|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
OP
|
$1,384.11
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$414.91 |
| Max. Negotiated Rate |
$2,432.92 |
| Rate for Payer: Aetna American Axle |
$899.67
|
| Rate for Payer: Aetna Commercial |
$1,176.49
|
| Rate for Payer: Aetna Medicare |
$805.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$899.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$967.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$967.60
|
| Rate for Payer: BCBS Complete |
$435.65
|
| Rate for Payer: BCBS MAPPO |
$774.08
|
| Rate for Payer: BCBS Trust/PPO |
$980.00
|
| Rate for Payer: BCN Commercial |
$980.00
|
| Rate for Payer: BCN Medicare Advantage |
$774.08
|
| Rate for Payer: Cash Price |
$1,107.29
|
| Rate for Payer: Cash Price |
$1,107.29
|
| Rate for Payer: Cash Price |
$1,107.29
|
| Rate for Payer: Cofinity Commercial |
$1,190.33
|
| Rate for Payer: Cofinity Commercial |
$968.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$968.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,107.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$774.08
|
| Rate for Payer: Healthscope Commercial |
$1,245.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$968.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,038.08
|
| Rate for Payer: Mclaren Medicaid |
$414.91
|
| Rate for Payer: Mclaren Medicare |
$774.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$812.78
|
| Rate for Payer: Meridian Medicaid |
$435.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$890.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,176.49
|
| Rate for Payer: Nomi Health Commercial |
$2,322.24
|
| Rate for Payer: PACE Medicare |
$735.38
|
| Rate for Payer: PACE SWMI |
$774.08
|
| Rate for Payer: PHP Commercial |
$1,176.49
|
| Rate for Payer: PHP Medicare Advantage |
$774.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$414.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$899.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,432.92
|
| Rate for Payer: Priority Health Medicare |
$774.08
|
| Rate for Payer: Priority Health Narrow Network |
$1,946.34
|
| Rate for Payer: Priority Health SBD |
$871.99
|
| Rate for Payer: Railroad Medicare Medicare |
$774.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,178.96
|
| Rate for Payer: UHC Core |
$816.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$774.08
|
| Rate for Payer: UHC Exchange |
$1,479.34
|
| Rate for Payer: UHC Medicare Advantage |
$774.08
|
| Rate for Payer: UHCCP Medicaid |
$414.91
|
| Rate for Payer: UMR Bronson Commercial |
$512.12
|
| Rate for Payer: VA VA |
$774.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,038.08
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna American Axle |
$36.40
|
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.40
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
| Rate for Payer: Priority Health SBD |
$35.28
|
| Rate for Payer: UMR Bronson Commercial |
$24.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 10572010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna American Axle |
$45.50
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna Medicare |
$35.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: BCBS Complete |
$28.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: UMR Bronson Commercial |
$25.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.50
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna American Axle |
$45.50
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna Medicare |
$35.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: BCBS Complete |
$28.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: UMR Bronson Commercial |
$25.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.50
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna American Axle |
$36.40
|
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.40
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
| Rate for Payer: Priority Health SBD |
$35.28
|
| Rate for Payer: UMR Bronson Commercial |
$20.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 10572010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna American Axle |
$45.50
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: UMR Bronson Commercial |
$30.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.50
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna American Axle |
$45.50
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: UMR Bronson Commercial |
$30.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.50
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS
|
Facility
|
OP
|
$9.52
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna American Axle |
$6.19
|
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Aetna Medicare |
$4.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: BCBS Complete |
$3.81
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Cofinity Commercial |
$8.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$8.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.09
|
| Rate for Payer: PHP Commercial |
$8.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health SBD |
$6.00
|
| Rate for Payer: UMR Bronson Commercial |
$3.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.14
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS
|
Facility
|
IP
|
$9.52
