|
IBUPROFEN 600 MG TABLET
|
Facility
|
OP
|
$4.05
|
|
|
Service Code
|
NDC 60687045711
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.27
|
| Rate for Payer: BCBS Complete |
$1.62
|
| Rate for Payer: BCBS MAPPO |
$1.01
|
| Rate for Payer: BCBS Trust/PPO |
$3.33
|
| Rate for Payer: BCN Commercial |
$3.15
|
| Rate for Payer: BCN Medicare Advantage |
$1.01
|
| 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: Health Alliance Plan Medicare Advantage |
$1.01
|
| Rate for Payer: Healthscope Commercial |
$3.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.44
|
| Rate for Payer: Nomi Health Commercial |
$3.32
|
| Rate for Payer: PACE Senior Care Partners |
$0.96
|
| Rate for Payer: PACE SWMI |
$1.01
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: PHP Medicare Advantage |
$1.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.63
|
| Rate for Payer: Priority Health HMO/PPO |
$3.52
|
| Rate for Payer: Priority Health Medicare |
$1.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.71
|
| Rate for Payer: Railroad Medicare Medicare |
$1.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC Core |
$3.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.01
|
| Rate for Payer: UHC Exchange |
$1.01
|
| Rate for Payer: UHC Medicare Advantage |
$1.01
|
| Rate for Payer: VA VA |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
OP
|
$164.50
|
|
|
Service Code
|
NDC 67877032001
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.07 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Aetna Medicare |
$42.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$51.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$51.41
|
| Rate for Payer: BCBS Complete |
$65.80
|
| Rate for Payer: BCBS MAPPO |
$41.12
|
| Rate for Payer: BCBS Trust/PPO |
$135.24
|
| Rate for Payer: BCN Commercial |
$127.90
|
| Rate for Payer: BCN Medicare Advantage |
$41.12
|
| 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: Health Alliance Plan Medicare Advantage |
$41.12
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$43.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.82
|
| Rate for Payer: Nomi Health Commercial |
$134.89
|
| Rate for Payer: PACE Senior Care Partners |
$39.07
|
| Rate for Payer: PACE SWMI |
$41.12
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: PHP Medicare Advantage |
$41.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.92
|
| Rate for Payer: Priority Health HMO/PPO |
$143.12
|
| Rate for Payer: Priority Health Medicare |
$41.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$110.22
|
| Rate for Payer: Railroad Medicare Medicare |
$41.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$144.76
|
| Rate for Payer: UHC Core |
$137.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.12
|
| Rate for Payer: UHC Exchange |
$41.12
|
| Rate for Payer: UHC Medicare Advantage |
$41.12
|
| Rate for Payer: VA VA |
$41.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.38
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 60687045701
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.00 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$105.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$126.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$126.31
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: BCBS MAPPO |
$101.05
|
| Rate for Payer: BCBS Trust/PPO |
$332.29
|
| Rate for Payer: BCN Commercial |
$314.27
|
| Rate for Payer: BCN Medicare Advantage |
$101.05
|
| 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: Health Alliance Plan Medicare Advantage |
$101.05
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$106.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$116.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Nomi Health Commercial |
$331.44
|
| Rate for Payer: PACE Senior Care Partners |
$96.00
|
| Rate for Payer: PACE SWMI |
$101.05
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: PHP Medicare Advantage |
$101.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.73
|
| Rate for Payer: Priority Health HMO/PPO |
$351.65
|
| Rate for Payer: Priority Health Medicare |
$102.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$270.81
|
| Rate for Payer: Railroad Medicare Medicare |
$101.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$355.70
|
| Rate for Payer: UHC Core |
$337.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$101.05
|
| Rate for Payer: UHC Exchange |
$101.05
|
| Rate for Payer: UHC Medicare Advantage |
$101.05
|
| Rate for Payer: VA VA |
$101.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
OP
|
$244.40
|
|
|
Service Code
|
NDC 55111068301
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.04 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna Medicare |
$63.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$76.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$76.38
