|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 63323-739-12
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$7.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 70860-751-41
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna American Axle |
$9.75
|
| Rate for Payer: Aetna Commercial |
$12.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.75
|
| Rate for Payer: BCBS Complete |
$6.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.75
|
| Rate for Payer: PHP Commercial |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
| Rate for Payer: Priority Health SBD |
$9.45
|
| Rate for Payer: UMR Bronson Commercial |
$5.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.25
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.56
|
|
|
Service Code
|
NDC 55390-029-10
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Aetna American Axle |
$10.76
|
| Rate for Payer: Aetna Commercial |
$14.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.76
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cofinity Commercial |
$11.59
|
| Rate for Payer: Cofinity Commercial |
$14.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.25
|
| Rate for Payer: Healthscope Commercial |
$14.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.08
|
| Rate for Payer: PHP Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.59
|
| Rate for Payer: Priority Health SBD |
$10.43
|
| Rate for Payer: UMR Bronson Commercial |
$7.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.42
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-25
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna American Axle |
$7.94
|
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.94
|
| Rate for Payer: BCBS Complete |
$4.88
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$8.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$10.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: Priority Health SBD |
$7.69
|
| Rate for Payer: UMR Bronson Commercial |
$4.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.16
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-01
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna American Axle |
$7.94
|
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.94
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$8.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$10.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: Priority Health SBD |
$7.69
|
| Rate for Payer: UMR Bronson Commercial |
$5.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.16
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 67457-433-00
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna American Axle |
$7.83
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$8.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.24
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.44
|
| Rate for Payer: Priority Health SBD |
$7.59
|
| Rate for Payer: UMR Bronson Commercial |
$4.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 9900-0006-29
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Aetna American Axle |
$8.26
|
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.26
|
| Rate for Payer: BCBS Complete |
$5.08
|
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Cofinity Commercial |
$10.92
|
| Rate for Payer: Cofinity Commercial |
$8.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.16
|
| Rate for Payer: Healthscope Commercial |
$11.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.80
|
| Rate for Payer: PHP Commercial |
$10.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.89
|
| Rate for Payer: Priority Health SBD |
$8.00
|
| Rate for Payer: UMR Bronson Commercial |
$4.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.52
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-01
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna American Axle |
$7.94
|
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.94
|
| Rate for Payer: BCBS Complete |
$4.88
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$8.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$10.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: Priority Health SBD |
$7.69
|
| Rate for Payer: UMR Bronson Commercial |
$4.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.16
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 63323-739-11
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: BCBS Complete |
$6.42
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-25
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna American Axle |
$7.94
|
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.94
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$8.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$10.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: Priority Health SBD |
$7.69
|
| Rate for Payer: UMR Bronson Commercial |
$5.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.16
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.56
|
|
|
Service Code
|
NDC 55390-029-10
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.13 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Aetna American Axle |
$10.76
|
| Rate for Payer: Aetna Commercial |
$14.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.76
|
| Rate for Payer: BCBS Complete |
$6.62
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cofinity Commercial |
$11.59
|
| Rate for Payer: Cofinity Commercial |
$14.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.25
|
| Rate for Payer: Healthscope Commercial |
$14.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.08
|
| Rate for Payer: PHP Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.59
|
| Rate for Payer: Priority Health SBD |
$10.43
|
| Rate for Payer: UMR Bronson Commercial |
$6.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.42
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 70860-751-02
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna American Axle |
$9.75
|
| Rate for Payer: Aetna Commercial |
$12.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.75
|
| Rate for Payer: BCBS Complete |
$6.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.75
|
| Rate for Payer: PHP Commercial |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
| Rate for Payer: Priority Health SBD |
$9.45
|
| Rate for Payer: UMR Bronson Commercial |
$5.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.25
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 67457-433-22