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna American Axle |
$6.19
|
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Cofinity Commercial |
$8.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$8.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.09
|
| Rate for Payer: PHP Commercial |
$8.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health SBD |
$6.00
|
| Rate for Payer: UMR Bronson Commercial |
$4.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.14
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS
|
Facility
|
IP
|
$34.34
|
|
|
Service Code
|
NDC 70000008801
|
| Hospital Charge Code |
152517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.11 |
| Max. Negotiated Rate |
$30.91 |
| Rate for Payer: Aetna American Axle |
$22.32
|
| Rate for Payer: Aetna Commercial |
$29.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.32
|
| Rate for Payer: Cash Price |
$27.47
|
| Rate for Payer: Cofinity Commercial |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$29.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.47
|
| Rate for Payer: Healthscope Commercial |
$30.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.19
|
| Rate for Payer: PHP Commercial |
$29.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.32
|
| Rate for Payer: Priority Health SBD |
$21.63
|
| Rate for Payer: UMR Bronson Commercial |
$15.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.76
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS
|
Facility
|
OP
|
$34.34
|
|
|
Service Code
|
NDC 70000008801
|
| Hospital Charge Code |
152517
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.71 |
| Max. Negotiated Rate |
$30.91 |
| Rate for Payer: Aetna American Axle |
$22.32
|
| Rate for Payer: Aetna Commercial |
$29.19
|
| Rate for Payer: Aetna Medicare |
$17.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.32
|
| Rate for Payer: BCBS Complete |
$13.74
|
| Rate for Payer: Cash Price |
$27.47
|
| Rate for Payer: Cofinity Commercial |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$29.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.47
|
| Rate for Payer: Healthscope Commercial |
$30.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.19
|
| Rate for Payer: PHP Commercial |
$29.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.32
|
| Rate for Payer: Priority Health SBD |
$21.63
|
| Rate for Payer: UMR Bronson Commercial |
$12.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.76
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION
|
Facility
|
OP
|
$120,400.03
|
|
|
Service Code
|
HCPCS J9266
|
| Hospital Charge Code |
12519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,509.80 |
| Max. Negotiated Rate |
$108,360.03 |
| Rate for Payer: Aetna American Axle |
$78,260.02
|
| Rate for Payer: Aetna Commercial |
$102,340.03
|
| Rate for Payer: Aetna Medicare |
$28,153.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78,260.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33,838.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33,838.16
|
| Rate for Payer: BCBS Complete |
$15,235.29
|
| Rate for Payer: BCBS MAPPO |
$27,070.53
|
| Rate for Payer: BCBS Trust/PPO |
$72,991.13
|
| Rate for Payer: BCN Commercial |
$72,991.13
|
| Rate for Payer: BCN Medicare Advantage |
$27,070.53
|
| Rate for Payer: Cash Price |
$96,320.02
|
| Rate for Payer: Cash Price |
$96,320.02
|
| Rate for Payer: Cofinity Commercial |
$84,280.02
|
| Rate for Payer: Cofinity Commercial |
$103,544.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$84,280.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96,320.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27,070.53
|
| Rate for Payer: Healthscope Commercial |
$108,360.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84,280.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90,300.02
|
| Rate for Payer: Mclaren Medicaid |
$14,509.80
|
| Rate for Payer: Mclaren Medicare |
$27,070.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28,424.06
|
| Rate for Payer: Meridian Medicaid |
$15,235.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31,131.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102,340.03
|
| Rate for Payer: Nomi Health Commercial |
$81,211.59
|
| Rate for Payer: PACE Medicare |
$25,717.00
|
| Rate for Payer: PACE SWMI |
$27,070.53
|
| Rate for Payer: PHP Commercial |
$102,340.03
|
| Rate for Payer: PHP Medicare Advantage |
$27,070.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$14,509.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78,260.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77,909.48
|
| Rate for Payer: Priority Health Medicare |
$27,070.53
|
| Rate for Payer: Priority Health Narrow Network |
$62,327.58
|
| Rate for Payer: Priority Health SBD |
$75,852.02
|
| Rate for Payer: Railroad Medicare Medicare |
$27,070.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76,200.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$27,070.53
|
| Rate for Payer: UHC Exchange |
$51,734.49
|
| Rate for Payer: UHC Medicare Advantage |
$27,070.53
|
| Rate for Payer: UHCCP Medicaid |
$14,509.80
|
| Rate for Payer: UMR Bronson Commercial |
$44,548.01
|
| Rate for Payer: VA VA |
$27,070.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90,300.02
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION
|
Facility
|
IP
|
$120,400.03