|
| Rate for Payer: BCBS Complete |
$97.76
|
| Rate for Payer: BCBS MAPPO |
$61.10
|
| Rate for Payer: BCBS Trust/PPO |
$200.92
|
| Rate for Payer: BCN Commercial |
$190.02
|
| Rate for Payer: BCN Medicare Advantage |
$61.10
|
| 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: Health Alliance Plan Medicare Advantage |
$61.10
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$64.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$70.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: Nomi Health Commercial |
$200.41
|
| Rate for Payer: PACE Senior Care Partners |
$58.04
|
| Rate for Payer: PACE SWMI |
$61.10
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: PHP Medicare Advantage |
$61.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health HMO/PPO |
$212.63
|
| Rate for Payer: Priority Health Medicare |
$61.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$163.75
|
| Rate for Payer: Railroad Medicare Medicare |
$61.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$215.07
|
| Rate for Payer: UHC Core |
$204.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$61.10
|
| Rate for Payer: UHC Exchange |
$61.10
|
| Rate for Payer: UHC Medicare Advantage |
$61.10
|
| Rate for Payer: VA VA |
$61.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 55111068301
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.86 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: BCBS Trust/PPO |
$199.50
|
| 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 Commercial |
$207.74
|
| Rate for Payer: Nomi Health Commercial |
$200.41
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health HMO/PPO |
$212.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$163.75
|
| 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
|
$4.05
|
|
|
Service Code
|
NDC 60687045711
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: BCBS Trust/PPO |
$3.31
|
| 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 Commercial |
$3.44
|
| Rate for Payer: Nomi Health Commercial |
$3.32
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.63
|
| Rate for Payer: Priority Health HMO/PPO |
$3.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.71
|
| 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 60687045701
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.73 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: BCBS Trust/PPO |
$329.95
|
| 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 Commercial |
$343.57
|
| Rate for Payer: Nomi Health Commercial |
$331.44
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.73
|
| Rate for Payer: Priority Health HMO/PPO |
$351.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$270.81
|
| 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
|
$164.50
|
|
|
Service Code
|
NDC 67877032001
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.92 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: BCBS Trust/PPO |
$134.28
|
| 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 Commercial |
$139.82
|
| Rate for Payer: Nomi Health Commercial |
$134.89
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.92
|
| Rate for Payer: Priority Health HMO/PPO |
$143.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$110.22
|
| 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
|
$185.65
|
|
|
Service Code
|
NDC 00904585461
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.67 |
| Max. Negotiated Rate |
$167.08 |
| Rate for Payer: Aetna Commercial |
$157.80
|
| Rate for Payer: BCBS Trust/PPO |
$151.55
|
| 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 Commercial |
$157.80
|
| Rate for Payer: Nomi Health Commercial |
$152.23
|
| Rate for Payer: PHP Commercial |
$157.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.67
|
| Rate for Payer: Priority Health HMO/PPO |
$161.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$124.39
|
| 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 00904585561
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$14.60 |
| Rate for Payer: Aetna Commercial |
$13.79
|
| Rate for Payer: BCBS Trust/PPO |
$13.24
|
| 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 Commercial |
$13.79
|
| Rate for Payer: Nomi Health Commercial |
$13.30
|
| Rate for Payer: PHP Commercial |
$13.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.54
|
| Rate for Payer: Priority Health HMO/PPO |
$14.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.87
|
| 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
|
|
|
IBUPROFEN 800 MG TABLET
|
Facility
|
OP
|
$16.22
|
|
|
Service Code
|
NDC 00904585561
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$14.60 |
| Rate for Payer: Aetna Commercial |
$13.79
|
| Rate for Payer: Aetna Medicare |
$4.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.07
|
| Rate for Payer: BCBS Complete |
$6.49
|
