|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.63
|
|
|
Service Code
|
NDC 68094-600-61
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna Commercial |
$3.09
|
| Rate for Payer: BCBS Trust/PPO |
$2.81
|
| Rate for Payer: BCN Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.19
|
| Rate for Payer: UHC Core |
$3.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.72
|
|
|
IBUPROFEN 200 MG TABLET
|
Facility
|
IP
|
$19.60
|
|
|
Service Code
|
NDC 0904-7914-61
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.95 |
| Max. Negotiated Rate |
$17.64 |
| Rate for Payer: Aetna Commercial |
$16.66
|
| Rate for Payer: BCBS Trust/PPO |
$15.15
|
| Rate for Payer: BCN Commercial |
$15.15
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cofinity Commercial |
$16.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.68
|
| Rate for Payer: Healthscope Commercial |
$17.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.66
|
| Rate for Payer: PHP Commercial |
$16.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.25
|
| Rate for Payer: UHC Core |
$16.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.70
|
|
|
IBUPROFEN 400 MG TABLET
|
Facility
|
IP
|
$126.90
|
|
|
Service Code
|
NDC 63739-672-10
|
| Hospital Charge Code |
3843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.40 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: BCBS Trust/PPO |
$98.07
|
| Rate for Payer: BCN Commercial |
$98.07
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.86
|
| Rate for Payer: PHP Commercial |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$110.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.67
|
| Rate for Payer: UHC Core |
$105.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.18
|
|
|
IBUPROFEN 400 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 0904-5853-61
|
| Hospital Charge Code |
3843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.73 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: BCBS Trust/PPO |
$116.23
|
| Rate for Payer: BCN Commercial |
$116.23
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$130.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$91.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$132.35
|
| Rate for Payer: UHC Core |
$125.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.80
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 55111-683-01
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.06 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: BCBS Trust/PPO |
$188.87
|
| Rate for Payer: BCN Commercial |
$188.87
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$212.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$149.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$215.07
|
| Rate for Payer: UHC Core |
$204.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 67877-320-01
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.90 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: BCBS Trust/PPO |
$125.31
|
| Rate for Payer: BCN Commercial |
$125.31
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$141.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$98.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.69
|
| Rate for Payer: UHC Core |
$135.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$164.50
|
|
|
Service Code
|
NDC 63739-684-10
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.33 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: BCBS Trust/PPO |
$127.13
|
| Rate for Payer: BCN Commercial |
$127.13
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.60
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$143.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$100.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$144.76
|
| Rate for Payer: UHC Core |
$137.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.38
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 60687-457-11
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: BCBS Trust/PPO |
$3.13
|
| Rate for Payer: BCN Commercial |
$3.13
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC Core |
$3.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 60687-457-01
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$246.52 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: BCBS Trust/PPO |
$312.37
|
| Rate for Payer: BCN Commercial |
$312.37
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$351.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$246.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$355.70
|
| Rate for Payer: UHC Core |
$337.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$185.65
|
|
|
Service Code
|
NDC 0904-5854-61
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.23 |
| Max. Negotiated Rate |
$167.08 |
| Rate for Payer: Aetna Commercial |
$157.80
|
| Rate for Payer: BCBS Trust/PPO |
$143.47
|
| Rate for Payer: BCN Commercial |
$143.47
|
| Rate for Payer: Cash Price |
$148.52
|
| Rate for Payer: Cofinity Commercial |
$159.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.52
|
| Rate for Payer: Healthscope Commercial |
$167.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.80
|
| Rate for Payer: PHP Commercial |
$157.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$161.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$113.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.37
|
| Rate for Payer: UHC Core |
$155.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.24
|
|
|
IBUPROFEN 800 MG TABLET
|
Facility
|
IP
|
$16.22
|
|
|
Service Code
|
NDC 0904-5855-61
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$14.60 |
| Rate for Payer: Aetna Commercial |
$13.79
|
| Rate for Payer: BCBS Trust/PPO |
$12.53
|
| Rate for Payer: BCN Commercial |
$12.53
|
| Rate for Payer: Cash Price |
$12.98
|
| Rate for Payer: Cofinity Commercial |
$13.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.98
|
| Rate for Payer: Healthscope Commercial |
$14.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.79
|
| Rate for Payer: PHP Commercial |
$13.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.27
|
| Rate for Payer: UHC Core |
$13.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.16
|
|
|
ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$4,479.97
|
|
|
Service Code
|
HCPCS J1744
|
| Hospital Charge Code |
153436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,732.33 |
| Max. Negotiated Rate |
$4,031.97 |
| Rate for Payer: Aetna Commercial |
$3,807.97
|
| Rate for Payer: Aetna Commercial |
$6,528.90
|
| Rate for Payer: BCBS Trust/PPO |
$3,462.12
|
| Rate for Payer: BCBS Trust/PPO |
$5,935.92
|
| Rate for Payer: BCN Commercial |
$5,935.92
|
| Rate for Payer: BCN Commercial |
$3,462.12
|
| Rate for Payer: Cash Price |
$6,144.85
|
| Rate for Payer: Cash Price |
$3,583.98
|
| Rate for Payer: Cofinity Commercial |
$6,605.71
|
| Rate for Payer: Cofinity Commercial |
$3,852.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,583.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,144.85
|
| Rate for Payer: Healthscope Commercial |
$6,912.95
|
| Rate for Payer: Healthscope Commercial |
$4,031.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,359.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,760.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,528.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,807.97
|
| Rate for Payer: PHP Commercial |
$6,528.90
|
| Rate for Payer: PHP Commercial |
