|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,676.55
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$1,508.90 |
| Rate for Payer: Aetna Commercial |
$1,425.07
|
| Rate for Payer: Aetna Commercial |
$2,494.16
|
| Rate for Payer: Aetna Medicare |
$435.90
|
| Rate for Payer: Aetna Medicare |
$762.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$523.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$916.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$523.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$916.97
|
| Rate for Payer: BCBS Complete |
$4.68
|
| Rate for Payer: BCBS Complete |
$4.68
|
| Rate for Payer: BCBS MAPPO |
$733.58
|
| Rate for Payer: BCBS MAPPO |
$419.14
|
| Rate for Payer: BCBS Trust/PPO |
$1,378.29
|
| Rate for Payer: BCBS Trust/PPO |
$2,412.30
|
| Rate for Payer: BCN Commercial |
$1,303.52
|
| Rate for Payer: BCN Commercial |
$2,281.43
|
| Rate for Payer: BCN Medicare Advantage |
$419.14
|
| Rate for Payer: BCN Medicare Advantage |
$733.58
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cash Price |
$1,341.24
|
| Rate for Payer: Cash Price |
$1,341.24
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cofinity Commercial |
$1,441.83
|
| Rate for Payer: Cofinity Commercial |
$2,523.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,347.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,341.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$419.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$733.58
|
| Rate for Payer: Healthscope Commercial |
$2,640.88
|
| Rate for Payer: Healthscope Commercial |
$1,508.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,257.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,200.73
|
| Rate for Payer: Mclaren Medicaid |
$4.45
|
| Rate for Payer: Mclaren Medicaid |
$4.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$770.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$440.09
|
| Rate for Payer: Meridian Medicaid |
$4.68
|
| Rate for Payer: Meridian Medicaid |
$4.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$482.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$843.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,425.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,494.16
|
| Rate for Payer: Nomi Health Commercial |
$1,374.77
|
| Rate for Payer: Nomi Health Commercial |
$2,406.13
|
| Rate for Payer: PACE Senior Care Partners |
$398.18
|
| Rate for Payer: PACE Senior Care Partners |
$696.90
|
| Rate for Payer: PACE SWMI |
$419.14
|
| Rate for Payer: PACE SWMI |
$733.58
|
| Rate for Payer: PHP Commercial |
$2,494.16
|
| Rate for Payer: PHP Commercial |
$1,425.07
|
| Rate for Payer: PHP Medicare Advantage |
$419.14
|
| Rate for Payer: PHP Medicare Advantage |
$733.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,089.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,907.30
|
| Rate for Payer: Priority Health HMO/PPO |
$2,552.85
|
| Rate for Payer: Priority Health HMO/PPO |
$1,458.60
|
| Rate for Payer: Priority Health Medicare |
$423.33
|
| Rate for Payer: Priority Health Medicare |
$740.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,123.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,965.99
|
| Rate for Payer: Railroad Medicare Medicare |
$733.58
|
| Rate for Payer: Railroad Medicare Medicare |
$419.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,582.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,475.36
|
| Rate for Payer: UHC Core |
$2,450.15
|
| Rate for Payer: UHC Core |
$1,399.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$419.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$733.58
|
| Rate for Payer: UHC Exchange |
$733.58
|
| Rate for Payer: UHC Exchange |
$419.14
|
| Rate for Payer: UHC Medicare Advantage |
$733.58
|
| Rate for Payer: UHC Medicare Advantage |
$419.14
|
| Rate for Payer: UHCCP Medicaid |
$4.45
|
| Rate for Payer: UHCCP Medicaid |
$4.45
|
| Rate for Payer: VA VA |
$419.14
|
| Rate for Payer: VA VA |
$733.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,257.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,200.73
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,676.55
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,089.76 |
| Max. Negotiated Rate |
$1,508.90 |
| Rate for Payer: Aetna Commercial |
$1,425.07
|
| Rate for Payer: Aetna Commercial |
$2,494.16
|
| Rate for Payer: BCBS Trust/PPO |
$1,368.57
|
