|
FERRIC DERISOMALTOSE 100 MG IRON/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,599.46
|
|
|
Service Code
|
HCPCS J1437
|
| Hospital Charge Code |
194928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$5,599.46 |
| Rate for Payer: Aetna Commercial |
$5,039.52
|
| Rate for Payer: Aetna Medicare |
$21.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.41
|
| Rate for Payer: ASR ASR |
$5,431.48
|
| Rate for Payer: BCBS Complete |
$12.04
|
| Rate for Payer: BCBS MAPPO |
$21.93
|
| Rate for Payer: BCBS Trust/PPO |
$4,616.76
|
| Rate for Payer: BCN Commercial |
$4,616.76
|
| Rate for Payer: BCN Medicare Advantage |
$21.93
|
| Rate for Payer: Cash Price |
$4,479.57
|
| Rate for Payer: Cash Price |
$4,479.57
|
| Rate for Payer: Cofinity Commercial |
$5,263.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,479.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21.93
|
| Rate for Payer: Healthscope Commercial |
$5,431.48
|
| Rate for Payer: Healthscope Whirlpool |
$5,599.46
|
| Rate for Payer: Humana Choice PPO Medicare |
$21.93
|
| Rate for Payer: Mclaren Commercial |
$5,039.52
|
| Rate for Payer: Mclaren Medicaid |
$21.93
|
| Rate for Payer: Mclaren Medicare |
$21.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.03
|
| Rate for Payer: Meridian Medicaid |
$12.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.22
|
| Rate for Payer: Molina Medicare/Medicaid |
$24.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,759.54
|
| Rate for Payer: Nomi Health Commercial |
$4,591.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,199.60
|
| Rate for Payer: PACE Medicare |
$20.83
|
| Rate for Payer: PACE SWMI |
$21.93
|
| Rate for Payer: PHP Commercial |
$24.12
|
| Rate for Payer: PHP Medicaid |
$11.75
|
| Rate for Payer: PHP Medicare Advantage |
$21.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.69
|
| Rate for Payer: Priority Health Medicare |
$21.93
|
| Rate for Payer: Priority Health Narrow Network |
$18.95
|
| Rate for Payer: Railroad Medicare Medicare |
$21.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,927.53
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$21.93
|
| Rate for Payer: UHC Exchange |
$33.99
|
| Rate for Payer: UHC Medicaid |
$11.47
|
| Rate for Payer: UHCCP DNSP |
$21.93
|
| Rate for Payer: UHCCP Medicaid |
$11.47
|
| Rate for Payer: VA VA |
$21.93
|
|
|
FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR
|
Facility
|
OP
|
$58.94
|
|
|
Service Code
|
NDC 10481011208
|
| Hospital Charge Code |
167585
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.81 |
| Max. Negotiated Rate |
$58.94 |
| Rate for Payer: Aetna Commercial |
$53.05
|
| Rate for Payer: Aetna Medicare |
$21.81
|
| Rate for Payer: ASR ASR |
$57.17
|
| Rate for Payer: BCBS Complete |
$23.58
|
| Rate for Payer: BCBS Trust/PPO |
$48.60
|
| Rate for Payer: BCN Commercial |
$48.60
|
| Rate for Payer: Cash Price |
$47.15
|
| Rate for Payer: Cofinity Commercial |
$55.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.15
|
| Rate for Payer: Healthscope Commercial |
$57.17
|
| Rate for Payer: Healthscope Whirlpool |
$58.94
|
| Rate for Payer: Mclaren Commercial |
$53.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.10
|
| Rate for Payer: Nomi Health Commercial |
$48.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$51.64
|
| Rate for Payer: Priority Health Narrow Network |
$41.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$51.87
|
|
|
FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR
|
Facility
|
IP
|
$58.94
|
|
|
Service Code
|
NDC 10481011208
|
| Hospital Charge Code |
167585
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$58.94 |
| Rate for Payer: Aetna Commercial |
$53.05
|
| Rate for Payer: ASR ASR |
$57.17
|
| Rate for Payer: BCBS Trust/PPO |
$48.40
|
| Rate for Payer: BCN Commercial |
$48.40
|
| Rate for Payer: Cash Price |
$47.15
|
| Rate for Payer: Cofinity Commercial |
$55.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.15
|
| Rate for Payer: Healthscope Commercial |
$57.17
|
| Rate for Payer: Healthscope Whirlpool |
$58.94
|
| Rate for Payer: Mclaren Commercial |
$53.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.10
|
| Rate for Payer: Nomi Health Commercial |
$48.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$51.87
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET
|
Facility
|
OP
|
$68.15
|
|
|
Service Code
|
NDC 904759161
|
| Hospital Charge Code |
3074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.22 |
| Max. Negotiated Rate |