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna American Axle |
$7.83
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$8.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.24
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.44
|
| Rate for Payer: Priority Health SBD |
$7.59
|
| Rate for Payer: UMR Bronson Commercial |
$4.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12,131.40
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
192405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.90 |
| Max. Negotiated Rate |
$10,918.26 |
| Rate for Payer: Aetna American Axle |
$7,885.41
|
| Rate for Payer: Aetna Commercial |
$10,311.69
|
| Rate for Payer: Aetna Medicare |
$28.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,885.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.05
|
| Rate for Payer: BCBS Complete |
$15.65
|
| Rate for Payer: BCBS MAPPO |
$27.24
|
| Rate for Payer: BCBS Trust/PPO |
$88.01
|
| Rate for Payer: BCN Medicare Advantage |
$27.24
|
| Rate for Payer: Cash Price |
$9,705.12
|
| Rate for Payer: Cash Price |
$9,705.12
|
| Rate for Payer: Cofinity Commercial |
$10,433.00
|
| Rate for Payer: Cofinity Commercial |
$8,491.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,705.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.24
|
| Rate for Payer: Healthscope Commercial |
$10,918.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,491.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,098.55
|
| Rate for Payer: Mclaren Medicaid |
$14.90
|
| Rate for Payer: Mclaren Medicare |
$27.24
|
| Rate for Payer: Meridian Medicaid |
$15.65
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$28.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10,311.69
|
| Rate for Payer: PACE Medicare |
$25.88
|
| Rate for Payer: PACE SWMI |
$27.24
|
| Rate for Payer: PHP Commercial |
$10,311.69
|
| Rate for Payer: PHP Medicare Advantage |
$27.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,491.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77.48
|
| Rate for Payer: Priority Health Medicare |
$27.24
|
| Rate for Payer: Priority Health Narrow Network |
$61.98
|
| Rate for Payer: Priority Health SBD |
$7,642.78
|
| Rate for Payer: Railroad Medicare Medicare |
$27.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$27.24
|
| Rate for Payer: UHC Medicare Advantage |
$28.06
|
| Rate for Payer: UMR Bronson Commercial |
$4,488.62
|
| Rate for Payer: VA VA |
$27.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,098.55
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12,131.40
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
192405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,337.82 |
| Max. Negotiated Rate |
$10,918.26 |
| Rate for Payer: Aetna American Axle |
$7,885.41
|
| Rate for Payer: Aetna Commercial |
$10,311.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,885.41
|
| Rate for Payer: Cash Price |
$9,705.12
|
| Rate for Payer: Cofinity Commercial |
$10,433.00
|
| Rate for Payer: Cofinity Commercial |
$8,491.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,705.12
|
| Rate for Payer: Healthscope Commercial |
$10,918.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,491.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,098.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10,311.69
|
| Rate for Payer: PHP Commercial |
$10,311.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,491.98
|
| Rate for Payer: Priority Health SBD |
$7,642.78
|
| Rate for Payer: UMR Bronson Commercial |
$5,337.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,098.55
|
|
|
FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$9,057.42
|
|
|
Service Code
|
CPT 26121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$600.20 |
| Max. Negotiated Rate |
$9,057.42 |
| Rate for Payer: Aetna Medicare |
$2,992.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,596.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,596.44
|
| Rate for Payer: BCBS Complete |
$1,652.63
|
| Rate for Payer: BCBS MAPPO |
$2,877.15
|
| Rate for Payer: BCBS Trust/PPO |
$2,111.70
|
| Rate for Payer: BCN Medicare Advantage |
$2,877.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,877.15
|
| Rate for Payer: Mclaren Medicaid |
$1,573.80
|
| Rate for Payer: Mclaren Medicare |
$2,877.15
|
| Rate for Payer: Meridian Medicaid |
$1,652.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,021.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,308.72
|
| Rate for Payer: PACE Medicare |
$2,733.29
|
| Rate for Payer: PACE SWMI |
$2,877.15
|
| Rate for Payer: PHP Medicare Advantage |
$2,877.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,573.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,057.42
|
| Rate for Payer: Priority Health Medicare |
$2,877.15
|
| Rate for Payer: Priority Health Narrow Network |
$7,245.94
|
| Rate for Payer: Railroad Medicare Medicare |
$2,877.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$660.22
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,877.15
|
| Rate for Payer: UHC Exchange |
$600.20
|
| Rate for Payer: UHC Medicare Advantage |
$2,963.46
|
| Rate for Payer: VA VA |
$2,877.15
|
|
|
FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);
|
Facility
|
OP
|
$9,057.42
|
|
|
Service Code
|
CPT 26123
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.29 |
| Max. Negotiated Rate |
$9,057.42 |
| Rate for Payer: Aetna Medicare |
$2,992.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,596.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,596.44
|
| Rate for Payer: BCBS Complete |
$1,652.63
|
| Rate for Payer: BCBS MAPPO |
$2,877.15
|
| Rate for Payer: BCBS Trust/PPO |
$3,101.15
|
| Rate for Payer: BCN Medicare Advantage |
$2,877.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,877.15
|
| Rate for Payer: Mclaren Medicaid |
$1,573.80
|
| Rate for Payer: Mclaren Medicare |
$2,877.15
|
| Rate for Payer: Meridian Medicaid |
$1,652.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,021.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,308.72
|
| Rate for Payer: PACE Medicare |
$2,733.29
|
| Rate for Payer: PACE SWMI |
$2,877.15
|
| Rate for Payer: PHP Medicare Advantage |
$2,877.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,573.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,057.42
|
| Rate for Payer: Priority Health Medicare |
$2,877.15
|
| Rate for Payer: Priority Health Narrow Network |
$7,245.94
|
| Rate for Payer: Railroad Medicare Medicare |
$2,877.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$919.92