| Rate for Payer: BCBS MAPPO |
$4.06
|
| Rate for Payer: BCBS Trust/PPO |
$13.33
|
| Rate for Payer: BCN Commercial |
$12.61
|
| Rate for Payer: BCN Medicare Advantage |
$4.06
|
| 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: Health Alliance Plan Medicare Advantage |
$4.06
|
| Rate for Payer: Healthscope Commercial |
$14.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.79
|
| Rate for Payer: Nomi Health Commercial |
$13.30
|
| Rate for Payer: PACE Senior Care Partners |
$3.85
|
| Rate for Payer: PACE SWMI |
$4.06
|
| Rate for Payer: PHP Commercial |
$13.79
|
| Rate for Payer: PHP Medicare Advantage |
$4.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.54
|
| Rate for Payer: Priority Health HMO/PPO |
$14.11
|
| Rate for Payer: Priority Health Medicare |
$4.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.87
|
| Rate for Payer: Railroad Medicare Medicare |
$4.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.27
|
| Rate for Payer: UHC Core |
$13.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.06
|
| Rate for Payer: UHC Exchange |
$4.06
|
| Rate for Payer: UHC Medicare Advantage |
$4.06
|
| Rate for Payer: VA VA |
$4.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.16
|
|
|
ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$3,124.80
|
|
|
Service Code
|
HCPCS J1744
|
| Hospital Charge Code |
153436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.65 |
| Max. Negotiated Rate |
$2,812.32 |
| Rate for Payer: Aetna Commercial |
$2,656.08
|
| Rate for Payer: Aetna Commercial |
$6,528.90
|
| Rate for Payer: Aetna Medicare |
$812.45
|
| Rate for Payer: Aetna Medicare |
$1,997.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$976.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,400.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$976.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,400.33
|
| Rate for Payer: BCBS Complete |
$102.54
|
| Rate for Payer: BCBS Complete |
$102.54
|
| Rate for Payer: BCBS MAPPO |
$1,920.26
|
| Rate for Payer: BCBS MAPPO |
$781.20
|
| Rate for Payer: BCBS Trust/PPO |
$2,568.90
|
| Rate for Payer: BCBS Trust/PPO |
$6,314.60
|
| Rate for Payer: BCN Commercial |
$2,429.53
|
| Rate for Payer: BCN Commercial |
$5,972.02
|
| Rate for Payer: BCN Medicare Advantage |
$781.20
|
| Rate for Payer: BCN Medicare Advantage |
$1,920.26
|
| Rate for Payer: Cash Price |
$6,144.85
|
| Rate for Payer: Cash Price |
$2,499.84
|
| Rate for Payer: Cash Price |
$2,499.84
|
| Rate for Payer: Cash Price |
$6,144.85
|
| Rate for Payer: Cofinity Commercial |
$2,687.33
|
| Rate for Payer: Cofinity Commercial |
$6,605.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,144.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,499.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$781.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,920.26
|
| Rate for Payer: Healthscope Commercial |
$6,912.95
|
| Rate for Payer: Healthscope Commercial |
$2,812.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,343.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,760.80
|
| Rate for Payer: Mclaren Medicaid |
$97.65
|
| Rate for Payer: Mclaren Medicaid |
$97.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,016.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$820.26
|
| Rate for Payer: Meridian Medicaid |
$102.54
|
| Rate for Payer: Meridian Medicaid |
$102.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$898.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,208.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,656.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,528.90
|
| Rate for Payer: Nomi Health Commercial |
$2,562.34
|
| Rate for Payer: Nomi Health Commercial |
$6,298.47
|
| Rate for Payer: PACE Senior Care Partners |
$742.14
|
| Rate for Payer: PACE Senior Care Partners |
$1,824.25
|
| Rate for Payer: PACE SWMI |
$781.20
|
| Rate for Payer: PACE SWMI |
$1,920.26
|
| Rate for Payer: PHP Commercial |
$6,528.90
|
| Rate for Payer: PHP Commercial |
$2,656.08
|
| Rate for Payer: PHP Medicare Advantage |
$781.20
|
| Rate for Payer: PHP Medicare Advantage |
$1,920.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,031.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,992.69
|
| Rate for Payer: Priority Health HMO/PPO |
$6,682.52
|
| Rate for Payer: Priority Health HMO/PPO |
$2,718.58
|
| Rate for Payer: Priority Health Medicare |
$789.01
|
| Rate for Payer: Priority Health Medicare |
$1,939.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2,093.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5,146.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1,920.26
|
| Rate for Payer: Railroad Medicare Medicare |
$781.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6,759.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,749.82
|
| Rate for Payer: UHC Core |
$6,413.69
|