| Rate for Payer: BCBS Trust/PPO |
$2,395.28
|
| Rate for Payer: BCN Commercial |
$1,295.64
|
| Rate for Payer: BCN Commercial |
$2,267.63
|
| Rate for Payer: Cash Price |
$1,341.24
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cofinity Commercial |
$2,523.51
|
| Rate for Payer: Cofinity Commercial |
$1,441.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,347.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,341.24
|
| Rate for Payer: Healthscope Commercial |
$1,508.90
|
| Rate for Payer: Healthscope Commercial |
$2,640.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,257.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,200.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,425.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,494.16
|
| Rate for Payer: Nomi Health Commercial |
$1,374.77
|
| Rate for Payer: Nomi Health Commercial |
$2,406.13
|
| Rate for Payer: PHP Commercial |
$1,425.07
|
| Rate for Payer: PHP Commercial |
$2,494.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,907.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,089.76
|
| Rate for Payer: Priority Health HMO/PPO |
$2,552.85
|
| Rate for Payer: Priority Health HMO/PPO |
$1,458.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,123.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,965.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,475.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,582.19
|
| Rate for Payer: UHC Core |
$1,399.92
|
| Rate for Payer: UHC Core |
$2,450.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,257.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,200.73
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$33.67
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.89 |
| Max. Negotiated Rate |
$30.30 |
| Rate for Payer: Aetna Commercial |
$28.62
|
| Rate for Payer: Aetna Commercial |
$35.25
|
| Rate for Payer: Aetna Commercial |
$35.34
|
| Rate for Payer: BCBS Trust/PPO |
$33.85
|
| Rate for Payer: BCBS Trust/PPO |
$27.48
|
| Rate for Payer: BCBS Trust/PPO |
$33.94
|
| Rate for Payer: BCN Commercial |
$32.05
|
| Rate for Payer: BCN Commercial |
$26.02
|
| Rate for Payer: BCN Commercial |
$32.13
|
| Rate for Payer: Cash Price |
$26.94
|
| Rate for Payer: Cash Price |
$33.26
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cofinity Commercial |
$35.76
|
| Rate for Payer: Cofinity Commercial |
$35.66
|
| Rate for Payer: Cofinity Commercial |
$28.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.26
|
| Rate for Payer: Healthscope Commercial |
$37.32
|
| Rate for Payer: Healthscope Commercial |
$30.30
|
| Rate for Payer: Healthscope Commercial |
$37.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.34
|
| Rate for Payer: Nomi Health Commercial |
$27.61
|
| Rate for Payer: Nomi Health Commercial |
$34.01
|
| Rate for Payer: Nomi Health Commercial |
$34.10
|
| Rate for Payer: PHP Commercial |
$35.25
|
| Rate for Payer: PHP Commercial |
$28.62
|
| Rate for Payer: PHP Commercial |
$35.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.96
|
| Rate for Payer: Priority Health HMO/PPO |
$36.17
|
| Rate for Payer: Priority Health HMO/PPO |
$36.08
|
| Rate for Payer: Priority Health HMO/PPO |
$29.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.63
|
| Rate for Payer: UHC Core |
$28.11
|
| Rate for Payer: UHC Core |
$34.72
|
| Rate for Payer: UHC Core |
$34.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.10
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$33.67
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$30.30 |
| Rate for Payer: Aetna Commercial |
$28.62
|
| Rate for Payer: Aetna Commercial |
$35.34
|
| Rate for Payer: Aetna Commercial |
$35.25
|
| Rate for Payer: Aetna Medicare |
$10.81
|
| Rate for Payer: Aetna Medicare |
$8.75
|
| Rate for Payer: Aetna Medicare |
$10.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.99
|
| Rate for Payer: BCBS Complete |
$16.59
|
| Rate for Payer: BCBS Complete |
$13.47
|
| Rate for Payer: BCBS Complete |
$16.63
|
| Rate for Payer: BCBS MAPPO |
$10.40
|
| Rate for Payer: BCBS MAPPO |
$8.42
|
| Rate for Payer: BCBS MAPPO |
$10.37
|
| Rate for Payer: BCBS Trust/PPO |
$34.09
|
| Rate for Payer: BCBS Trust/PPO |
$27.68
|
| Rate for Payer: BCBS Trust/PPO |
$34.18
|
| Rate for Payer: BCN Commercial |
$32.24
|
| Rate for Payer: BCN Commercial |
$32.33
|
| Rate for Payer: BCN Commercial |
$26.18
|
