|
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
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 00517037501
|
| Hospital Charge Code |
108702
|
|
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 SOLUTION
|
Facility
|
OP
|
$518.38
|
|
|
Service Code
|
NDC 00517037501
|
| Hospital Charge Code |
108702
|
|
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 SOLUTION
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
108702
|
|
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 SOLUTION
|
Facility
|
OP
|
$518.38
|
|
|
Service Code
|
NDC 00517037505
|
| Hospital Charge Code |
108702
|
|
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 SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
108702
|
|
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 SOLUTION
|
Facility
|
IP
|
$518.38
|
|
|
Service Code
|
NDC 00517037505
|
| Hospital Charge Code |
108702
|
|
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
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.90 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna Medicare |
$109.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$131.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$131.45
|
| Rate for Payer: BCBS Complete |
$168.26
|
| Rate for Payer: BCBS MAPPO |
$105.16
|
| Rate for Payer: BCBS Trust/PPO |
$345.82
|
| Rate for Payer: BCN Commercial |
$327.06
|
| Rate for Payer: BCN Medicare Advantage |
$105.16
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$105.16
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$110.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Nomi Health Commercial |
$344.93
|
| Rate for Payer: PACE Senior Care Partners |
$99.90
|
| Rate for Payer: PACE SWMI |
$105.16
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: PHP Medicare Advantage |
$105.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.42
|
| Rate for Payer: Priority Health HMO/PPO |
$365.97
|
| Rate for Payer: Priority Health Medicare |
$106.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$281.84
|
| Rate for Payer: Railroad Medicare Medicare |
$105.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$370.17
|
| Rate for Payer: UHC Core |
$351.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$105.16
|
| Rate for Payer: UHC Exchange |
$105.16
|
| Rate for Payer: UHC Medicare Advantage |
$105.16
|
| Rate for Payer: VA VA |
$105.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$120.18
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.12 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna Commercial |
$102.15
|
| Rate for Payer: BCBS Trust/PPO |
$98.10
|
| Rate for Payer: BCN Commercial |
$92.88
|
| Rate for Payer: Cash Price |
$96.14
|
| Rate for Payer: Cofinity Commercial |
$103.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.14
|
| Rate for Payer: Healthscope Commercial |
$108.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.15
|
| Rate for Payer: Nomi Health Commercial |
$98.55
|
| Rate for Payer: PHP Commercial |
$102.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.12
|
| Rate for Payer: Priority Health HMO/PPO |
$104.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$80.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.76
|
| Rate for Payer: UHC Core |
$100.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.14
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: BCBS Trust/PPO |
$343.38
|
| Rate for Payer: BCN Commercial |
$325.08
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Nomi Health Commercial |
$344.93
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.42
|
| Rate for Payer: Priority Health HMO/PPO |
$365.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$281.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$370.17
|
| Rate for Payer: UHC Core |
$351.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: BCBS Trust/PPO |
$1.97
|
| Rate for Payer: BCN Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.93
|
| Rate for Payer: Healthscope Commercial |
$2.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.05
|
| Rate for Payer: Nomi Health Commercial |
$1.98
|
| Rate for Payer: PHP Commercial |
$2.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.57
|
| Rate for Payer: Priority Health HMO/PPO |
$2.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.12
|
| Rate for Payer: UHC Core |
$2.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$120.18
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna Commercial |
$102.15
|
| Rate for Payer: Aetna Medicare |
$31.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37.56
|
| Rate for Payer: BCBS Complete |
$48.07
|
| Rate for Payer: BCBS MAPPO |
$30.04
|
| Rate for Payer: BCBS Trust/PPO |
$98.80
|
| Rate for Payer: BCN Commercial |
$93.44
|
