|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$390.10
|
|
|
Service Code
|
NDC 60687-558-01
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.07 |
| Max. Negotiated Rate |
$390.10 |
| Rate for Payer: Aetna Commercial |
$351.09
|
| Rate for Payer: ASR ASR |
$378.40
|
| Rate for Payer: BCBS Trust/PPO |
$302.44
|
| Rate for Payer: BCN Commercial |
$302.44
|
| Rate for Payer: Cash Price |
$312.08
|
| Rate for Payer: Cofinity Commercial |
$366.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.08
|
| Rate for Payer: Healthscope Commercial |
$390.10
|
| Rate for Payer: Healthscope Whirlpool |
$378.40
|
| Rate for Payer: Mclaren Commercial |
$351.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$331.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$343.29
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 60687-558-11
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: ASR ASR |
$3.78
|
| Rate for Payer: BCBS Trust/PPO |
$3.02
|
| Rate for Payer: BCN Commercial |
$3.02
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.12
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: Healthscope Whirlpool |
$3.78
|
| Rate for Payer: Mclaren Commercial |
$3.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.43
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$18.86
|
|
|
Service Code
|
NDC 17478-100-02
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna Commercial |
$16.97
|
| Rate for Payer: ASR ASR |
$18.29
|
| Rate for Payer: BCBS Trust/PPO |
$14.62
|
| Rate for Payer: BCN Commercial |
$14.62
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cofinity Commercial |
$17.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.09
|
| Rate for Payer: Healthscope Commercial |
$18.86
|
| Rate for Payer: Healthscope Whirlpool |
$18.29
|
| Rate for Payer: Mclaren Commercial |
$16.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.60
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$40.25
|
|
|
Service Code
|
NDC 24208-735-01
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.18 |
| Max. Negotiated Rate |
$40.25 |
| Rate for Payer: Aetna Commercial |
$36.22
|
| Rate for Payer: ASR ASR |
$39.04
|
| Rate for Payer: BCBS Trust/PPO |
$31.21
|
| Rate for Payer: BCN Commercial |
$31.21
|
| Rate for Payer: Cash Price |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$37.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.20
|
| Rate for Payer: Healthscope Commercial |
$40.25
|
| Rate for Payer: Healthscope Whirlpool |
$39.04
|
| Rate for Payer: Mclaren Commercial |
$36.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$35.42
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$12.78 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: ASR ASR |
$12.40
|
| Rate for Payer: BCBS Trust/PPO |
$9.91
|
| Rate for Payer: BCN Commercial |
$9.91
|
| Rate for Payer: Cash Price |
$10.22
|
| Rate for Payer: Cofinity Commercial |
$12.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.22
|
| Rate for Payer: Healthscope Commercial |
$12.78
|
| Rate for Payer: Healthscope Whirlpool |
$12.40
|
| Rate for Payer: Mclaren Commercial |
$11.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.25
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$94.64
|
|
|
Service Code
|
NDC 0065-0396-02
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$94.64 |
| Rate for Payer: Aetna Commercial |
$85.18
|
| Rate for Payer: ASR ASR |
$91.80
|
| Rate for Payer: BCBS Trust/PPO |
$73.37
|
| Rate for Payer: BCN Commercial |
$73.37
|
| Rate for Payer: Cash Price |
$75.71
|
| Rate for Payer: Cofinity Commercial |
$88.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.71
|
| Rate for Payer: Healthscope Commercial |
$94.64
|
| Rate for Payer: Healthscope Whirlpool |
$91.80
|
| Rate for Payer: Mclaren Commercial |
$85.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$80.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.28
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,292.03
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,704.42 |
| Max. Negotiated Rate |
$5,292.03 |
| Rate for Payer: Aetna Commercial |
$4,762.83
|
| Rate for Payer: ASR ASR |
$5,133.27
|
| Rate for Payer: BCBS Trust/PPO |
$4,102.91
|
| Rate for Payer: BCN Commercial |
$4,102.91
|
| Rate for Payer: Cash Price |
$4,233.63
|
| Rate for Payer: Cofinity Commercial |
$4,974.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,233.62
|
| Rate for Payer: Healthscope Commercial |
$5,292.03