| Rate for Payer: UHC Core |
$2,609.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$781.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,920.26
|
| Rate for Payer: UHC Exchange |
$1,920.26
|
| Rate for Payer: UHC Exchange |
$781.20
|
| Rate for Payer: UHC Medicare Advantage |
$1,920.26
|
| Rate for Payer: UHC Medicare Advantage |
$781.20
|
| Rate for Payer: UHCCP Medicaid |
$97.65
|
| Rate for Payer: UHCCP Medicaid |
$97.65
|
| Rate for Payer: VA VA |
$781.20
|
| Rate for Payer: VA VA |
$1,920.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,343.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,760.80
|
|
|
ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$3,124.80
|
|
|
Service Code
|
HCPCS J1744
|
| Hospital Charge Code |
153436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,031.12 |
| Max. Negotiated Rate |
$2,812.32 |
| Rate for Payer: Aetna Commercial |
$2,656.08
|
| Rate for Payer: Aetna Commercial |
$6,528.90
|
| Rate for Payer: BCBS Trust/PPO |
$2,550.77
|
| Rate for Payer: BCBS Trust/PPO |
$6,270.05
|
| Rate for Payer: BCN Commercial |
$2,414.85
|
| Rate for Payer: BCN Commercial |
$5,935.92
|
| Rate for Payer: Cash Price |
$2,499.84
|
| Rate for Payer: Cash Price |
$6,144.85
|
| Rate for Payer: Cofinity Commercial |
$6,605.71
|
| Rate for Payer: Cofinity Commercial |
$2,687.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,144.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,499.84
|
| Rate for Payer: Healthscope Commercial |
$2,812.32
|
| Rate for Payer: Healthscope Commercial |
$6,912.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,343.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,760.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,656.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,528.90
|
| Rate for Payer: Nomi Health Commercial |
$2,562.34
|
| Rate for Payer: Nomi Health Commercial |
$6,298.47
|
| Rate for Payer: PHP Commercial |
$2,656.08
|
| Rate for Payer: PHP Commercial |
$6,528.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,992.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,031.12
|
| Rate for Payer: Priority Health HMO/PPO |
$6,682.52
|
| Rate for Payer: Priority Health HMO/PPO |
$2,718.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2,093.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5,146.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,749.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6,759.33
|
| Rate for Payer: UHC Core |
$2,609.21
|
| Rate for Payer: UHC Core |
$6,413.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,343.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,760.80
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$9,101.67
|
|
|
Service Code
|
NDC 00597019705
|
| Hospital Charge Code |
176112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,161.65 |
| Max. Negotiated Rate |
$8,191.50 |
| Rate for Payer: Aetna Commercial |
$7,736.42
|
| Rate for Payer: Aetna Medicare |
$2,366.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,844.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,844.27
|
| Rate for Payer: BCBS Complete |
$3,640.67
|
| Rate for Payer: BCBS MAPPO |
$2,275.42
|
| Rate for Payer: BCBS Trust/PPO |
$7,482.48
|
| Rate for Payer: BCN Commercial |
$7,076.55
|
| Rate for Payer: BCN Medicare Advantage |
$2,275.42
|
| Rate for Payer: Cash Price |
$7,281.34
|
| Rate for Payer: Cofinity Commercial |
$7,827.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,281.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,275.42
|
| Rate for Payer: Healthscope Commercial |
$8,191.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,826.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,389.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,616.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,736.42
|
| Rate for Payer: Nomi Health Commercial |
$7,463.37
|
| Rate for Payer: PACE Senior Care Partners |
$2,161.65
|
| Rate for Payer: PACE SWMI |
$2,275.42
|
| Rate for Payer: PHP Commercial |
$7,736.42
|
| Rate for Payer: PHP Medicare Advantage |
$2,275.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,916.09
|
| Rate for Payer: Priority Health HMO/PPO |
$7,918.45
|
| Rate for Payer: Priority Health Medicare |
$2,298.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6,098.12
|
| Rate for Payer: Railroad Medicare Medicare |
$2,275.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,009.47
|
| Rate for Payer: UHC Core |
$7,599.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,275.42
|
| Rate for Payer: UHC Exchange |
$2,275.42
|
| Rate for Payer: UHC Medicare Advantage |
$2,275.42
|
| Rate for Payer: VA VA |
$2,275.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,826.25
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$9,101.67
|
|
|
Service Code
|
NDC 00597019705
|
| Hospital Charge Code |