| Rate for Payer: BCN Medicare Advantage |
$8.42
|
| Rate for Payer: BCN Medicare Advantage |
$10.37
|
| Rate for Payer: BCN Medicare Advantage |
$10.40
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cash Price |
$33.26
|
| Rate for Payer: Cash Price |
$26.94
|
| Rate for Payer: Cofinity Commercial |
$35.76
|
| Rate for Payer: Cofinity Commercial |
$28.96
|
| Rate for Payer: Cofinity Commercial |
$35.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.37
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.42
|
| Rate for Payer: Healthscope Commercial |
$37.32
|
| Rate for Payer: Healthscope Commercial |
$30.30
|
| Rate for Payer: Healthscope Commercial |
$37.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.62
|
| Rate for Payer: Nomi Health Commercial |
$34.10
|
| Rate for Payer: Nomi Health Commercial |
$27.61
|
| Rate for Payer: Nomi Health Commercial |
$34.01
|
| Rate for Payer: PACE Senior Care Partners |
$9.88
|
| Rate for Payer: PACE Senior Care Partners |
$8.00
|
| Rate for Payer: PACE Senior Care Partners |
$9.85
|
| Rate for Payer: PACE SWMI |
$10.37
|
| Rate for Payer: PACE SWMI |
$8.42
|
| Rate for Payer: PACE SWMI |
$10.40
|
| Rate for Payer: PHP Commercial |
$35.34
|
| Rate for Payer: PHP Commercial |
$35.25
|
| Rate for Payer: PHP Commercial |
$28.62
|
| Rate for Payer: PHP Medicare Advantage |
$10.37
|
| Rate for Payer: PHP Medicare Advantage |
$10.40
|
| Rate for Payer: PHP Medicare Advantage |
$8.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.96
|
| Rate for Payer: Priority Health HMO/PPO |
$36.17
|
| Rate for Payer: Priority Health HMO/PPO |
$29.29
|
| Rate for Payer: Priority Health HMO/PPO |
$36.08
|
| Rate for Payer: Priority Health Medicare |
$8.50
|
| Rate for Payer: Priority Health Medicare |
$10.50
|
| Rate for Payer: Priority Health Medicare |
$10.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.56
|
| Rate for Payer: Railroad Medicare Medicare |
$10.37
|
| Rate for Payer: Railroad Medicare Medicare |
$10.40
|
| Rate for Payer: Railroad Medicare Medicare |
$8.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.63
|
| Rate for Payer: UHC Core |
$34.72
|
| Rate for Payer: UHC Core |
$34.63
|
| Rate for Payer: UHC Core |
$28.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.37
|
| Rate for Payer: UHC Exchange |
$10.37
|
| Rate for Payer: UHC Exchange |
$8.42
|
| Rate for Payer: UHC Exchange |
$10.40
|
| Rate for Payer: UHC Medicare Advantage |
$8.42
|
| Rate for Payer: UHC Medicare Advantage |
$10.37
|
| Rate for Payer: UHC Medicare Advantage |
$10.40
|
| Rate for Payer: VA VA |
$10.37
|
| Rate for Payer: VA VA |
$10.40
|
| Rate for Payer: VA VA |
$8.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.10
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: BCBS Trust/PPO |
$168.53
|
| Rate for Payer: BCN Commercial |
$159.55
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO |
$179.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$138.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.68
|
| Rate for Payer: UHC Core |
$172.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$194.25
|
|
|
Service Code
|
NDC 70700026894
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: BCBS Trust/PPO |
$158.57
|
| Rate for Payer: BCN Commercial |
$150.12
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO |
$169.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.94
|
| Rate for Payer: UHC Core |
$162.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$241.84
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.20 |
| Max. Negotiated Rate |
$217.66 |
| Rate for Payer: Aetna Commercial |
$205.56
|
| Rate for Payer: BCBS Trust/PPO |
$197.41
|
| Rate for Payer: BCN Commercial |
$186.89
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$207.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.47
|
| Rate for Payer: Healthscope Commercial |
$217.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: Nomi Health Commercial |
$198.31
|
| Rate for Payer: PHP Commercial |
$205.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.20
|
| Rate for Payer: Priority Health HMO/PPO |
$210.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$162.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$212.82
|
| Rate for Payer: UHC Core |
$201.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.38
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$194.25
|
|
|
Service Code
|
NDC 70700026899