| Rate for Payer: BCN Medicare Advantage |
$30.04
|
| Rate for Payer: Cash Price |
$96.14
|
| Rate for Payer: Cofinity Commercial |
$103.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$30.04
|
| Rate for Payer: Healthscope Commercial |
$108.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.15
|
| Rate for Payer: Nomi Health Commercial |
$98.55
|
| Rate for Payer: PACE Senior Care Partners |
$28.54
|
| Rate for Payer: PACE SWMI |
$30.04
|
| Rate for Payer: PHP Commercial |
$102.15
|
| Rate for Payer: PHP Medicare Advantage |
$30.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.12
|
| Rate for Payer: Priority Health HMO/PPO |
$104.56
|
| Rate for Payer: Priority Health Medicare |
$30.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$80.52
|
| Rate for Payer: Railroad Medicare Medicare |
$30.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.76
|
| Rate for Payer: UHC Core |
$100.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$30.04
|
| Rate for Payer: UHC Exchange |
$30.04
|
| Rate for Payer: UHC Medicare Advantage |
$30.04
|
| Rate for Payer: VA VA |
$30.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.14
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$2.41
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: Aetna Medicare |
$0.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.75
|
| Rate for Payer: BCBS Complete |
$0.96
|
| Rate for Payer: BCBS MAPPO |
$0.60
|
| Rate for Payer: BCBS Trust/PPO |
$1.98
|
| Rate for Payer: BCN Commercial |
$1.87
|
| Rate for Payer: BCN Medicare Advantage |
$0.60
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.60
|
| Rate for Payer: Healthscope Commercial |
$2.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.05
|
| Rate for Payer: Nomi Health Commercial |
$1.98
|
| Rate for Payer: PACE Senior Care Partners |
$0.57
|
| Rate for Payer: PACE SWMI |
$0.60
|
| Rate for Payer: PHP Commercial |
$2.05
|
| Rate for Payer: PHP Medicare Advantage |
$0.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.57
|
| Rate for Payer: Priority Health HMO/PPO |
$2.10
|
| Rate for Payer: Priority Health Medicare |
$0.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.61
|
| Rate for Payer: Railroad Medicare Medicare |
$0.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.12
|
| Rate for Payer: UHC Core |
$2.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.60
|
| Rate for Payer: UHC Exchange |
$0.60
|
| Rate for Payer: UHC Medicare Advantage |
$0.60
|
| Rate for Payer: VA VA |
$0.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
INHALATIONAL SPACING DEVICE
|
Facility
|
IP
|
$39.08
|
|
|
Service Code
|
NDC 08373747800
|
| Hospital Charge Code |
113188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.40 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna Commercial |
$33.22
|
| Rate for Payer: BCBS Trust/PPO |
$31.90
|
| Rate for Payer: BCN Commercial |
$30.20
|
| Rate for Payer: Cash Price |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$33.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.26
|
| Rate for Payer: Healthscope Commercial |
$35.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.22
|
| Rate for Payer: Nomi Health Commercial |
$32.05
|
| Rate for Payer: PHP Commercial |
$33.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.40
|
| Rate for Payer: Priority Health HMO/PPO |
$34.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.39
|
| Rate for Payer: UHC Core |
$32.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.31
|
|
|
INHALATIONAL SPACING DEVICE
|
Facility
|
OP
|
$39.08
|
|
|
Service Code
|
NDC 08373747800
|
| Hospital Charge Code |
113188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna Commercial |
$33.22
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.21
|
| Rate for Payer: BCBS Complete |
$15.63
|
| Rate for Payer: BCBS MAPPO |
$9.77
|
| Rate for Payer: BCBS Trust/PPO |
$32.13
|
| Rate for Payer: BCN Commercial |
$30.38
|
| Rate for Payer: BCN Medicare Advantage |
$9.77
|
| Rate for Payer: Cash Price |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$33.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$35.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.22
|
| Rate for Payer: Nomi Health Commercial |
$32.05
|
| Rate for Payer: PACE Senior Care Partners |
$9.28
|
| Rate for Payer: PACE SWMI |
$9.77
|
| Rate for Payer: PHP Commercial |
$33.22
|
| Rate for Payer: PHP Medicare Advantage |
$9.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.40
|
| Rate for Payer: Priority Health HMO/PPO |
$34.00
|
| Rate for Payer: Priority Health Medicare |
$9.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.18
|
| Rate for Payer: Railroad Medicare Medicare |
$9.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.39
|
| Rate for Payer: UHC Core |
