|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,016.25
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$447.15 |
| Max. Negotiated Rate |
$914.62 |
| Rate for Payer: Aetna American Axle |
$660.56
|
| Rate for Payer: Aetna Commercial |
$863.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$660.56
|
| Rate for Payer: Cash Price |
$813.00
|
| Rate for Payer: Cofinity Commercial |
$711.38
|
| Rate for Payer: Cofinity Commercial |
$873.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$711.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$813.00
|
| Rate for Payer: Healthscope Commercial |
$914.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$711.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$762.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$863.81
|
| Rate for Payer: PHP Commercial |
$863.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$660.56
|
| Rate for Payer: Priority Health SBD |
$640.24
|
| Rate for Payer: UMR Bronson Commercial |
$447.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$762.19
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,016.25
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.01 |
| Max. Negotiated Rate |
$914.62 |
| Rate for Payer: Aetna American Axle |
$660.56
|
| Rate for Payer: Aetna Commercial |
$863.81
|
| Rate for Payer: Aetna Medicare |
$508.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$660.56
|
| Rate for Payer: BCBS Complete |
$406.50
|
| Rate for Payer: Cash Price |
$813.00
|
| Rate for Payer: Cofinity Commercial |
$711.38
|
| Rate for Payer: Cofinity Commercial |
$873.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$711.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$813.00
|
| Rate for Payer: Healthscope Commercial |
$914.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$711.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$762.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$863.81
|
| Rate for Payer: PHP Commercial |
$863.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$660.56
|
| Rate for Payer: Priority Health SBD |
$640.24
|
| Rate for Payer: UMR Bronson Commercial |
$376.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$762.19
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.24 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna American Axle |
$29.90
|
| Rate for Payer: Aetna Commercial |
$39.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.90
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Cofinity Commercial |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$39.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.80
|
| Rate for Payer: Healthscope Commercial |
$41.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.10
|
| Rate for Payer: PHP Commercial |
$39.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.90
|
| Rate for Payer: Priority Health SBD |
$28.98
|
| Rate for Payer: UMR Bronson Commercial |
$20.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.50
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna American Axle |
$29.90
|
| Rate for Payer: Aetna Commercial |
$39.10
|
| Rate for Payer: Aetna Medicare |
$23.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.90
|
| Rate for Payer: BCBS Complete |
$18.40
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Cofinity Commercial |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$39.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.80
|
| Rate for Payer: Healthscope Commercial |
$41.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.10
|
| Rate for Payer: PHP Commercial |
$39.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.90
|
| Rate for Payer: Priority Health SBD |
$28.98
|
| Rate for Payer: UMR Bronson Commercial |
$17.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.50
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$1.99
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna American Axle |
$1.29
|
| Rate for Payer: Aetna American Axle |
$47.38
|
| Rate for Payer: Aetna Commercial |
$1.69
|
| Rate for Payer: Aetna Commercial |
$61.97
|
| Rate for Payer: Aetna Medicare |
$1.00
|
| Rate for Payer: Aetna Medicare |
$36.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.38
|
| Rate for Payer: BCBS Complete |
$29.16
|
| Rate for Payer: BCBS Complete |
$0.80
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cofinity Commercial |
$1.71
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Cofinity Commercial |
$51.03
|
| Rate for Payer: Cofinity Commercial |
$62.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.32
|
| Rate for Payer: Healthscope Commercial |
$65.61
|
| Rate for Payer: Healthscope Commercial |
$1.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.97
|
| Rate for Payer: PHP Commercial |
$61.97
|
| Rate for Payer: PHP Commercial |
$1.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health SBD |
$45.93
|
| Rate for Payer: Priority Health SBD |
$1.25
|
| Rate for Payer: UMR Bronson Commercial |
$0.74
|
| Rate for Payer: UMR Bronson Commercial |
$26.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.49