|
| Rate for Payer: Healthscope Whirlpool |
$5,133.27
|
| Rate for Payer: Mclaren Commercial |
$4,762.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,498.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,704.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,656.99
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$292.64
|
|
|
Service Code
|
NDC 42023-123-06
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$204.85 |
| Max. Negotiated Rate |
$292.64 |
| Rate for Payer: Aetna Commercial |
$263.38
|
| Rate for Payer: ASR ASR |
$283.86
|
| Rate for Payer: BCBS Trust/PPO |
$226.88
|
| Rate for Payer: BCN Commercial |
$226.88
|
| Rate for Payer: Cash Price |
$234.12
|
| Rate for Payer: Cofinity Commercial |
$275.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.11
|
| Rate for Payer: Healthscope Commercial |
$292.64
|
| Rate for Payer: Healthscope Whirlpool |
$283.86
|
| Rate for Payer: Mclaren Commercial |
$263.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$248.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$257.52
|
|
|
DAPTOMYCIN 350 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$53.80
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
186972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.66 |
| Max. Negotiated Rate |
$53.80 |
| Rate for Payer: Aetna Commercial |
$48.42
|
| Rate for Payer: Aetna Commercial |
$83.81
|
| Rate for Payer: ASR ASR |
$52.19
|
| Rate for Payer: ASR ASR |
$90.33
|
| Rate for Payer: BCBS Trust/PPO |
$41.71
|
| Rate for Payer: BCBS Trust/PPO |
$72.20
|
| Rate for Payer: BCN Commercial |
$72.20
|
| Rate for Payer: BCN Commercial |
$41.71
|
| Rate for Payer: Cash Price |
$43.04
|
| Rate for Payer: Cash Price |
$74.49
|
| Rate for Payer: Cofinity Commercial |
$50.57
|
| Rate for Payer: Cofinity Commercial |
$87.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.04
|
| Rate for Payer: Healthscope Commercial |
$53.80
|
| Rate for Payer: Healthscope Commercial |
$93.12
|
| Rate for Payer: Healthscope Whirlpool |
$90.33
|
| Rate for Payer: Healthscope Whirlpool |
$52.19
|
| Rate for Payer: Mclaren Commercial |
$48.42
|
| Rate for Payer: Mclaren Commercial |
$83.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$45.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$81.95
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.18
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
36989
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$129.18 |
| Rate for Payer: Aetna Commercial |
$116.26
|
| Rate for Payer: Aetna Commercial |
$78.22
|
| Rate for Payer: Aetna Commercial |
$59.60
|
| Rate for Payer: Aetna Commercial |
$45.14
|
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Commercial |
$77.75
|
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Aetna Commercial |
$1,196.41
|
| Rate for Payer: ASR ASR |
$64.23
|
| Rate for Payer: ASR ASR |
$125.30
|
| Rate for Payer: ASR ASR |
$84.30
|
| Rate for Payer: ASR ASR |
$83.95
|
| Rate for Payer: ASR ASR |
$1,289.46
|
| Rate for Payer: ASR ASR |
$54.78
|
| Rate for Payer: ASR ASR |
$83.80
|
| Rate for Payer: ASR ASR |
$48.65
|
| Rate for Payer: BCBS Trust/PPO |
$1,030.64
|
| Rate for Payer: BCBS Trust/PPO |
$67.38
|
| Rate for Payer: BCBS Trust/PPO |
$66.98
|
| Rate for Payer: BCBS Trust/PPO |
$43.78
|
| Rate for Payer: BCBS Trust/PPO |
$51.34
|
| Rate for Payer: BCBS Trust/PPO |
$100.15
|
| Rate for Payer: BCBS Trust/PPO |
$67.10
|
| Rate for Payer: BCBS Trust/PPO |
$38.88
|
| Rate for Payer: BCN Commercial |
$1,030.64
|
| Rate for Payer: BCN Commercial |
$43.78
|
| Rate for Payer: BCN Commercial |
$38.88
|
| Rate for Payer: BCN Commercial |
$66.98
|
| Rate for Payer: BCN Commercial |
$100.15
|
| Rate for Payer: BCN Commercial |
$67.10
|
| Rate for Payer: BCN Commercial |
$67.38
|
| Rate for Payer: BCN Commercial |
$51.34
|
| Rate for Payer: Cash Price |
$69.11
|
| Rate for Payer: Cash Price |
$103.35
|
| Rate for Payer: Cash Price |
$1,063.48
|
| Rate for Payer: Cash Price |
$40.12
|
| Rate for Payer: Cash Price |
$45.18
|
| Rate for Payer: Cash Price |
$52.97
|
| Rate for Payer: Cash Price |
$69.24
|
| Rate for Payer: Cash Price |
$69.53
|
| Rate for Payer: Cofinity Commercial |
$121.43
|
| Rate for Payer: Cofinity Commercial |
$81.21
|
| Rate for Payer: Cofinity Commercial |
$1,249.58
|
| Rate for Payer: Cofinity Commercial |
$53.08
|
| Rate for Payer: Cofinity Commercial |
$47.14
|
| Rate for Payer: Cofinity Commercial |
$81.70
|