176112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,916.09 |
| Max. Negotiated Rate |
$8,191.50 |
| Rate for Payer: Aetna Commercial |
$7,736.42
|
| Rate for Payer: BCBS Trust/PPO |
$7,429.69
|
| Rate for Payer: BCN Commercial |
$7,033.77
|
| Rate for Payer: Cash Price |
$7,281.34
|
| Rate for Payer: Cofinity Commercial |
$7,827.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,281.34
|
| Rate for Payer: Healthscope Commercial |
$8,191.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,826.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,736.42
|
| Rate for Payer: Nomi Health Commercial |
$7,463.37
|
| Rate for Payer: PHP Commercial |
$7,736.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,916.09
|
| Rate for Payer: Priority Health HMO/PPO |
$7,918.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6,098.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,009.47
|
| Rate for Payer: UHC Core |
$7,599.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,826.25
|
|
|
IMPACT PEPTIDE/VITAL 1.5 INTERMITTENT FEED
|
Facility
|
OP
|
$66.60
|
|
|
Service Code
|
NDC 43900097370
|
| Hospital Charge Code |
200090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Aetna Commercial |
$56.61
|
| Rate for Payer: Aetna Medicare |
$17.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20.81
|
| Rate for Payer: BCBS Complete |
$26.64
|
| Rate for Payer: BCBS MAPPO |
$16.65
|
| Rate for Payer: BCBS Trust/PPO |
$54.75
|
| Rate for Payer: BCN Commercial |
$51.78
|
| Rate for Payer: BCN Medicare Advantage |
$16.65
|
| 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: Health Alliance Plan Medicare Advantage |
$16.65
|
| Rate for Payer: Healthscope Commercial |
$59.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.61
|
| Rate for Payer: Nomi Health Commercial |
$54.61
|
| Rate for Payer: PACE Senior Care Partners |
$15.82
|
| Rate for Payer: PACE SWMI |
$16.65
|
| Rate for Payer: PHP Commercial |
$56.61
|
| Rate for Payer: PHP Medicare Advantage |
$16.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.29
|
| Rate for Payer: Priority Health HMO/PPO |
$57.94
|
| Rate for Payer: Priority Health Medicare |
$16.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.62
|
| Rate for Payer: Railroad Medicare Medicare |
$16.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.61
|
| Rate for Payer: UHC Core |
$55.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.65
|
| Rate for Payer: UHC Exchange |
$16.65
|
| Rate for Payer: UHC Medicare Advantage |
$16.65
|
| Rate for Payer: VA VA |
$16.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.95
|
|
|
IMPACT PEPTIDE/VITAL 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$66.60
|
|
|
Service Code
|
NDC 43900097370
|
| Hospital Charge Code |
200090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.29 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Aetna Commercial |
$56.61
|
| Rate for Payer: BCBS Trust/PPO |
$54.37
|
| 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 Commercial |
$56.61
|
| Rate for Payer: Nomi Health Commercial |
$54.61
|
| Rate for Payer: PHP Commercial |
$56.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.29
|
| Rate for Payer: Priority Health HMO/PPO |
$57.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.62
|
| 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
|
|
|
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
|
Facility
|
OP
|
$297.19
|
|
|
Service Code
|
CPT 10061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$283.02 |
| Max. Negotiated Rate |
$297.19 |
| Rate for Payer: BCBS Complete |
$297.19
|
| Rate for Payer: Mclaren Medicaid |
$283.02
|
| Rate for Payer: Meridian Medicaid |
$297.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$283.02
|
| Rate for Payer: UHCCP Medicaid |
$283.02
|
|
|
INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION
|
Facility
|
OP
|
$1,205.21
|
|
|
Service Code
|
CPT 10140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,147.75 |
| Max. Negotiated Rate |
$1,205.21 |
| Rate for Payer: BCBS Complete |
$1,205.21
|
| Rate for Payer: Mclaren Medicaid |
$1,147.75
|
| Rate for Payer: Meridian Medicaid |
$1,205.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,147.75
|
| Rate for Payer: UHCCP Medicaid |
$1,147.75
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$1,190.46
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,133.70 |
| Max. Negotiated Rate |
$1,190.46 |
| Rate for Payer: BCBS Complete |
$1,190.46
|
| Rate for Payer: Mclaren Medicaid |
$1,133.70
|
| Rate for Payer: Meridian Medicaid |
$1,190.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,133.70
|
| Rate for Payer: UHCCP Medicaid |
$1,133.70
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$518.38
|
|
|
Service Code
|
NDC 00517037501
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$123.12 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: Aetna Medicare |