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$1.99
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna American Axle |
$1.29
|
| Rate for Payer: Aetna American Axle |
$47.38
|
| Rate for Payer: Aetna Commercial |
$1.69
|
| Rate for Payer: Aetna Commercial |
$61.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.38
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cofinity Commercial |
$62.69
|
| Rate for Payer: Cofinity Commercial |
$51.03
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Cofinity Commercial |
$1.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.32
|
| Rate for Payer: Healthscope Commercial |
$1.79
|
| Rate for Payer: Healthscope Commercial |
$65.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.69
|
| Rate for Payer: PHP Commercial |
$61.97
|
| Rate for Payer: PHP Commercial |
$1.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health SBD |
$1.25
|
| Rate for Payer: Priority Health SBD |
$45.93
|
| Rate for Payer: UMR Bronson Commercial |
$0.88
|
| Rate for Payer: UMR Bronson Commercial |
$32.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.67
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna American Axle |
$27.30
|
| Rate for Payer: Aetna Commercial |
$35.70
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.30
|
| Rate for Payer: BCBS Complete |
$16.80
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$29.40
|
| Rate for Payer: Cofinity Commercial |
$36.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$37.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: PHP Commercial |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$26.46
|
| Rate for Payer: UMR Bronson Commercial |
$15.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.50
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna American Axle |
$27.30
|
| Rate for Payer: Aetna Commercial |
$35.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.30
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$29.40
|
| Rate for Payer: Cofinity Commercial |
$36.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$37.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: PHP Commercial |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$26.46
|
| Rate for Payer: UMR Bronson Commercial |
$18.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.50
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna American Axle |
$113.75
|
| Rate for Payer: Aetna American Axle |
$1.16
|
| Rate for Payer: Aetna Commercial |
$148.75
|
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna Medicare |
$87.50
|
| Rate for Payer: Aetna Medicare |
$0.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.16
|
| Rate for Payer: BCBS Complete |
$0.71
|
| Rate for Payer: BCBS Complete |
$70.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$150.50
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Cofinity Commercial |
$1.25
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.42
|
| Rate for Payer: Healthscope Commercial |
$1.60
|
| Rate for Payer: Healthscope Commercial |
$157.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.51
|
| Rate for Payer: PHP Commercial |
$1.51
|
| Rate for Payer: PHP Commercial |
$148.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.16
|
| Rate for Payer: Priority Health SBD |
$1.12
|
| Rate for Payer: Priority Health SBD |
$110.25
|
| Rate for Payer: UMR Bronson Commercial |
$64.75
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.25
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna American Axle |
$113.75
|
| Rate for Payer: Aetna American Axle |
$1.16
|
| Rate for Payer: Aetna Commercial |
$148.75
|
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.16
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Cofinity Commercial |
$1.25
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Cofinity Commercial |
$150.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$122.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.42
|
| Rate for Payer: Healthscope Commercial |
$157.50
|
| Rate for Payer: Healthscope Commercial |
$1.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.75
|
| Rate for Payer: PHP Commercial |
$1.51
|
| Rate for Payer: PHP Commercial |
$148.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.16
|
| Rate for Payer: Priority Health SBD |
$110.25
|
| Rate for Payer: Priority Health SBD |
$1.12
|
| Rate for Payer: UMR Bronson Commercial |
$77.00
|
| Rate for Payer: UMR Bronson Commercial |
$0.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.33
|
|
|
IOPAMIDOL 61 % ORAL SOLUTION
|
Facility
|
IP
|
$11.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
180462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna American Axle |
$7.28
|
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.52
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health SBD |
$7.06
|
| Rate for Payer: UMR Bronson Commercial |
$4.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.40
|
|
|
IOPAMIDOL 61 % ORAL SOLUTION
|
Facility
|
OP
|
$11.20
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