$68.15 |
| Rate for Payer: Aetna Commercial |
$61.34
|
| Rate for Payer: Aetna Medicare |
$25.22
|
| Rate for Payer: ASR ASR |
$66.11
|
| Rate for Payer: BCBS Complete |
$27.26
|
| Rate for Payer: BCBS Trust/PPO |
$56.19
|
| Rate for Payer: BCN Commercial |
$56.19
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$64.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$66.11
|
| Rate for Payer: Healthscope Whirlpool |
$68.15
|
| Rate for Payer: Mclaren Commercial |
$61.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$54.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.93
|
| Rate for Payer: Nomi Health Commercial |
$55.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$59.71
|
| Rate for Payer: Priority Health Narrow Network |
$47.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.97
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET
|
Facility
|
IP
|
$68.15
|
|
|
Service Code
|
NDC 904759161
|
| Hospital Charge Code |
3074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.11 |
| Max. Negotiated Rate |
$68.15 |
| Rate for Payer: Aetna Commercial |
$61.34
|
| Rate for Payer: ASR ASR |
$66.11
|
| Rate for Payer: BCBS Trust/PPO |
$55.96
|
| Rate for Payer: BCN Commercial |
$55.96
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$64.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$66.11
|
| Rate for Payer: Healthscope Whirlpool |
$68.15
|
| Rate for Payer: Mclaren Commercial |
$61.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.93
|
| Rate for Payer: Nomi Health Commercial |
$55.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.97
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,000.30
|
|
|
Service Code
|
HCPCS Q0138
|
| Hospital Charge Code |
98312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1,000.30 |
| Rate for Payer: Aetna Commercial |
$900.27
|
| Rate for Payer: Aetna Medicare |
$0.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.29
|
| Rate for Payer: ASR ASR |
$970.29
|
| Rate for Payer: BCBS Complete |
$0.13
|
| Rate for Payer: BCBS MAPPO |
$0.23
|
| Rate for Payer: BCBS Trust/PPO |
$824.75
|
| Rate for Payer: BCN Commercial |
$824.75
|
| Rate for Payer: BCN Medicare Advantage |
$0.23
|
| Rate for Payer: Cash Price |
$800.24
|
| Rate for Payer: Cash Price |
$800.24
|
| Rate for Payer: Cofinity Commercial |
$940.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$800.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.23
|
| Rate for Payer: Healthscope Commercial |
$970.29
|
| Rate for Payer: Healthscope Whirlpool |
$1,000.30
|
| Rate for Payer: Humana Choice PPO Medicare |
$0.23
|
| Rate for Payer: Mclaren Commercial |
$900.27
|
| Rate for Payer: Mclaren Medicaid |
$0.23
|
| Rate for Payer: Mclaren Medicare |
$0.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.24
|
| Rate for Payer: Meridian Medicaid |
$0.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$850.26
|
| Rate for Payer: Nomi Health Commercial |
$820.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$750.23
|
| Rate for Payer: PACE Medicare |
$0.22
|
| Rate for Payer: PACE SWMI |
$0.23
|
| Rate for Payer: PHP Commercial |
$0.25
|
| Rate for Payer: PHP Medicaid |
$0.12
|
| Rate for Payer: PHP Medicare Advantage |
$0.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.37
|
| Rate for Payer: Priority Health Medicare |
$0.23
|
| Rate for Payer: Priority Health Narrow Network |
$0.30
|
| Rate for Payer: Railroad Medicare Medicare |
$0.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$880.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.23
|
| Rate for Payer: UHC Exchange |
$0.36
|
| Rate for Payer: UHC Medicaid |
$0.12
|
| Rate for Payer: UHCCP DNSP |
$0.23
|
| Rate for Payer: UHCCP Medicaid |
$0.12
|
| Rate for Payer: VA VA |
$0.23
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,000.30
|
|
|
Service Code
|
HCPCS Q0138
|
| Hospital Charge Code |
98312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$750.23 |
| Max. Negotiated Rate |
$1,000.30 |
| Rate for Payer: Aetna Commercial |
$900.27
|
| Rate for Payer: ASR ASR |
$970.29
|
| Rate for Payer: BCBS Trust/PPO |
$821.45
|
| Rate for Payer: BCN Commercial |
$821.45
|
| Rate for Payer: Cash Price |
$800.24
|
| Rate for Payer: Cofinity Commercial |
$940.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$800.24
|
| Rate for Payer: Healthscope Commercial |
$970.29
|
| Rate for Payer: Healthscope Whirlpool |
$1,000.30
|
| Rate for Payer: Mclaren Commercial |
$900.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$850.26