$134.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$161.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$161.99
|
| Rate for Payer: BCBS Complete |
$207.35
|
| Rate for Payer: BCBS MAPPO |
$129.60
|
| Rate for Payer: BCBS Trust/PPO |
$426.16
|
| Rate for Payer: BCN Commercial |
$403.04
|
| Rate for Payer: BCN Medicare Advantage |
$129.60
|
| 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: Health Alliance Plan Medicare Advantage |
$129.60
|
| Rate for Payer: Healthscope Commercial |
$466.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$388.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$136.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$149.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.62
|
| Rate for Payer: Nomi Health Commercial |
$425.07
|
| Rate for Payer: PACE Senior Care Partners |
$123.12
|
| Rate for Payer: PACE SWMI |
$129.60
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: PHP Medicare Advantage |
$129.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.95
|
| Rate for Payer: Priority Health HMO/PPO |
$450.99
|
| Rate for Payer: Priority Health Medicare |
$130.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$347.31
|
| Rate for Payer: Railroad Medicare Medicare |
$129.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$456.17
|
| Rate for Payer: UHC Core |
$432.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$129.60
|
| Rate for Payer: UHC Exchange |
$129.60
|
| Rate for Payer: UHC Medicare Advantage |
$129.60
|
| Rate for Payer: VA VA |
$129.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$388.78
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 00517037505
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$336.95 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: BCBS Trust/PPO |
$423.15
|
| 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 Commercial |
$440.62
|
| Rate for Payer: Nomi Health Commercial |
$425.07
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.95
|
| Rate for Payer: Priority Health HMO/PPO |
$450.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$347.31
|
| 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 00517037510
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$308.86 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: BCBS Trust/PPO |
$387.88
|
| 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 Commercial |
$403.89
|
| Rate for Payer: Nomi Health Commercial |
$389.64
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health HMO/PPO |
$413.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$318.36
|
| 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
|
OP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.85 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$123.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$148.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$148.49
|
| Rate for Payer: BCBS Complete |
$190.07
|
| Rate for Payer: BCBS MAPPO |
$118.79
|
| Rate for Payer: BCBS Trust/PPO |
$390.64
|
| Rate for Payer: BCN Commercial |
$369.44
|
| Rate for Payer: BCN Medicare Advantage |
$118.79
|
| 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: Health Alliance Plan Medicare Advantage |
$118.79
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$124.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$136.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Nomi Health Commercial |
$389.64
|
| Rate for Payer: PACE Senior Care Partners |
$112.85
|
| Rate for Payer: PACE SWMI |
$118.79
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: PHP Medicare Advantage |
$118.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health HMO/PPO |
$413.40
|
| Rate for Payer: Priority Health Medicare |
$119.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$318.36
|
| Rate for Payer: Railroad Medicare Medicare |
$118.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.15
|
| Rate for Payer: UHC Core |
$396.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$118.79
|
| Rate for Payer: UHC Exchange |
$118.79
|
| Rate for Payer: UHC Medicare Advantage |
$118.79
|
| Rate for Payer: VA VA |
$118.79
|
| 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 00517037501
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$336.95 |
| Max. Negotiated Rate |
$466.54 |
| Rate for Payer: Aetna Commercial |
$440.62
|
| Rate for Payer: BCBS Trust/PPO |
$423.15
|
| 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 Commercial |
$440.62
|
| Rate for Payer: Nomi Health Commercial |
$425.07
|
| Rate for Payer: PHP Commercial |
$440.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.95
|
| Rate for Payer: Priority Health HMO/PPO |
$450.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$347.31
|
| 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
|
|