$32.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.77
|
| Rate for Payer: UHC Exchange |
$9.77
|
| Rate for Payer: UHC Medicare Advantage |
$9.77
|
| Rate for Payer: VA VA |
$9.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.31
|
|
|
INHALATIONAL SPACING DEVICE
|
Facility
|
IP
|
$29.35
|
|
|
Service Code
|
NDC 08373077478
|
| Hospital Charge Code |
113188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.08 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Aetna Commercial |
$24.95
|
| Rate for Payer: BCBS Trust/PPO |
$23.96
|
| Rate for Payer: BCN Commercial |
$22.68
|
| Rate for Payer: Cash Price |
$23.48
|
| Rate for Payer: Cofinity Commercial |
$25.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.48
|
| Rate for Payer: Healthscope Commercial |
$26.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.95
|
| Rate for Payer: Nomi Health Commercial |
$24.07
|
| Rate for Payer: PHP Commercial |
$24.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.08
|
| Rate for Payer: Priority Health HMO/PPO |
$25.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.83
|
| Rate for Payer: UHC Core |
$24.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.01
|
|
|
INHALATIONAL SPACING DEVICE
|
Facility
|
OP
|
$29.35
|
|
|
Service Code
|
NDC 08373077478
|
| Hospital Charge Code |
113188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Aetna Commercial |
$24.95
|
| Rate for Payer: Aetna Medicare |
$7.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.17
|
| Rate for Payer: BCBS Complete |
$11.74
|
| Rate for Payer: BCBS MAPPO |
$7.34
|
| Rate for Payer: BCBS Trust/PPO |
$24.13
|
| Rate for Payer: BCN Commercial |
$22.82
|
| Rate for Payer: BCN Medicare Advantage |
$7.34
|
| Rate for Payer: Cash Price |
$23.48
|
| Rate for Payer: Cofinity Commercial |
$25.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.34
|
| Rate for Payer: Healthscope Commercial |
$26.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.95
|
| Rate for Payer: Nomi Health Commercial |
$24.07
|
| Rate for Payer: PACE Senior Care Partners |
$6.97
|
| Rate for Payer: PACE SWMI |
$7.34
|
| Rate for Payer: PHP Commercial |
$24.95
|
| Rate for Payer: PHP Medicare Advantage |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.08
|
| Rate for Payer: Priority Health HMO/PPO |
$25.53
|
| Rate for Payer: Priority Health Medicare |
$7.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.66
|
| Rate for Payer: Railroad Medicare Medicare |
$7.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.83
|
| Rate for Payer: UHC Core |
$24.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.34
|
| Rate for Payer: UHC Exchange |
$7.34
|
| Rate for Payer: UHC Medicare Advantage |
$7.34
|
| Rate for Payer: VA VA |
$7.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.01
|
|
|
INHALER, ASSIST DEVICES, ACCESSORIES
|
Facility
|
IP
|
$25.87
|
|
|
Service Code
|
NDC 08373081111
|
| Hospital Charge Code |
118717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Aetna Commercial |
$21.99
|
| Rate for Payer: BCBS Trust/PPO |
$21.12
|
| Rate for Payer: BCN Commercial |
$19.99
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cofinity Commercial |
$22.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.70
|
| Rate for Payer: Healthscope Commercial |
$23.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.99
|
| Rate for Payer: Nomi Health Commercial |
$21.21
|
| Rate for Payer: PHP Commercial |
$21.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.82
|
| Rate for Payer: Priority Health HMO/PPO |
$22.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.77
|
| Rate for Payer: UHC Core |
$21.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.40
|
|
|
INHALER, ASSIST DEVICES, ACCESSORIES
|
Facility
|
OP
|
$25.87
|
|
|
Service Code
|
NDC 08373081111
|
| Hospital Charge Code |
118717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Aetna Commercial |
$21.99
|
| Rate for Payer: Aetna Medicare |
$6.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.08
|
| Rate for Payer: BCBS Complete |
$10.35
|
| Rate for Payer: BCBS MAPPO |
$6.47
|
| Rate for Payer: BCBS Trust/PPO |
$21.27
|
| Rate for Payer: BCN Commercial |
$20.11
|
| Rate for Payer: BCN Medicare Advantage |
$6.47
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cofinity Commercial |
$22.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.47
|
| Rate for Payer: Healthscope Commercial |
$23.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.99
|
| Rate for Payer: Nomi Health Commercial |
$21.21
|
| Rate for Payer: PACE Senior Care Partners |
$6.14
|
| Rate for Payer: PACE SWMI |
$6.47
|
| Rate for Payer: PHP Commercial |
$21.99
|
| Rate for Payer: PHP Medicare Advantage |
$6.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.82
|
