate for Payer: UHC Medicare Advantage |
$10,258.28
|
| Rate for Payer: VA VA |
$9,959.50
|
|
|
EPISTAXIS WITHOUT MCC
|
Facility
|
IP
|
$13,974.71
|
|
|
Service Code
|
MS-DRG 151
|
| Min. Negotiated Rate |
$5,740.99 |
| Max. Negotiated Rate |
$13,974.71 |
| Rate for Payer: Aetna Medicare |
$6,284.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,553.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,553.94
|
| Rate for Payer: BCBS MAPPO |
$6,043.15
|
| Rate for Payer: BCBS Trust/PPO |
$13,974.71
|
| Rate for Payer: BCN Medicare Advantage |
$6,043.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,043.15
|
| Rate for Payer: Mclaren Medicare |
$6,043.15
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,345.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,949.62
|
| Rate for Payer: PACE Medicare |
$5,740.99
|
| Rate for Payer: PACE SWMI |
$6,043.15
|
| Rate for Payer: PHP Medicare Advantage |
$6,043.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,059.48
|
| Rate for Payer: Priority Health Medicare |
$6,043.15
|
| Rate for Payer: Priority Health Narrow Network |
$8,847.58
|
| Rate for Payer: Railroad Medicare Medicare |
$6,043.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,756.26
|
| Rate for Payer: UHC Core |
$7,213.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,043.15
|
| Rate for Payer: UHC Exchange |
$7,726.27
|
| Rate for Payer: UHC Medicare Advantage |
$6,224.44
|
| Rate for Payer: VA VA |
$6,043.15
|
|
|
EPLERENONE 50 MG TABLET
|
Facility
|
IP
|
$164.45
|
|
|
Service Code
|
NDC 0378-1031-93
|
| Hospital Charge Code |
36984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$139.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.89
|
| Rate for Payer: Cash Price |
$131.56
|
| Rate for Payer: Cofinity Commercial |
$115.12
|
| Rate for Payer: Cofinity Commercial |
$141.43
|
| Rate for Payer: Healthscope Commercial |
$148.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.78
|
| Rate for Payer: PHP Commercial |
$139.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.12
|
| Rate for Payer: Priority Health SBD |
$103.60
|
|
|
EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION
|
Facility
|
IP
|
$568.14
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
9938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$357.93 |
| Max. Negotiated Rate |
$511.33 |
| Rate for Payer: Aetna Commercial |
$482.92
|
| Rate for Payer: Aetna Commercial |
$424.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$324.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$369.29
|
| Rate for Payer: Cash Price |
$454.51
|
| Rate for Payer: Cash Price |
$399.61
|
| Rate for Payer: Cofinity Commercial |
$429.58
|
| Rate for Payer: Cofinity Commercial |
$397.70
|
| Rate for Payer: Cofinity Commercial |
$488.60
|
| Rate for Payer: Cofinity Commercial |
$349.66
|
| Rate for Payer: Healthscope Commercial |
$511.33
|
| Rate for Payer: Healthscope Commercial |
$449.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$424.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$482.92
|
| Rate for Payer: PHP Commercial |
$482.92
|
| Rate for Payer: PHP Commercial |
$424.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$349.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.70
|
| Rate for Payer: Priority Health SBD |
$357.93
|
| Rate for Payer: Priority Health SBD |
$314.69
|
|
|
EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION
|
Facility
|
OP
|
$499.51
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
9938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$449.56 |
| Rate for Payer: Aetna Commercial |
$424.58
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$324.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.11
|
| Rate for Payer: BCBS Complete |
$5.10
|
| Rate for Payer: BCBS MAPPO |
$8.89
|
| Rate for Payer: BCBS Trust/PPO |
$26.30
|
| Rate for Payer: BCN Medicare Advantage |
$8.89
|
| Rate for Payer: Cash Price |
$399.61
|
| Rate for Payer: Cash Price |
$399.61
|
| Rate for Payer: Cofinity Commercial |
$429.58
|
| Rate for Payer: Cofinity Commercial |
$349.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.89
|
| Rate for Payer: Healthscope Commercial |
$449.56
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicare |
$8.89
|
| Rate for Payer: Meridian Medicaid |
$5.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$424.58
|
| Rate for Payer: PACE Medicare |
$8.44
|
| Rate for Payer: PACE SWMI |
$8.89
|
| Rate for Payer: PHP Commercial |
$424.58
|
| Rate for Payer: PHP Medicare Advantage |
$8.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$349.66
|
| Rate for Payer: Priority Health Medicare |
$8.89
|
| Rate for Payer: Priority Health SBD |
$314.69
|
| Rate for Payer: Railroad Medicare Medicare |
$8.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.89
|
| Rate for Payer: UHC Medicare Advantage |
$9.15
|
| Rate for Payer: VA VA |
$8.89
|
|
|
EPOETIN ALFA 20,000 UNIT/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$1,634.30
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
115705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,029.61 |
| Max. Negotiated Rate |
$1,470.87 |
| Rate for Payer: Aetna Commercial |
$1,389.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,062.30
|
| Rate for Payer: Cash Price |
$1,307.44
|
| Rate for Payer: Cofinity Commercial |
$1,405.50
|
| Rate for Payer: Cofinity Commercial |
$1,144.01
|
| Rate for Payer: Healthscope Commercial |
$1,470.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,389.16
|
| Rate for Payer: PHP Commercial |
$1,389.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,144.01
|
| Rate for Payer: Priority Health SBD |
$1,029.61
|
|
|
EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION
|
Facility
|
OP
|
$1,024.25
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
14643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$921.82 |
| Rate for Payer: Aetna Commercial |
$870.61
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$665.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.11
|
| Rate for Payer: BCBS Complete |
$5.10
|
| Rate for Payer: BCBS MAPPO |
$8.89
|
| Rate for Payer: BCBS Trust/PPO |
$26.30
|
| Rate for Payer: BCN Medicare Advantage |
$8.89
|
| Rate for Payer: Cash Price |
$819.40
|
| Rate for Payer: Cash Price |
$819.40
|
| Rate for Payer: Cofinity Commercial |
$880.86
|
| Rate for Payer: Cofinity Commercial |
$716.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.89
|
| Rate for Payer: Healthscope Commercial |
$921.82
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicare |
$8.89
|
| Rate for Payer: Meridian Medicaid |
$5.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$870.61
|
| Rate for Payer: PACE Medicare |
$8.44
|
| Rate for Payer: PACE SWMI |
$8.89
|
| Rate for Payer: PHP Commercial |
$870.61
|
| Rate for Payer: PHP Medicare Advantage |
$8.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$716.98
|
| Rate for Payer: Priority Health Medicare |
$8.89
|
| Rate for Payer: Priority Health SBD |
$645.28
|
| Rate for Payer: Railroad Medicare Medicare |
$8.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.89
|
| Rate for Payer: UHC Medicare Advantage |
$9.15
|
| Rate for Payer: VA VA |
$8.89
|
|