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: BCBS Trust/PPO |
$158.57
|
| Rate for Payer: BCN Commercial |
$150.12
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO |
$169.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.94
|
| Rate for Payer: UHC Core |
$162.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna Medicare |
$53.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$64.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$64.52
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: BCBS MAPPO |
$51.62
|
| Rate for Payer: BCBS Trust/PPO |
$169.73
|
| Rate for Payer: BCN Commercial |
$160.52
|
| Rate for Payer: BCN Medicare Advantage |
$51.62
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$51.62
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$54.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: PACE Senior Care Partners |
$49.03
|
| Rate for Payer: PACE SWMI |
$51.62
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: PHP Medicare Advantage |
$51.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO |
$179.62
|
| Rate for Payer: Priority Health Medicare |
$52.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$138.33
|
| Rate for Payer: Railroad Medicare Medicare |
$51.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.68
|
| Rate for Payer: UHC Core |
$172.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$51.62
|
| Rate for Payer: UHC Exchange |
$51.62
|
| Rate for Payer: UHC Medicare Advantage |
$51.62
|
| Rate for Payer: VA VA |
$51.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$241.84
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.44 |
| Max. Negotiated Rate |
$217.66 |
| Rate for Payer: Aetna Commercial |
$205.56
|
| Rate for Payer: Aetna Medicare |
$62.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$75.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$75.58
|
| Rate for Payer: BCBS Complete |
$96.74
|
| Rate for Payer: BCBS MAPPO |
$60.46
|
| Rate for Payer: BCBS Trust/PPO |
$198.82
|
| Rate for Payer: BCN Commercial |
$188.03
|
| Rate for Payer: BCN Medicare Advantage |
$60.46
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$207.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$60.46
|
| Rate for Payer: Healthscope Commercial |
$217.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$63.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$69.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: Nomi Health Commercial |
$198.31
|
| Rate for Payer: PACE Senior Care Partners |
$57.44
|
| Rate for Payer: PACE SWMI |
$60.46
|
| Rate for Payer: PHP Commercial |
$205.56
|
| Rate for Payer: PHP Medicare Advantage |
$60.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.20
|
| Rate for Payer: Priority Health HMO/PPO |
$210.40
|
| Rate for Payer: Priority Health Medicare |
$61.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$162.03
|
| Rate for Payer: Railroad Medicare Medicare |
$60.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$212.82
|
| Rate for Payer: UHC Core |
$201.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$60.46
|
| Rate for Payer: UHC Exchange |
$60.46
|
| Rate for Payer: UHC Medicare Advantage |
$60.46
|
| Rate for Payer: VA VA |
$60.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.38
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$194.25
|
|
|
Service Code
|
NDC 70700026899
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: Aetna Medicare |
$50.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$60.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$60.70
|
| Rate for Payer: BCBS Complete |
$77.70
|
| Rate for Payer: BCBS MAPPO |
$48.56
|
| Rate for Payer: BCBS Trust/PPO |
$159.69
|
| Rate for Payer: BCN Commercial |
$151.03
|
| Rate for Payer: BCN Medicare Advantage |
$48.56
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.56
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$50.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: PACE Senior Care Partners |
$46.13
|
| Rate for Payer: PACE SWMI |
$48.56
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: PHP Medicare Advantage |
$48.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO |
$169.00
|
| Rate for Payer: Priority Health Medicare |
$49.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.15
|
| Rate for Payer: Railroad Medicare Medicare |
$48.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.94
|