| Rate for Payer: Cofinity Commercial |
$62.25
|
| Rate for Payer: Cofinity Commercial |
$81.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,063.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.12
|
| Rate for Payer: Healthscope Commercial |
$66.22
|
| Rate for Payer: Healthscope Commercial |
$50.15
|
| Rate for Payer: Healthscope Commercial |
$86.39
|
| Rate for Payer: Healthscope Commercial |
$86.55
|
| Rate for Payer: Healthscope Commercial |
$86.91
|
| Rate for Payer: Healthscope Commercial |
$1,329.34
|
| Rate for Payer: Healthscope Commercial |
$56.47
|
| Rate for Payer: Healthscope Commercial |
$129.18
|
| Rate for Payer: Healthscope Whirlpool |
$83.95
|
| Rate for Payer: Healthscope Whirlpool |
$54.78
|
| Rate for Payer: Healthscope Whirlpool |
$84.30
|
| Rate for Payer: Healthscope Whirlpool |
$64.23
|
| Rate for Payer: Healthscope Whirlpool |
$48.65
|
| Rate for Payer: Healthscope Whirlpool |
$1,289.46
|
| Rate for Payer: Healthscope Whirlpool |
$83.80
|
| Rate for Payer: Healthscope Whirlpool |
$125.30
|
| Rate for Payer: Mclaren Commercial |
$78.22
|
| Rate for Payer: Mclaren Commercial |
$77.90
|
| Rate for Payer: Mclaren Commercial |
$77.75
|
| Rate for Payer: Mclaren Commercial |
$45.14
|
| Rate for Payer: Mclaren Commercial |
$50.82
|
| Rate for Payer: Mclaren Commercial |
$116.26
|
| Rate for Payer: Mclaren Commercial |
$1,196.41
|
| Rate for Payer: Mclaren Commercial |
$59.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,129.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$42.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$930.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$76.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$76.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$58.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$113.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,169.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$76.48
|
|
|
DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE
|
Facility
|
IP
|
$2,412.46
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
116632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,688.72 |
| Max. Negotiated Rate |
$2,412.46 |
| Rate for Payer: Aetna Commercial |
$2,171.21
|
| Rate for Payer: ASR ASR |
$2,340.09
|
| Rate for Payer: BCBS Trust/PPO |
$1,870.38
|
| Rate for Payer: BCN Commercial |
$1,870.38
|
| Rate for Payer: Cash Price |
$1,929.97
|
| Rate for Payer: Cofinity Commercial |
$2,267.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,929.97
|
| Rate for Payer: Healthscope Commercial |
$2,412.46
|
| Rate for Payer: Healthscope Whirlpool |
$2,340.09
|
| Rate for Payer: Mclaren Commercial |
$2,171.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,050.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,688.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,122.96
|
|
|
DARBEPOETIN ALFA 100 MCG/ML IN POLYSORBATE INJECTION
|
Facility
|
IP
|
$2,229.83
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
116659
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,560.88 |
| Max. Negotiated Rate |
$2,229.83 |
| Rate for Payer: Aetna Commercial |
$2,006.85
|
| Rate for Payer: Aetna Commercial |
$2,171.21
|
| Rate for Payer: ASR ASR |
$2,340.09
|
| Rate for Payer: ASR ASR |
$2,162.94
|
| Rate for Payer: BCBS Trust/PPO |
$1,728.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,870.38
|
| Rate for Payer: BCN Commercial |
$1,728.79
|
| Rate for Payer: BCN Commercial |
$1,870.38
|
| Rate for Payer: Cash Price |
$1,929.97
|
| Rate for Payer: Cash Price |
$1,783.87
|
| Rate for Payer: Cofinity Commercial |
$2,096.04
|
| Rate for Payer: Cofinity Commercial |
$2,267.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,783.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,929.97
|
| Rate for Payer: Healthscope Commercial |
$2,412.46
|
| Rate for Payer: Healthscope Commercial |
$2,229.83
|
| Rate for Payer: Healthscope Whirlpool |
$2,162.94
|
| Rate for Payer: Healthscope Whirlpool |
$2,340.09
|
| Rate for Payer: Mclaren Commercial |
$2,171.21
|
| Rate for Payer: Mclaren Commercial |
$2,006.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,895.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,050.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,688.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,560.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,962.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,122.96