$3,807.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,135.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,376.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,897.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6,682.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4,684.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2,732.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,942.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6,759.33
|
| Rate for Payer: UHC Core |
$3,740.77
|
| Rate for Payer: UHC Core |
$6,413.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,359.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,760.80
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$9,098.12
|
|
|
Service Code
|
NDC 0597-0197-05
|
| Hospital Charge Code |
176112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,548.94 |
| Max. Negotiated Rate |
$8,188.31 |
| Rate for Payer: Aetna Commercial |
$7,733.40
|
| Rate for Payer: BCBS Trust/PPO |
$7,031.03
|
| Rate for Payer: BCN Commercial |
$7,031.03
|
| Rate for Payer: Cash Price |
$7,278.50
|
| Rate for Payer: Cofinity Commercial |
$7,824.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,278.50
|
| Rate for Payer: Healthscope Commercial |
$8,188.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,823.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,733.40
|
| Rate for Payer: PHP Commercial |
$7,733.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,368.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,915.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5,548.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,006.35
|
| Rate for Payer: UHC Core |
$7,596.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,823.59
|
|
|
IMPACT PEPTIDE 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$66.60
|
|
|
Service Code
|
NDC 4390097370
|
| Hospital Charge Code |
200090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.62 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Aetna Commercial |
$56.61
|
| Rate for Payer: BCBS Trust/PPO |
$51.47
|
| Rate for Payer: BCN Commercial |
$51.47
|
| Rate for Payer: Cash Price |
$53.28
|
| Rate for Payer: Cofinity Commercial |
$57.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.28
|
| Rate for Payer: Healthscope Commercial |
$59.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.61
|
| Rate for Payer: PHP Commercial |
$56.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$57.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.61
|
| Rate for Payer: UHC Core |
$55.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.95
|
|
|
IMPLANTABLE TISSUE MARKER
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS A4648
|
| Min. Negotiated Rate |
$102.14 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: Aetna Commercial |
$102.14
|
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: BCN Commercial |
$136.96
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
|
|
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
|
Facility
|
OP
|
$274.65
|
|
|
Service Code
|
CPT 10061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$261.57 |
| Max. Negotiated Rate |
$274.65 |
| Rate for Payer: BCBS Complete |
$274.65
|
| Rate for Payer: Mclaren Medicaid |
$261.57
|
| Rate for Payer: Meridian Medicaid |
$274.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$261.57
|
|
|
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE
|
Facility
|
OP
|
$137.89
|
|
|
Service Code
|
CPT 10060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$131.33 |
| Max. Negotiated Rate |
$137.89 |
| Rate for Payer: BCBS Complete |
$137.89
|
| Rate for Payer: Mclaren Medicaid |
$131.33
|
| Rate for Payer: Meridian Medicaid |
$137.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$131.33
|
|
|
INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION
|
Facility
|
OP
|
$1,116.73
|
|
|
Service Code
|
CPT 10140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,063.55 |
| Max. Negotiated Rate |
$1,116.73 |
| Rate for Payer: BCBS Complete |
$1,116.73
|
| Rate for Payer: Mclaren Medicaid |
$1,063.55
|
| Rate for Payer: Meridian Medicaid |
$1,116.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,063.55
|
|
|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE
|
Facility
|
OP
|
$274.65
|
|
|
Service Code
|
CPT 10120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$261.57 |
| Max. Negotiated Rate |
$274.65 |
| Rate for Payer: BCBS Complete |
$274.65
|
| Rate for Payer: Mclaren Medicaid |
$261.57
|
| Rate for Payer: Meridian Medicaid |
$274.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$261.57
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$1,107.03
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,054.31 |
| Max. Negotiated Rate |
$1,107.03 |
| Rate for Payer: BCBS Complete |
$1,107.03
|
| Rate for Payer: Mclaren Medicaid |
$1,054.31
|
| Rate for Payer: Meridian Medicaid |
$1,107.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,054.31
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.16 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: BCBS Trust/PPO |
$400.60
|
| Rate for Payer: BCN Commercial |
$400.60
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$388.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$440.62
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$450.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$316.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$456.17
|
| Rate for Payer: UHC Core |
$432.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$388.78
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 0517-0375-10
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$289.81 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: BCBS Trust/PPO |
$367.21
|
| Rate for Payer: BCN Commercial |
$367.21
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$413.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$289.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.15
|
| Rate for Payer: UHC Core |
$396.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.16 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: BCBS Trust/PPO |
$400.60
|
| Rate for Payer: BCN Commercial |
$400.60
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$388.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$440.62
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$450.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$316.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$456.17
|
| Rate for Payer: UHC Core |
$432.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$388.78
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 0517-0375-10
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$289.81 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: BCBS Trust/PPO |
$367.21
|
| Rate for Payer: BCN Commercial |
$367.21
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$413.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$289.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.15
|
| Rate for Payer: UHC Core |
$396.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$316.16 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: BCBS Trust/PPO |
$400.60
|
| Rate for Payer: BCN Commercial |
$400.60
|
| Rate for Payer: Cash Price |
$414.70
|
| Rate for Payer: Cofinity Commercial |
$445.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.70
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$388.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$440.62
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$450.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$316.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$456.17
|
| Rate for Payer: UHC Core |
$432.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$388.78
|
|