| Rate for Payer: Priority Health HMO/PPO |
$22.51
|
| Rate for Payer: Priority Health Medicare |
$6.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.33
|
| Rate for Payer: Railroad Medicare Medicare |
$6.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.77
|
| Rate for Payer: UHC Core |
$21.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.47
|
| Rate for Payer: UHC Exchange |
$6.47
|
| Rate for Payer: UHC Medicare Advantage |
$6.47
|
| Rate for Payer: VA VA |
$6.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.40
|
|
|
INHALER, ASSIST DEVICES, ACCESSORIES
|
Facility
|
IP
|
$24.83
|
|
|
Service Code
|
NDC 08373081211
|
| Hospital Charge Code |
118717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.14 |
| Max. Negotiated Rate |
$22.35 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: BCBS Trust/PPO |
$20.27
|
| Rate for Payer: BCN Commercial |
$19.19
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Cofinity Commercial |
$21.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.86
|
| Rate for Payer: Healthscope Commercial |
$22.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Nomi Health Commercial |
$20.36
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.14
|
| Rate for Payer: Priority Health HMO/PPO |
$21.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.85
|
| Rate for Payer: UHC Core |
$20.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.62
|
|
|
INHALER, ASSIST DEVICES, ACCESSORIES
|
Facility
|
OP
|
$24.83
|
|
|
Service Code
|
NDC 08373081211
|
| Hospital Charge Code |
118717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.90 |
| Max. Negotiated Rate |
$22.35 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$6.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.76
|
| Rate for Payer: BCBS Complete |
$9.93
|
| Rate for Payer: BCBS MAPPO |
$6.21
|
| Rate for Payer: BCBS Trust/PPO |
$20.41
|
| Rate for Payer: BCN Commercial |
$19.31
|
| Rate for Payer: BCN Medicare Advantage |
$6.21
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Cofinity Commercial |
$21.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.21
|
| Rate for Payer: Healthscope Commercial |
$22.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Nomi Health Commercial |
$20.36
|
| Rate for Payer: PACE Senior Care Partners |
$5.90
|
| Rate for Payer: PACE SWMI |
$6.21
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Medicare Advantage |
$6.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.14
|
| Rate for Payer: Priority Health HMO/PPO |
$21.60
|
| Rate for Payer: Priority Health Medicare |
$6.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.64
|
| Rate for Payer: Railroad Medicare Medicare |
$6.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.85
|
| Rate for Payer: UHC Core |
$20.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.21
|
| Rate for Payer: UHC Exchange |
$6.21
|
| Rate for Payer: UHC Medicare Advantage |
$6.21
|
| Rate for Payer: VA VA |
$6.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.62
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
|
Facility
|
OP
|
$515.13
|
|
|
Service Code
|
CPT G0260
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$490.57 |
| Max. Negotiated Rate |
$515.13 |
| Rate for Payer: BCBS Complete |
$515.13
|
| Rate for Payer: Mclaren Medicaid |
$490.57
|
| Rate for Payer: Meridian Medicaid |
$515.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$490.57
|
| Rate for Payer: UHCCP Medicaid |
$490.57
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
|
Facility
|
OP
|
$515.13
|
|
|
Service Code
|
CPT G0260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$490.57 |
| Max. Negotiated Rate |
$515.13 |
| Rate for Payer: BCBS Complete |
$515.13
|
| Rate for Payer: Mclaren Medicaid |
$490.57
|
| Rate for Payer: Meridian Medicaid |
$515.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$490.57
|
| Rate for Payer: UHCCP Medicaid |
$490.57
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$515.13
|
|
|
Service Code
|
CPT 64447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$490.57 |
| Max. Negotiated Rate |
$515.13 |
| Rate for Payer: BCBS Complete |
$515.13
|
| Rate for Payer: Mclaren Medicaid |
$490.57
|
| Rate for Payer: Meridian Medicaid |
$515.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$490.57
|
| Rate for Payer: UHCCP Medicaid |
$490.57
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$515.13
|
|
|
Service Code
|
CPT 64454
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$490.57 |
| Max. Negotiated Rate |
$515.13 |
| Rate for Payer: BCBS Complete |
$515.13
|
| Rate for Payer: Mclaren Medicaid |
$490.57
|
| Rate for Payer: Meridian Medicaid |
$515.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$490.57
|
| Rate for Payer: UHCCP Medicaid |
$490.57
|
|
