|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
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 |
$175.81 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$237.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: BCBS Complete |
$190.07
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: UMR Bronson Commercial |
$175.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
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 |
$209.07 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: UMR Bronson Commercial |
$209.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$232.38
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.98 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna Medicare |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: BCBS Complete |
$92.95
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$85.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.49 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$120.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.54 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$230.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070102
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.49 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$120.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.54 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$230.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$232.38
|
|
|
Service Code
|
NDC 17238042425
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.98 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna Medicare |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: BCBS Complete |
$92.95
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$85.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.87 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$193.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.25 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$102.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238042425
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.25 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$102.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070102
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.87 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$193.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$957.40
|
|
|
Service Code
|
NDC 63323065903
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$354.24 |
| Max. Negotiated Rate |
$861.66 |
| Rate for Payer: Aetna American Axle |
$622.31
|
| Rate for Payer: Aetna Commercial |
$813.79
|
| Rate for Payer: Aetna Medicare |
$478.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.31
|
| Rate for Payer: BCBS Complete |
$382.96
|
| Rate for Payer: Cash Price |
$765.92
|
| Rate for Payer: Cofinity Commercial |
$670.18
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$670.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$765.92
|
| Rate for Payer: Healthscope Commercial |
$861.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$813.79
|
| Rate for Payer: PHP Commercial |
$813.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$622.31
|
| Rate for Payer: Priority Health SBD |
$603.16
|
| Rate for Payer: UMR Bronson Commercial |
$354.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.05
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$962.98
|
|
|
Service Code
|
NDC 63323065909
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$356.30 |
| Max. Negotiated Rate |
$866.68 |
| Rate for Payer: Aetna American Axle |
$625.94
|
| Rate for Payer: Aetna Commercial |
$818.53
|
| Rate for Payer: Aetna Medicare |
$481.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$625.94
|
| Rate for Payer: BCBS Complete |
$385.19
|
| Rate for Payer: Cash Price |
$770.38
|
| Rate for Payer: Cofinity Commercial |
$674.09
|
| Rate for Payer: Cofinity Commercial |
$828.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$674.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$770.38
|
| Rate for Payer: Healthscope Commercial |
$866.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$674.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$722.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$818.53
|
| Rate for Payer: PHP Commercial |
$818.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$625.94
|
| Rate for Payer: Priority Health SBD |
$606.68
|
| Rate for Payer: UMR Bronson Commercial |
$356.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$722.24
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$957.40
|
|
|
Service Code
|
NDC 63323065903
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$421.26 |
| Max. Negotiated Rate |
$861.66 |
| Rate for Payer: Aetna American Axle |
$622.31
|
| Rate for Payer: Aetna Commercial |
$813.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.31
|
| Rate for Payer: Cash Price |
$765.92
|
| Rate for Payer: Cofinity Commercial |
$670.18
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$670.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$765.92
|
| Rate for Payer: Healthscope Commercial |
$861.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$813.79
|
| Rate for Payer: PHP Commercial |
$813.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$622.31
|
| Rate for Payer: Priority Health SBD |
$603.16
|
| Rate for Payer: UMR Bronson Commercial |
$421.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.05
|
|