| Rate for Payer: UHC Core |
$162.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.56
|
| Rate for Payer: UHC Exchange |
$48.56
|
| Rate for Payer: UHC Medicare Advantage |
$48.56
|
| Rate for Payer: VA VA |
$48.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$194.25
|
|
|
Service Code
|
NDC 70700026894
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: Aetna Medicare |
$50.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$60.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$60.70
|
| Rate for Payer: BCBS Complete |
$77.70
|
| Rate for Payer: BCBS MAPPO |
$48.56
|
| Rate for Payer: BCBS Trust/PPO |
$159.69
|
| Rate for Payer: BCN Commercial |
$151.03
|
| Rate for Payer: BCN Medicare Advantage |
$48.56
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.56
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$50.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: PACE Senior Care Partners |
$46.13
|
| Rate for Payer: PACE SWMI |
$48.56
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: PHP Medicare Advantage |
$48.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO |
$169.00
|
| Rate for Payer: Priority Health Medicare |
$49.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.15
|
| Rate for Payer: Railroad Medicare Medicare |
$48.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.94
|
| Rate for Payer: UHC Core |
$162.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.56
|
| Rate for Payer: UHC Exchange |
$48.56
|
| Rate for Payer: UHC Medicare Advantage |
$48.56
|
| Rate for Payer: VA VA |
$48.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$19.87
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: Aetna Medicare |
$5.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.21
|
| Rate for Payer: BCBS Complete |
$7.95
|
| Rate for Payer: BCBS MAPPO |
$4.97
|
| Rate for Payer: BCBS Trust/PPO |
$16.34
|
| Rate for Payer: BCN Commercial |
$15.45
|
| Rate for Payer: BCN Medicare Advantage |
$4.97
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.97
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: Nomi Health Commercial |
$16.29
|
| Rate for Payer: PACE Senior Care Partners |
$4.72
|
| Rate for Payer: PACE SWMI |
$4.97
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: PHP Medicare Advantage |
$4.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health HMO/PPO |
$17.29
|
| Rate for Payer: Priority Health Medicare |
$5.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.31
|
| Rate for Payer: Railroad Medicare Medicare |
$4.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.49
|
| Rate for Payer: UHC Core |
$16.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.97
|
| Rate for Payer: UHC Exchange |
$4.97
|
| Rate for Payer: UHC Medicare Advantage |
$4.97
|
| Rate for Payer: VA VA |
$4.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.90
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$19.87
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.92 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: BCBS Trust/PPO |
$16.22
|
| Rate for Payer: BCN Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: Nomi Health Commercial |
$16.29
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health HMO/PPO |
$17.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.49
|
| Rate for Payer: UHC Core |
$16.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.90
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
OP
|
$53.14
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.62 |
| Max. Negotiated Rate |
$47.83 |
| Rate for Payer: Aetna Commercial |
$45.17
|
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Medicare |
$13.82
|
| Rate for Payer: Aetna Medicare |
$104.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$125.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$125.14
|
| Rate for Payer: BCBS Complete |
$160.18
|
| Rate for Payer: BCBS Complete |
$21.26
|
| Rate for Payer: BCBS MAPPO |
$100.11
|
| Rate for Payer: BCBS MAPPO |
$13.28
|
| Rate for Payer: BCBS Trust/PPO |
$43.69
|
| Rate for Payer: BCBS Trust/PPO |
$329.20
|
| Rate for Payer: BCN Commercial |
$41.32
|
| Rate for Payer: BCN Commercial |
$311.34
|
| Rate for Payer: BCN Medicare Advantage |
$13.28
|
| Rate for Payer: BCN Medicare Advantage |
$100.11
|
| Rate for Payer: Cash Price |
$42.51
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Cofinity Commercial |