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,877.15
|
| Rate for Payer: UHC Exchange |
$836.29
|
| Rate for Payer: UHC Medicare Advantage |
$2,963.46
|
| Rate for Payer: VA VA |
$2,877.15
|
|
|
FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$954.11
|
|
|
Service Code
|
CPT 26125
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$954.11 |
| Rate for Payer: BCBS Trust/PPO |
$954.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.14
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$261.95
|
|
|
FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONTRACTURE); OPEN, PARTIAL
|
Facility
|
OP
|
$9,057.42
|
|
|
Service Code
|
CPT 26045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$475.12 |
| Max. Negotiated Rate |
$9,057.42 |
| Rate for Payer: Aetna Medicare |
$2,992.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,596.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,596.44
|
| Rate for Payer: BCBS Complete |
$1,652.63
|
| Rate for Payer: BCBS MAPPO |
$2,877.15
|
| Rate for Payer: BCBS Trust/PPO |
$2,111.70
|
| Rate for Payer: BCN Medicare Advantage |
$2,877.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,877.15
|
| Rate for Payer: Mclaren Medicaid |
$1,573.80
|
| Rate for Payer: Mclaren Medicare |
$2,877.15
|
| Rate for Payer: Meridian Medicaid |
$1,652.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,021.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,308.72
|
| Rate for Payer: PACE Medicare |
$2,733.29
|
| Rate for Payer: PACE SWMI |
$2,877.15
|
| Rate for Payer: PHP Medicare Advantage |
$2,877.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,573.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,057.42
|
| Rate for Payer: Priority Health Medicare |
$2,877.15
|
| Rate for Payer: Priority Health Narrow Network |
$7,245.94
|
| Rate for Payer: Railroad Medicare Medicare |
$2,877.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$522.63
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,877.15
|
| Rate for Payer: UHC Exchange |
$475.12
|
| Rate for Payer: UHC Medicare Advantage |
$2,963.46
|
| Rate for Payer: VA VA |
$2,877.15
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 0338-0519-13
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna American Axle |
$130.00
|
| Rate for Payer: Aetna Commercial |
$170.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$172.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$180.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.00
|
| Rate for Payer: PHP Commercial |
$170.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.00
|
| Rate for Payer: Priority Health SBD |
$126.00
|
| Rate for Payer: UMR Bronson Commercial |
$88.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.00
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 0338-0519-58
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Aetna American Axle |
$6.18
|
| Rate for Payer: Aetna Commercial |
$8.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.18
|
| Rate for Payer: BCBS Complete |
$3.80
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cofinity Commercial |
$6.65
|
| Rate for Payer: Cofinity Commercial |
$8.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$8.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.08
|
| Rate for Payer: PHP Commercial |
$8.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.65
|
| Rate for Payer: Priority Health SBD |
$5.98
|
| Rate for Payer: UMR Bronson Commercial |
$3.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.12
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 0338-9540-03
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna American Axle |
$8.45
|
| Rate for Payer: Aetna Commercial |
$11.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.45
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cofinity Commercial |
$11.18
|
| Rate for Payer: Cofinity Commercial |
$9.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.40
|
| Rate for Payer: Healthscope Commercial |
$11.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.05
|
| Rate for Payer: PHP Commercial |
$11.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.10
|
| Rate for Payer: Priority Health SBD |
$8.19
|
| Rate for Payer: UMR Bronson Commercial |
$5.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.75
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 0338-9540-04
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Aetna American Axle |
$16.25
|
| Rate for Payer: Aetna Commercial |
$21.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.25
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cofinity Commercial |
$17.50
|
| Rate for Payer: Cofinity Commercial |
$21.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.00
|
| Rate for Payer: Healthscope Commercial |
$22.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.25
|
| Rate for Payer: PHP Commercial |
$21.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.50
|
| Rate for Payer: Priority Health SBD |
$15.75
|
| Rate for Payer: UMR Bronson Commercial |
$11.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.75
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 0338-9540-08
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Aetna American Axle |
$16.25
|
| Rate for Payer: Aetna Commercial |
$21.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.25
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cofinity Commercial |
$17.50
|
| Rate for Payer: Cofinity Commercial |
$21.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.00
|
| Rate for Payer: Healthscope Commercial |
$22.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.25
|
| Rate for Payer: PHP Commercial |
$21.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.50
|
| Rate for Payer: Priority Health SBD |
$15.75
|
| Rate for Payer: UMR Bronson Commercial |
$11.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.75
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$10.25
|
|
|
Service Code
|
NDC 0338-9540-02
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna American Axle |
$6.66
|
| Rate for Payer: Aetna Commercial |
$8.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.66
|
| Rate for Payer: Cash Price |
$8.20
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.20
|
| Rate for Payer: Healthscope Commercial |
$9.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.71
|
| Rate for Payer: PHP Commercial |
$8.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.69
|
|