|
|
|
Service Code
|
HCPCS J9266
|
| Hospital Charge Code |
12519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52,976.01 |
| Max. Negotiated Rate |
$108,360.03 |
| Rate for Payer: Aetna American Axle |
$78,260.02
|
| Rate for Payer: Aetna Commercial |
$102,340.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78,260.02
|
| Rate for Payer: Cash Price |
$96,320.02
|
| Rate for Payer: Cofinity Commercial |
$103,544.03
|
| Rate for Payer: Cofinity Commercial |
$84,280.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$84,280.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96,320.02
|
| Rate for Payer: Healthscope Commercial |
$108,360.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84,280.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90,300.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102,340.03
|
| Rate for Payer: PHP Commercial |
$102,340.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78,260.02
|
| Rate for Payer: Priority Health SBD |
$75,852.02
|
| Rate for Payer: UMR Bronson Commercial |
$52,976.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90,300.02
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR
|
Facility
|
IP
|
$11,749.74
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
173747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,169.89 |
| Max. Negotiated Rate |
$10,574.77 |
| Rate for Payer: Aetna American Axle |
$7,637.33
|
| Rate for Payer: Aetna Commercial |
$9,987.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,637.33
|
| Rate for Payer: Cash Price |
$9,399.79
|
| Rate for Payer: Cofinity Commercial |
$10,104.78
|
| Rate for Payer: Cofinity Commercial |
$8,224.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,224.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,399.79
|
| Rate for Payer: Healthscope Commercial |
$10,574.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,224.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,812.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,987.28
|
| Rate for Payer: PHP Commercial |
$9,987.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,637.33
|
| Rate for Payer: Priority Health SBD |
$7,402.34
|
| Rate for Payer: UMR Bronson Commercial |
$5,169.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,812.30
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR
|
Facility
|
OP
|
$11,749.74
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
173747
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$10,574.77 |
| Rate for Payer: Aetna American Axle |
$7,637.33
|
| Rate for Payer: Aetna Commercial |
$9,987.28
|
| Rate for Payer: Aetna Medicare |
$20.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,637.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.98
|
| Rate for Payer: BCBS Complete |
$11.24
|
| Rate for Payer: BCBS MAPPO |
$19.98
|
| Rate for Payer: BCBS Trust/PPO |
$832.24
|
| Rate for Payer: BCN Commercial |
$832.24
|
| Rate for Payer: BCN Medicare Advantage |
$19.98
|
| Rate for Payer: Cash Price |
$9,399.79
|
| Rate for Payer: Cash Price |
$9,399.79
|
| Rate for Payer: Cofinity Commercial |
$8,224.82
|
| Rate for Payer: Cofinity Commercial |
$10,104.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,224.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,399.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$10,574.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,224.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,812.30
|
| Rate for Payer: Mclaren Medicaid |
$10.71
|
| Rate for Payer: Mclaren Medicare |
$19.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.98
|
| Rate for Payer: Meridian Medicaid |
$11.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,987.28
|
| Rate for Payer: Nomi Health Commercial |
$59.94
|
| Rate for Payer: PACE Medicare |
$18.98
|
| Rate for Payer: PACE SWMI |
$19.98
|
| Rate for Payer: PHP Commercial |
$9,987.28
|
| Rate for Payer: PHP Medicare Advantage |
$19.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,637.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$89.64
|
| Rate for Payer: Priority Health Medicare |
$19.98
|
| Rate for Payer: Priority Health Narrow Network |
$71.71
|
| Rate for Payer: Priority Health SBD |
$7,402.34
|
| Rate for Payer: Railroad Medicare Medicare |
$19.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.98
|
| Rate for Payer: UHC Exchange |
$38.18
|
| Rate for Payer: UHC Medicare Advantage |
$19.98
|
| Rate for Payer: UHCCP Medicaid |
$10.71
|
| Rate for Payer: UMR Bronson Commercial |
$4,347.40
|
| Rate for Payer: VA VA |
$19.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,812.30
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$9,392.27
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,132.60 |
| Max. Negotiated Rate |
$8,453.04 |
| Rate for Payer: Aetna American Axle |
$6,104.98
|
| Rate for Payer: Aetna Commercial |
$7,983.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,104.98
|
| Rate for Payer: Cash Price |
$7,513.82
|
| Rate for Payer: Cofinity Commercial |
$6,574.59
|
| Rate for Payer: Cofinity Commercial |
$8,077.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,574.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,513.82
|
| Rate for Payer: Healthscope Commercial |
$8,453.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,574.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,044.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,983.43