|
| Rate for Payer: Nomi Health Commercial |
$820.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$750.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$880.27
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$4,755.78
|
|
|
Service Code
|
APR-DRG 7223
|
| Min. Negotiated Rate |
$4,299.79 |
| Max. Negotiated Rate |
$4,755.78 |
| Rate for Payer: BCBS Complete |
$4,755.78
|
| Rate for Payer: Mclaren Medicaid |
$4,529.31
|
| Rate for Payer: Meridian Medicaid |
$4,755.78
|
| Rate for Payer: PHP Medicaid |
$4,299.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,529.31
|
| Rate for Payer: UHC Medicaid |
$4,529.31
|
| Rate for Payer: UHCCP Medicaid |
$4,529.31
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$12,627.85
|
|
|
Service Code
|
MSDRG 864
|
| Min. Negotiated Rate |
$7,739.65 |
| Max. Negotiated Rate |
$12,627.85 |
| Rate for Payer: Aetna Medicare |
$8,147.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,183.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,183.75
|
| Rate for Payer: BCBS MAPPO |
$8,147.00
|
| Rate for Payer: BCN Medicare Advantage |
$8,147.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,147.00
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,147.00
|
| Rate for Payer: Mclaren Medicare |
$8,147.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,554.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,369.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,961.70
|
| Rate for Payer: PACE Medicare |
$7,739.65
|
| Rate for Payer: PACE SWMI |
$8,147.00
|
| Rate for Payer: PHP Commercial |
$8,961.70
|
| Rate for Payer: PHP Medicare Advantage |
$8,147.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$12,195.93
|
| Rate for Payer: Priority Health Medicare |
$8,147.00
|
| Rate for Payer: Priority Health Narrow Network |
$9,756.75
|
| Rate for Payer: Railroad Medicare Medicare |
$8,147.00
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,147.00
|
| Rate for Payer: UHC Exchange |
$12,627.85
|
| Rate for Payer: UHCCP DNSP |
$8,147.00
|
| Rate for Payer: VA VA |
$8,147.00
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$2,504.05
|
|
|
Service Code
|
APR-DRG 7221
|
| Min. Negotiated Rate |
$2,263.96 |
| Max. Negotiated Rate |
$2,504.05 |
| Rate for Payer: BCBS Complete |
$2,504.05
|
| Rate for Payer: Mclaren Medicaid |
$2,384.80
|
| Rate for Payer: Meridian Medicaid |
$2,504.05
|
| Rate for Payer: PHP Medicaid |
$2,263.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,384.80
|
| Rate for Payer: UHC Medicaid |
$2,384.80
|
| Rate for Payer: UHCCP Medicaid |
$2,384.80
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$10,361.68
|
|
|
Service Code
|
APR-DRG 7224
|
| Min. Negotiated Rate |
$9,368.20 |
| Max. Negotiated Rate |
$10,361.68 |
| Rate for Payer: BCBS Complete |
$10,361.68
|
| Rate for Payer: Mclaren Medicaid |
$9,868.27
|
| Rate for Payer: Meridian Medicaid |
$10,361.68
|
| Rate for Payer: PHP Medicaid |
$9,368.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,868.27
|
| Rate for Payer: UHC Medicaid |
$9,868.27
|
| Rate for Payer: UHCCP Medicaid |
$9,868.27
|
|
|
FEVER AND INFLAMMATORY CONDITIONS
|
Facility
|
IP
|
$3,027.20
|
|
|
Service Code
|
APR-DRG 7222
|
| Min. Negotiated Rate |
$2,736.95 |
| Max. Negotiated Rate |
$3,027.20 |
| Rate for Payer: BCBS Complete |
$3,027.20
|
| Rate for Payer: Mclaren Medicaid |
$2,883.05
|
| Rate for Payer: Meridian Medicaid |
$3,027.20
|
| Rate for Payer: PHP Medicaid |
$2,736.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,883.05
|
| Rate for Payer: UHC Medicaid |
$2,883.05
|
| Rate for Payer: UHCCP Medicaid |
$2,883.05
|
|
|
FIBERSOURCE HN BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
161567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN BOLUS FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
161567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
168938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN CONTINUOUS FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
168938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN CYCLIC FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
200077
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN CYCLIC FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
200077
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN INTERMITTENT FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
200076
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Complete |
$1.90