180462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna American Axle |
$7.28
|
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Aetna Medicare |
$5.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: BCBS Complete |
$4.48
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.52
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health SBD |
$7.06
|
| Rate for Payer: UMR Bronson Commercial |
$4.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.40
|
|
|
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$92,322.68
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$83,090.41 |
| Rate for Payer: Aetna American Axle |
$60,009.74
|
| Rate for Payer: Aetna Commercial |
$78,474.28
|
| Rate for Payer: Aetna Medicare |
$190.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60,009.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$229.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$229.35
|
| Rate for Payer: BCBS Complete |
$103.26
|
| Rate for Payer: BCBS MAPPO |
$183.48
|
| Rate for Payer: BCN Medicare Advantage |
$183.48
|
| Rate for Payer: Cash Price |
$73,858.14
|
| Rate for Payer: Cash Price |
$73,858.14
|
| Rate for Payer: Cofinity Commercial |
$79,397.50
|
| Rate for Payer: Cofinity Commercial |
$64,625.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$64,625.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73,858.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$183.48
|
| Rate for Payer: Healthscope Commercial |
$83,090.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$64,625.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69,242.01
|
| Rate for Payer: Mclaren Medicaid |
$98.35
|
| Rate for Payer: Mclaren Medicare |
$183.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$192.65
|
| Rate for Payer: Meridian Medicaid |
$103.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78,474.28
|
| Rate for Payer: PACE Medicare |
$174.31
|
| Rate for Payer: PACE SWMI |
$183.48
|
| Rate for Payer: PHP Commercial |
$78,474.28
|
| Rate for Payer: PHP Medicare Advantage |
$183.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$98.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60,009.74
|
| Rate for Payer: Priority Health Medicare |
$183.48
|
| Rate for Payer: Priority Health SBD |
$58,163.29
|
| Rate for Payer: Railroad Medicare Medicare |
$183.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$516.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$183.48
|
| Rate for Payer: UHC Exchange |
$350.65
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: UHCCP Medicaid |
$98.35
|
| Rate for Payer: UMR Bronson Commercial |
$34,159.39
|
| Rate for Payer: VA VA |
$183.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69,242.01
|
|
|
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$92,322.68
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152408
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40,621.98 |
| Max. Negotiated Rate |
$83,090.41 |
| Rate for Payer: Aetna American Axle |
$60,009.74
|
| Rate for Payer: Aetna Commercial |
$78,474.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60,009.74
|
| Rate for Payer: Cash Price |
$73,858.14
|
| Rate for Payer: Cofinity Commercial |
$64,625.88
|
| Rate for Payer: Cofinity Commercial |
$79,397.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$64,625.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73,858.14
|
| Rate for Payer: Healthscope Commercial |
$83,090.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$64,625.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69,242.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78,474.28
|
| Rate for Payer: PHP Commercial |
$78,474.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60,009.74
|
| Rate for Payer: Priority Health SBD |
$58,163.29
|
| Rate for Payer: UMR Bronson Commercial |
$40,621.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69,242.01
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23,080.72
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$20,772.65 |
| Rate for Payer: Aetna American Axle |
$15,002.47
|
| Rate for Payer: Aetna Commercial |
$19,618.61
|
| Rate for Payer: Aetna Medicare |
$190.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,002.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$229.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$229.35
|
| Rate for Payer: BCBS Complete |
$103.26
|
| Rate for Payer: BCBS MAPPO |
$183.48
|
| Rate for Payer: BCN Medicare Advantage |
$183.48
|
| Rate for Payer: Cash Price |
$18,464.58
|
| Rate for Payer: Cash Price |
$18,464.58
|
| Rate for Payer: Cofinity Commercial |
$19,849.42
|
| Rate for Payer: Cofinity Commercial |
$16,156.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$16,156.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,464.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$183.48
|
| Rate for Payer: Healthscope Commercial |
$20,772.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16,156.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17,310.54
|
| Rate for Payer: Mclaren Medicaid |