|
| Rate for Payer: PHP Commercial |
$7,983.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,104.98
|
| Rate for Payer: Priority Health SBD |
$5,917.13
|
| Rate for Payer: UMR Bronson Commercial |
$4,132.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,044.20
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$9,392.27
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
32267
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$8,453.04 |
| Rate for Payer: Aetna American Axle |
$6,104.98
|
| Rate for Payer: Aetna Commercial |
$7,983.43
|
| Rate for Payer: Aetna Medicare |
$20.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,104.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.98
|
| Rate for Payer: BCBS Complete |
$11.24
|
| Rate for Payer: BCBS MAPPO |
$19.98
|
| Rate for Payer: BCBS Trust/PPO |
$832.24
|
| Rate for Payer: BCN Commercial |
$832.24
|
| Rate for Payer: BCN Medicare Advantage |
$19.98
|
| Rate for Payer: Cash Price |
$7,513.82
|
| Rate for Payer: Cash Price |
$7,513.82
|
| Rate for Payer: Cofinity Commercial |
$8,077.35
|
| Rate for Payer: Cofinity Commercial |
$6,574.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,574.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,513.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$8,453.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,574.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,044.20
|
| Rate for Payer: Mclaren Medicaid |
$10.71
|
| Rate for Payer: Mclaren Medicare |
$19.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.98
|
| Rate for Payer: Meridian Medicaid |
$11.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,983.43
|
| Rate for Payer: Nomi Health Commercial |
$59.94
|
| Rate for Payer: PACE Medicare |
$18.98
|
| Rate for Payer: PACE SWMI |
$19.98
|
| Rate for Payer: PHP Commercial |
$7,983.43
|
| Rate for Payer: PHP Medicare Advantage |
$19.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,104.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$89.64
|
| Rate for Payer: Priority Health Medicare |
$19.98
|
| Rate for Payer: Priority Health Narrow Network |
$71.71
|
| Rate for Payer: Priority Health SBD |
$5,917.13
|
| Rate for Payer: Railroad Medicare Medicare |
$19.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.98
|
| Rate for Payer: UHC Exchange |
$38.18
|
| Rate for Payer: UHC Medicare Advantage |
$19.98
|
| Rate for Payer: UHCCP Medicaid |
$10.71
|
| Rate for Payer: UMR Bronson Commercial |
$3,475.14
|
| Rate for Payer: VA VA |
$19.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,044.20
|
|
|
PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,301.28
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
195654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,332.56 |
| Max. Negotiated Rate |
$4,771.15 |
| Rate for Payer: Aetna American Axle |
$3,445.83
|
| Rate for Payer: Aetna Commercial |
$4,506.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,445.83
|
| Rate for Payer: Cash Price |
$4,241.02
|
| Rate for Payer: Cofinity Commercial |
$3,710.90
|
| Rate for Payer: Cofinity Commercial |
$4,559.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,710.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,241.02
|
| Rate for Payer: Healthscope Commercial |
$4,771.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,710.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,975.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,506.09
|
| Rate for Payer: PHP Commercial |
$4,506.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,445.83
|
| Rate for Payer: Priority Health SBD |
$3,339.81
|
| Rate for Payer: UMR Bronson Commercial |
$2,332.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,975.96
|
|
|
PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,301.28
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
195654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$4,771.15 |
| Rate for Payer: Cash Price |
$4,241.02
|
| Rate for Payer: Cofinity Commercial |
$4,559.10
|
| Rate for Payer: Cofinity Commercial |
$3,710.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,710.90
|
| Rate for Payer: Aetna American Axle |
$3,445.83
|
| Rate for Payer: Aetna Commercial |
$4,506.09
|
| Rate for Payer: Aetna Medicare |
$121.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,445.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$146.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$146.26
|
| Rate for Payer: BCBS Complete |
$65.85
|
| Rate for Payer: BCBS MAPPO |
$117.01
|
| Rate for Payer: BCBS Trust/PPO |
$342.76
|
| Rate for Payer: BCN Commercial |
$342.76
|
| Rate for Payer: BCN Medicare Advantage |
$117.01
|
| Rate for Payer: Cash Price |
$4,241.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,241.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.01
|
| Rate for Payer: Healthscope Commercial |
$4,771.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,710.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,975.96
|
| Rate for Payer: Mclaren Medicaid |
$62.72
|
| Rate for Payer: Mclaren Medicare |
$117.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$122.86
|
| Rate for Payer: Meridian Medicaid |
$65.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,506.09
|