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.16
|
| Rate for Payer: Priority Health Narrow Network |
$3.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIBERSOURCE HN INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018555
|
| Hospital Charge Code |
200076
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.75
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
FIDAXOMICIN 200 MG TABLET
|
Facility
|
OP
|
$17,910.22
|
|
|
Service Code
|
NDC 52015008001
|
| Hospital Charge Code |
152861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,626.78 |
| Max. Negotiated Rate |
$17,910.22 |
| Rate for Payer: Aetna Commercial |
$16,119.20
|
| Rate for Payer: Aetna Medicare |
$6,626.78
|
| Rate for Payer: ASR ASR |
$17,372.91
|
| Rate for Payer: BCBS Complete |
$7,164.09
|
| Rate for Payer: BCBS Trust/PPO |
$14,766.98
|
| Rate for Payer: BCN Commercial |
$14,766.98
|
| Rate for Payer: Cash Price |
$14,328.18
|
| Rate for Payer: Cofinity Commercial |
$16,835.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,328.18
|
| Rate for Payer: Healthscope Commercial |
$17,372.91
|
| Rate for Payer: Healthscope Whirlpool |
$17,910.22
|
| Rate for Payer: Mclaren Commercial |
$16,119.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,328.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,223.69
|
| Rate for Payer: Nomi Health Commercial |
$14,686.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,432.67
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$15,692.93
|
| Rate for Payer: Priority Health Narrow Network |
$12,555.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15,760.99
|
|
|
FIDAXOMICIN 200 MG TABLET
|
Facility
|
IP
|
$17,910.22
|
|
|
Service Code
|
NDC 52015008001
|
| Hospital Charge Code |
152861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13,432.67 |
| Max. Negotiated Rate |
$17,910.22 |
| Rate for Payer: Aetna Commercial |
$16,119.20
|
| Rate for Payer: ASR ASR |
$17,372.91
|
| Rate for Payer: BCBS Trust/PPO |
$14,707.87
|
| Rate for Payer: BCN Commercial |
$14,707.87
|
| Rate for Payer: Cash Price |
$14,328.18
|
| Rate for Payer: Cofinity Commercial |
$16,835.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,328.18
|
| Rate for Payer: Healthscope Commercial |
$17,372.91
|
| Rate for Payer: Healthscope Whirlpool |
$17,910.22
|
| Rate for Payer: Mclaren Commercial |
$16,119.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,223.69
|
| Rate for Payer: Nomi Health Commercial |
$14,686.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,432.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15,760.99
|
|
|
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$787.14
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
188115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$787.14 |
| Rate for Payer: Aetna Commercial |
$708.42
|
| Rate for Payer: Aetna Commercial |
$708.43
|
| Rate for Payer: Aetna Medicare |
$0.28
|
| Rate for Payer: Aetna Medicare |
$0.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.35
|
| Rate for Payer: ASR ASR |
$763.52
|
| Rate for Payer: ASR ASR |
$763.52
|
| Rate for Payer: BCBS Complete |
$0.15
|
| Rate for Payer: BCBS Complete |
$0.15
|
| Rate for Payer: BCBS MAPPO |
$0.28
|
| Rate for Payer: BCBS MAPPO |
$0.28
|
| Rate for Payer: BCBS Trust/PPO |
$649.00
|
| Rate for Payer: BCBS Trust/PPO |
$648.99
|
| Rate for Payer: BCN Commercial |
$649.00
|
| Rate for Payer: BCN Commercial |
$648.99
|
| Rate for Payer: BCN Medicare Advantage |
$0.28
|
| Rate for Payer: BCN Medicare Advantage |
$0.28
|
| Rate for Payer: Cash Price |
$629.71
|
| Rate for Payer: Cash Price |
$629.71
|
| Rate for Payer: Cash Price |
$629.71
|
| Rate for Payer: Cash Price |
$629.71
|
| Rate for Payer: Cofinity Commercial |
$739.91
|
| Rate for Payer: Cofinity Commercial |
$739.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$629.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$629.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.28
|
| Rate for Payer: Healthscope Commercial |
$763.52
|
| Rate for Payer: Healthscope Commercial |
$763.52
|
| Rate for Payer: Healthscope Whirlpool |
$787.14
|
| Rate for Payer: Healthscope Whirlpool |
$787.14
|
| Rate for Payer: Humana Choice PPO Medicare |
$0.28
|
| Rate for Payer: Humana Choice PPO Medicare |
$0.28
|
| Rate for Payer: Mclaren Commercial |
$708.43
|
| Rate for Payer: Mclaren Commercial |
$708.42
|
| Rate for Payer: Mclaren Medicaid |
$0.28
|
| Rate for Payer: Mclaren Medicaid |
$0.28
|
| Rate for Payer: Mclaren Medicare |