$98.35
|
| Rate for Payer: Mclaren Medicare |
$183.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$192.65
|
| Rate for Payer: Meridian Medicaid |
$103.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,618.61
|
| Rate for Payer: PACE Medicare |
$174.31
|
| Rate for Payer: PACE SWMI |
$183.48
|
| Rate for Payer: PHP Commercial |
$19,618.61
|
| Rate for Payer: PHP Medicare Advantage |
$183.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$98.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,002.47
|
| Rate for Payer: Priority Health Medicare |
$183.48
|
| Rate for Payer: Priority Health SBD |
$14,540.85
|
| Rate for Payer: Railroad Medicare Medicare |
$183.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$516.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$183.48
|
| Rate for Payer: UHC Exchange |
$350.65
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: UHCCP Medicaid |
$98.35
|
| Rate for Payer: UMR Bronson Commercial |
$8,539.87
|
| Rate for Payer: VA VA |
$183.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17,310.54
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23,080.72
|
|
|
Service Code
|
HCPCS J9228
|
| Hospital Charge Code |
152407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,155.52 |
| Max. Negotiated Rate |
$20,772.65 |
| Rate for Payer: Aetna American Axle |
$15,002.47
|
| Rate for Payer: Aetna Commercial |
$19,618.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,002.47
|
| Rate for Payer: Cash Price |
$18,464.58
|
| Rate for Payer: Cofinity Commercial |
$16,156.50
|
| Rate for Payer: Cofinity Commercial |
$19,849.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$16,156.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,464.58
|
| Rate for Payer: Healthscope Commercial |
$20,772.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16,156.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17,310.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,618.61
|
| Rate for Payer: PHP Commercial |
$19,618.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,002.47
|
| Rate for Payer: Priority Health SBD |
$14,540.85
|
| Rate for Payer: UMR Bronson Commercial |
$10,155.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17,310.54
|
|
|
IPL CHEEKS FIRST
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
HCPCS 00126
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$83.20 |
| Rate for Payer: Aetna Medicare |
$64.00
|
| Rate for Payer: BCBS Complete |
$51.20
|
| Rate for Payer: Cash Price |
$102.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.20
|
| Rate for Payer: UMR Bronson Commercial |
$58.88
|
|
|
IPL CHEST FIRST
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00128
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
| Rate for Payer: UMR Bronson Commercial |
$140.76
|
|
|
IPL CHEST SECOND
|
Professional
|
Both
|
$204.00
|
|
|
Service Code
|
HCPCS 00129
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Aetna Medicare |
$102.00
|
| Rate for Payer: BCBS Complete |
$81.60
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.60
|
| Rate for Payer: UMR Bronson Commercial |
$93.84
|
|
|
IPL FACE FIRST
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 00130
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$92.00 |
| Max. Negotiated Rate |
$149.50 |
| Rate for Payer: Aetna Medicare |
$115.00
|
| Rate for Payer: BCBS Complete |
$92.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.50
|
| Rate for Payer: UMR Bronson Commercial |
$105.80
|
|
|
IPL FACE, NECK, CHEST FIRST
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 00132
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Aetna Medicare |
$204.00
|
| Rate for Payer: BCBS Complete |
$163.20
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.20
|
| Rate for Payer: UMR Bronson Commercial |
$187.68
|
|
|
IPL FACE, NECK, CHEST SECOND
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
HCPCS 00133
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$182.65 |
| Rate for Payer: Aetna Medicare |
$140.50
|
| Rate for Payer: BCBS Complete |
$112.40
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.65
|
| Rate for Payer: UMR Bronson Commercial |
$129.26
|
|
|
IPL FACE & NECK FIRST
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 00134
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: UMR Bronson Commercial |
$117.30
|
|
|
IPL FACE & NECK SECOND
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 00135
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.60 |
| Max. Negotiated Rate |
$116.35 |
| Rate for Payer: Aetna Medicare |
$89.50
|
| Rate for Payer: BCBS Complete |
$71.60
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.35
|
| Rate for Payer: UMR Bronson Commercial |
$82.34
|
|
|
IPL FACE SECOND
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS 00131
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$66.30 |
| Rate for Payer: Aetna Medicare |
$51.00
|
| Rate for Payer: BCBS Complete |
$40.80
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.30
|
| Rate for Payer: UMR Bronson Commercial |
$46.92
|
|