| Rate for Payer: Nomi Health Commercial |
$351.03
|
| Rate for Payer: PACE Medicare |
$111.16
|
| Rate for Payer: PACE SWMI |
$117.01
|
| Rate for Payer: PHP Commercial |
$4,506.09
|
| Rate for Payer: PHP Medicare Advantage |
$117.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$62.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,445.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$277.88
|
| Rate for Payer: Priority Health Medicare |
$117.01
|
| Rate for Payer: Priority Health Narrow Network |
$222.30
|
| Rate for Payer: Priority Health SBD |
$3,339.81
|
| Rate for Payer: Railroad Medicare Medicare |
$117.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$329.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.01
|
| Rate for Payer: UHC Exchange |
$223.62
|
| Rate for Payer: UHC Medicare Advantage |
$117.01
|
| Rate for Payer: UHCCP Medicaid |
$62.72
|
| Rate for Payer: UMR Bronson Commercial |
$1,961.47
|
| Rate for Payer: VA VA |
$117.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,975.96
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$6,368.78
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
192102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$5,731.90 |
| Rate for Payer: Aetna American Axle |
$4,139.71
|
| Rate for Payer: Aetna Commercial |
$5,413.46
|
| Rate for Payer: Aetna Medicare |
$25.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,139.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30.89
|
| Rate for Payer: BCBS Complete |
$13.91
|
| Rate for Payer: BCBS MAPPO |
$24.71
|
| Rate for Payer: BCBS Trust/PPO |
$519.41
|
| Rate for Payer: BCN Commercial |
$519.41
|
| Rate for Payer: BCN Medicare Advantage |
$24.71
|
| Rate for Payer: Cash Price |
$5,095.02
|
| Rate for Payer: Cash Price |
$5,095.02
|
| Rate for Payer: Cofinity Commercial |
$5,477.15
|
| Rate for Payer: Cofinity Commercial |
$4,458.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,458.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,095.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.71
|
| Rate for Payer: Healthscope Commercial |
$5,731.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,458.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,776.58
|
| Rate for Payer: Mclaren Medicaid |
$13.24
|
| Rate for Payer: Mclaren Medicare |
$24.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.95
|
| Rate for Payer: Meridian Medicaid |
$13.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,413.46
|
| Rate for Payer: Nomi Health Commercial |
$74.13
|
| Rate for Payer: PACE Medicare |
$23.47
|
| Rate for Payer: PACE SWMI |
$24.71
|
| Rate for Payer: PHP Commercial |
$5,413.46
|
| Rate for Payer: PHP Medicare Advantage |
$24.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,139.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$997.96
|
| Rate for Payer: Priority Health Medicare |
$24.71
|
| Rate for Payer: Priority Health Narrow Network |
$798.37
|
| Rate for Payer: Priority Health SBD |
$4,012.33
|
| Rate for Payer: Railroad Medicare Medicare |
$24.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$24.71
|
| Rate for Payer: UHC Exchange |
$47.22
|
| Rate for Payer: UHC Medicare Advantage |
$24.71
|
| Rate for Payer: UHCCP Medicaid |
$13.24
|
| Rate for Payer: UMR Bronson Commercial |
$2,356.45
|
| Rate for Payer: VA VA |
$24.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,776.58
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$6,368.78
|
|
|
Service Code
|
HCPCS Q5120
|
| Hospital Charge Code |
192102
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,802.26 |
| Max. Negotiated Rate |
$5,731.90 |
| Rate for Payer: Aetna American Axle |
$4,139.71
|
| Rate for Payer: Aetna Commercial |
$5,413.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,139.71
|
| Rate for Payer: Cash Price |
$5,095.02
|
| Rate for Payer: Cofinity Commercial |
$4,458.15
|
| Rate for Payer: Cofinity Commercial |
$5,477.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,458.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,095.02
|
| Rate for Payer: Healthscope Commercial |
$5,731.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,458.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,776.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,413.46
|
| Rate for Payer: PHP Commercial |
$5,413.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,139.71
|
| Rate for Payer: Priority Health SBD |
$4,012.33
|
| Rate for Payer: UMR Bronson Commercial |
$2,802.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,776.58
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR
|
Facility
|
IP
|
$8,837.40
|
|
|
Service Code
|
NDC 70114013001
|
| Hospital Charge Code |
206387
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,888.46 |
| Max. Negotiated Rate |
$7,953.66 |
| Rate for Payer: Aetna American Axle |
$5,744.31
|
| Rate for Payer: Aetna Commercial |
$7,511.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,744.31
|
| Rate for Payer: Cash Price |
$7,069.92
|
| Rate for Payer: Cofinity Commercial |
$6,186.18
|
| Rate for Payer: Cofinity Commercial |
$7,600.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,186.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,069.92
|
| Rate for Payer: Healthscope Commercial |
$7,953.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,186.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,628.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,511.79