$0.28
|
| Rate for Payer: Mclaren Medicare |
$0.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.29
|
| Rate for Payer: Meridian Medicaid |
$0.15
|
| Rate for Payer: Meridian Medicaid |
$0.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.32
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.07
|
| Rate for Payer: Nomi Health Commercial |
$645.45
|
| Rate for Payer: Nomi Health Commercial |
$645.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$590.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$590.35
|
| Rate for Payer: PACE Medicare |
$0.27
|
| Rate for Payer: PACE Medicare |
$0.27
|
| Rate for Payer: PACE SWMI |
$0.28
|
| Rate for Payer: PACE SWMI |
$0.28
|
| Rate for Payer: PHP Commercial |
$0.31
|
| Rate for Payer: PHP Commercial |
$0.31
|
| Rate for Payer: PHP Medicaid |
$0.15
|
| Rate for Payer: PHP Medicaid |
$0.15
|
| Rate for Payer: PHP Medicare Advantage |
$0.28
|
| Rate for Payer: PHP Medicare Advantage |
$0.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.22
|
| Rate for Payer: Priority Health Medicare |
$0.28
|
| Rate for Payer: Priority Health Medicare |
$0.28
|
| Rate for Payer: Priority Health Narrow Network |
$0.18
|
| Rate for Payer: Priority Health Narrow Network |
$0.18
|
| Rate for Payer: Railroad Medicare Medicare |
$0.28
|
| Rate for Payer: Railroad Medicare Medicare |
$0.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$692.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$692.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.28
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.28
|
| Rate for Payer: UHC Exchange |
$0.43
|
| Rate for Payer: UHC Exchange |
$0.43
|
| Rate for Payer: UHC Medicaid |
$0.15
|
| Rate for Payer: UHC Medicaid |
$0.15
|
| Rate for Payer: UHCCP DNSP |
$0.28
|
| Rate for Payer: UHCCP DNSP |
$0.28
|
| Rate for Payer: UHCCP Medicaid |
$0.15
|
| Rate for Payer: UHCCP Medicaid |
$0.15
|
| Rate for Payer: VA VA |
$0.28
|
| Rate for Payer: VA VA |
$0.28
|
|
|
FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$787.14
|
|
|
Service Code
|
HCPCS Q5110
|
| Hospital Charge Code |
188115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$590.35 |
| Max. Negotiated Rate |
$787.14 |
| Rate for Payer: Aetna Commercial |
$708.42
|
| Rate for Payer: Aetna Commercial |
$708.43
|
| Rate for Payer: ASR ASR |
$763.52
|
| Rate for Payer: ASR ASR |
$763.52
|
| Rate for Payer: BCBS Trust/PPO |
$646.40
|
| Rate for Payer: BCBS Trust/PPO |
$646.40
|
| Rate for Payer: BCN Commercial |
$646.40
|
| Rate for Payer: BCN Commercial |
$646.40
|
| Rate for Payer: Cash Price |
$629.71
|
| Rate for Payer: Cash Price |
$629.71
|
| Rate for Payer: Cofinity Commercial |
$739.91
|
| Rate for Payer: Cofinity Commercial |
$739.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$629.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$629.71
|
| Rate for Payer: Healthscope Commercial |
$763.52
|
| Rate for Payer: Healthscope Commercial |
$763.52
|
| Rate for Payer: Healthscope Whirlpool |
$787.14
|
| Rate for Payer: Healthscope Whirlpool |
$787.14
|
| Rate for Payer: Mclaren Commercial |
$708.43
|
| Rate for Payer: Mclaren Commercial |
$708.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.07
|
| Rate for Payer: Nomi Health Commercial |
$645.45
|
| Rate for Payer: Nomi Health Commercial |
$645.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$590.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$590.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$692.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$692.68
|
|
|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE
|
Facility
|
IP
|
$707.48
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
175519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$530.61 |
| Max. Negotiated Rate |
$707.48 |
| Rate for Payer: Aetna Commercial |
$636.73
|
| Rate for Payer: ASR ASR |
$686.26
|
| Rate for Payer: BCBS Trust/PPO |
$580.98
|
| Rate for Payer: BCN Commercial |
$580.98
|
| Rate for Payer: Cash Price |
$565.98
|
| Rate for Payer: Cofinity Commercial |
$665.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$565.98
|
| Rate for Payer: Healthscope Commercial |
$686.26
|
| Rate for Payer: Healthscope Whirlpool |
$707.48
|
| Rate for Payer: Mclaren Commercial |
$636.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$601.36
|
| Rate for Payer: Nomi Health Commercial |
$580.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$530.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$622.58
|
|