|
|
|
DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE
|
Facility
|
IP
|
$4,824.93
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
116630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,377.45 |
| Max. Negotiated Rate |
$4,824.93 |
| Rate for Payer: Aetna Commercial |
$4,342.44
|
| Rate for Payer: ASR ASR |
$4,680.18
|
| Rate for Payer: BCBS Trust/PPO |
$3,740.77
|
| Rate for Payer: BCN Commercial |
$3,740.77
|
| Rate for Payer: Cash Price |
$3,859.94
|
| Rate for Payer: Cofinity Commercial |
$4,535.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,859.94
|
| Rate for Payer: Healthscope Commercial |
$4,824.93
|
| Rate for Payer: Healthscope Whirlpool |
$4,680.18
|
| Rate for Payer: Mclaren Commercial |
$4,342.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,101.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,377.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,245.94
|
|
|
DARBEPOETIN ALFA 200 MCG/ML IN POLYSORBATE INJECTION
|
Facility
|
IP
|
$4,824.93
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
116661
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,377.45 |
| Max. Negotiated Rate |
$4,824.93 |
| Rate for Payer: Aetna Commercial |
$4,342.44
|
| Rate for Payer: ASR ASR |
$4,680.18
|
| Rate for Payer: BCBS Trust/PPO |
$3,740.77
|
| Rate for Payer: BCN Commercial |
$3,740.77
|
| Rate for Payer: Cash Price |
$3,859.94
|
| Rate for Payer: Cofinity Commercial |
$4,535.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,859.94
|
| Rate for Payer: Healthscope Commercial |
$4,824.93
|
| Rate for Payer: Healthscope Whirlpool |
$4,680.18
|
| Rate for Payer: Mclaren Commercial |
$4,342.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,101.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,377.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,245.94
|
|
|
DARBEPOETIN ALFA 25 MCG/ML IN POLYSORBATE INJECTION
|
Facility
|
IP
|
$669.09
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$468.36 |
| Max. Negotiated Rate |
$669.09 |
| Rate for Payer: Aetna Commercial |
$602.18
|
| Rate for Payer: ASR ASR |
$649.02
|
| Rate for Payer: BCBS Trust/PPO |
$518.75
|
| Rate for Payer: BCN Commercial |
$518.75
|
| Rate for Payer: Cash Price |
$535.27
|
| Rate for Payer: Cofinity Commercial |
$628.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$535.27
|
| Rate for Payer: Healthscope Commercial |
$669.09
|
| Rate for Payer: Healthscope Whirlpool |
$649.02
|
| Rate for Payer: Mclaren Commercial |
$602.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$568.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$588.80
|
|
|
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE
|
Facility
|
IP
|
$5,880.39
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
116631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,116.27 |
| Max. Negotiated Rate |
$5,880.39 |
| Rate for Payer: Aetna Commercial |
$5,292.35
|
| Rate for Payer: ASR ASR |
$5,703.98
|
| Rate for Payer: BCBS Trust/PPO |
$4,559.07
|
| Rate for Payer: BCN Commercial |
$4,559.07
|
| Rate for Payer: Cash Price |
$4,704.32
|
| Rate for Payer: Cofinity Commercial |
$5,527.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,704.31
|
| Rate for Payer: Healthscope Commercial |
$5,880.39
|
| Rate for Payer: Healthscope Whirlpool |
$5,703.98
|
| Rate for Payer: Mclaren Commercial |
$5,292.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,998.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,116.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,174.74
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE
|
Facility
|
IP
|
$964.98
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76965
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$675.49 |
| Max. Negotiated Rate |
$964.98 |
| Rate for Payer: Aetna Commercial |
$868.48
|
| Rate for Payer: ASR ASR |
$936.03
|
| Rate for Payer: BCBS Trust/PPO |
$748.15
|
| Rate for Payer: BCN Commercial |
$748.15
|
| Rate for Payer: Cash Price |
$771.99
|
| Rate for Payer: Cofinity Commercial |
$907.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$771.98
|
| Rate for Payer: Healthscope Commercial |
$964.98
|
| Rate for Payer: Healthscope Whirlpool |
$936.03
|
| Rate for Payer: Mclaren Commercial |
$868.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$820.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$675.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$849.18
|
|
|