|
| Rate for Payer: PHP Commercial |
$7,511.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,744.31
|
| Rate for Payer: Priority Health SBD |
$5,567.56
|
| Rate for Payer: UMR Bronson Commercial |
$3,888.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,628.05
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR
|
Facility
|
OP
|
$8,837.40
|
|
|
Service Code
|
NDC 70114013001
|
| Hospital Charge Code |
206387
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,269.84 |
| Max. Negotiated Rate |
$7,953.66 |
| Rate for Payer: Aetna American Axle |
$5,744.31
|
| Rate for Payer: Aetna Commercial |
$7,511.79
|
| Rate for Payer: Aetna Medicare |
$4,418.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,744.31
|
| Rate for Payer: BCBS Complete |
$3,534.96
|
| Rate for Payer: Cash Price |
$7,069.92
|
| Rate for Payer: Cofinity Commercial |
$6,186.18
|
| Rate for Payer: Cofinity Commercial |
$7,600.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,186.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,069.92
|
| Rate for Payer: Healthscope Commercial |
$7,953.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,186.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,628.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,511.79
|
| Rate for Payer: PHP Commercial |
$7,511.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,744.31
|
| Rate for Payer: Priority Health SBD |
$5,567.56
|
| Rate for Payer: UMR Bronson Commercial |
$3,269.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,628.05
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,304.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
189200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.65 |
| Max. Negotiated Rate |
$4,773.60 |
| Rate for Payer: Aetna American Axle |
$3,447.60
|
| Rate for Payer: Aetna Commercial |
$4,508.40
|
| Rate for Payer: Aetna Medicare |
$140.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,447.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$169.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$169.44
|
| Rate for Payer: BCBS Complete |
$76.29
|
| Rate for Payer: BCBS MAPPO |
$135.55
|
| Rate for Payer: BCBS Trust/PPO |
$386.59
|
| Rate for Payer: BCN Commercial |
$386.59
|
| Rate for Payer: BCN Medicare Advantage |
$135.55
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cofinity Commercial |
$4,561.44
|
| Rate for Payer: Cofinity Commercial |
$3,712.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,712.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,243.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$135.55
|
| Rate for Payer: Healthscope Commercial |
$4,773.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,712.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,978.00
|
| Rate for Payer: Mclaren Medicaid |
$72.65
|
| Rate for Payer: Mclaren Medicare |
$135.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$142.33
|
| Rate for Payer: Meridian Medicaid |
$76.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$155.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,508.40
|
| Rate for Payer: Nomi Health Commercial |
$406.65
|
| Rate for Payer: PACE Medicare |
$128.77
|
| Rate for Payer: PACE SWMI |
$135.55
|
| Rate for Payer: PHP Commercial |
$4,508.40
|
| Rate for Payer: PHP Medicare Advantage |
$135.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$72.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,447.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$412.64
|
| Rate for Payer: Priority Health Medicare |
$135.55
|
| Rate for Payer: Priority Health Narrow Network |
$330.11
|
| Rate for Payer: Priority Health SBD |
$3,341.52
|
| Rate for Payer: Railroad Medicare Medicare |
$135.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$381.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$135.55
|
| Rate for Payer: UHC Exchange |
$259.05
|
| Rate for Payer: UHC Medicare Advantage |
$135.55
|
| Rate for Payer: UHCCP Medicaid |
$72.65
|
| Rate for Payer: UMR Bronson Commercial |
$1,962.48
|
| Rate for Payer: VA VA |
$135.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,978.00
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,304.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
189200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,333.76 |
| Max. Negotiated Rate |
$4,773.60 |
| Rate for Payer: Aetna American Axle |
$3,447.60
|
| Rate for Payer: Aetna Commercial |
$4,508.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,447.60
|
| Rate for Payer: Cash Price |
$4,243.20
|
| Rate for Payer: Cofinity Commercial |
$3,712.80
|
| Rate for Payer: Cofinity Commercial |
$4,561.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,712.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,243.20
|
| Rate for Payer: Healthscope Commercial |
$4,773.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,712.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,978.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,508.40
|
| Rate for Payer: PHP Commercial |
$4,508.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,447.60
|
| Rate for Payer: Priority Health SBD |
$3,341.52
|
| Rate for Payer: UMR Bronson Commercial |
$2,333.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,978.00
|
|