$45.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$100.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.28
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$47.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$105.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$115.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Nomi Health Commercial |
$43.57
|
| Rate for Payer: Nomi Health Commercial |
$328.36
|
| Rate for Payer: PACE Senior Care Partners |
$12.62
|
| Rate for Payer: PACE Senior Care Partners |
$95.10
|
| Rate for Payer: PACE SWMI |
$13.28
|
| Rate for Payer: PACE SWMI |
$100.11
|
| Rate for Payer: PHP Commercial |
$45.17
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: PHP Medicare Advantage |
$100.11
|
| Rate for Payer: PHP Medicare Advantage |
$13.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health HMO/PPO |
$348.38
|
| Rate for Payer: Priority Health HMO/PPO |
$46.23
|
| Rate for Payer: Priority Health Medicare |
$13.42
|
| Rate for Payer: Priority Health Medicare |
$101.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.29
|
| Rate for Payer: Railroad Medicare Medicare |
$100.11
|
| Rate for Payer: Railroad Medicare Medicare |
$13.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.76
|
| Rate for Payer: UHC Core |
$44.37
|
| Rate for Payer: UHC Core |
$334.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$100.11
|
| Rate for Payer: UHC Exchange |
$100.11
|
| Rate for Payer: UHC Exchange |
$13.28
|
| Rate for Payer: UHC Medicare Advantage |
$100.11
|
| Rate for Payer: UHC Medicare Advantage |
$13.28
|
| Rate for Payer: VA VA |
$100.11
|
| Rate for Payer: VA VA |
$13.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.33
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
IP
|
$400.44
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$260.29 |
| Max. Negotiated Rate |
$360.40 |
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Commercial |
$45.17
|
| Rate for Payer: BCBS Trust/PPO |
$326.88
|
| Rate for Payer: BCBS Trust/PPO |
$43.38
|
| Rate for Payer: BCN Commercial |
$309.46
|
| Rate for Payer: BCN Commercial |
$41.07
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$42.51
|
| Rate for Payer: Cofinity Commercial |
$45.70
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$47.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.17
|
| Rate for Payer: Nomi Health Commercial |
$328.36
|
| Rate for Payer: Nomi Health Commercial |
$43.57
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: PHP Commercial |
$45.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health HMO/PPO |
$46.23
|
| Rate for Payer: Priority Health HMO/PPO |
$348.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.76
|
| Rate for Payer: UHC Core |
$334.37
|
| Rate for Payer: UHC Core |
$44.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.86
|
|
|
FRAXEL ARMS - BILATERAL
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00166
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL CHEST
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00155
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL FACE & NECK
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00162
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL FULL FACE
|
Professional
|
Both
|
$612.00
|
|
|
Service Code
|
HCPCS 00152
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna Medicare |
$306.00
|
| Rate for Payer: BCBS Complete |
$244.80
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.80
|
|
|
FRAXEL HANDS
|
Professional
|
Both
|
$357.00
|
|
|
Service Code
|
HCPCS 00154
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$232.05 |
| Rate for Payer: Aetna Medicare |
$178.50
|
| Rate for Payer: BCBS Complete |
$142.80
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.05
|
|
|
FRAXEL LARGE SCAR
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00161
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL MEDIUM SCAR
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00160
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
|
|
FRAXEL NECK
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 00153
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Aetna Medicare |
$204.00
|
| Rate for Payer: BCBS Complete |
$163.20
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.20
|
|
|
FRAXEL NECK & CHEST
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00163
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
|