DARBEPOETIN ALFA 40 MCG/ML IN POLYSORBATE INJECTION
|
Facility
|
IP
|
$964.99
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$675.49 |
| Max. Negotiated Rate |
$964.99 |
| Rate for Payer: Aetna Commercial |
$868.49
|
| Rate for Payer: ASR ASR |
$936.04
|
| Rate for Payer: BCBS Trust/PPO |
$748.16
|
| Rate for Payer: BCN Commercial |
$748.16
|
| Rate for Payer: Cash Price |
$771.99
|
| Rate for Payer: Cofinity Commercial |
$907.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$771.99
|
| Rate for Payer: Healthscope Commercial |
$964.99
|
| Rate for Payer: Healthscope Whirlpool |
$936.04
|
| Rate for Payer: Mclaren Commercial |
$868.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$820.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$675.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$849.19
|
|
|
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE
|
Facility
|
IP
|
$9,800.65
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
76334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,860.46 |
| Max. Negotiated Rate |
$9,800.65 |
| Rate for Payer: Aetna Commercial |
$8,820.58
|
| Rate for Payer: ASR ASR |
$9,506.63
|
| Rate for Payer: BCBS Trust/PPO |
$7,598.44
|
| Rate for Payer: BCN Commercial |
$7,598.44
|
| Rate for Payer: Cash Price |
$7,840.52
|
| Rate for Payer: Cofinity Commercial |
$9,212.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,840.52
|
| Rate for Payer: Healthscope Commercial |
$9,800.65
|
| Rate for Payer: Healthscope Whirlpool |
$9,506.63
|
| Rate for Payer: Mclaren Commercial |
$8,820.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8,330.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,860.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8,624.57
|
|
|
DARBEPOETIN ALFA 60 MCG/ML IN POLYSORBATE INJECTION
|
Facility
|
IP
|
$1,447.48
|
|
|
Service Code
|
HCPCS J0881
|
| Hospital Charge Code |
116658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,013.24 |
| Max. Negotiated Rate |
$1,447.48 |
| Rate for Payer: Aetna Commercial |
$1,302.73
|
| Rate for Payer: ASR ASR |
$1,404.06
|
| Rate for Payer: BCBS Trust/PPO |
$1,122.23
|
| Rate for Payer: BCN Commercial |
$1,122.23
|
| Rate for Payer: Cash Price |
$1,157.99
|
| Rate for Payer: Cofinity Commercial |
$1,360.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,157.98
|
| Rate for Payer: Healthscope Commercial |
$1,447.48
|
| Rate for Payer: Healthscope Whirlpool |
$1,404.06
|
| Rate for Payer: Mclaren Commercial |
$1,302.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,230.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,013.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,273.78
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC
|
Facility
|
IP
|
$24,170.02
|
|
|
Service Code
|
MS-DRG 744
|
| Min. Negotiated Rate |
$16,737.18 |
| Max. Negotiated Rate |
$24,170.02 |
| Rate for Payer: Aetna Medicare |
$17,618.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22,022.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22,022.60
|
| Rate for Payer: BCBS MAPPO |
$17,618.08
|
| Rate for Payer: BCN Medicare Advantage |
$17,618.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,618.08
|
| Rate for Payer: Humana Choice PPO Medicare |
$17,618.08
|
| Rate for Payer: Mclaren Medicare |
$17,618.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18,498.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,260.79
|
| Rate for Payer: PACE Medicare |
$16,737.18
|
| Rate for Payer: PACE SWMI |
$17,618.08
|
| Rate for Payer: PHP Commercial |
$19,379.89
|
| Rate for Payer: PHP Medicare Advantage |
$17,618.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24,170.02
|
| Rate for Payer: Priority Health Medicare |
$17,618.08
|
| Rate for Payer: Priority Health Narrow Network |
$19,336.02
|
| Rate for Payer: Railroad Medicare Medicare |
$17,618.08
|
| Rate for Payer: UHC Medicare Advantage |
$18,146.62
|
| Rate for Payer: VA VA |
$17,618.08
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC
|
Facility
|
IP
|
$13,300.96
|
|
|
Service Code
|
MS-DRG 745
|
| Min. Negotiated Rate |
$9,928.72 |
| Max. Negotiated Rate |
$13,300.96 |
| Rate for Payer: Aetna Medicare |
$10,451.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,064.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,064.10
|
| Rate for Payer: BCBS MAPPO |
$10,451.28
|
| Rate for Payer: BCN Medicare Advantage |
$10,451.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,451.28
|
| Rate for Payer: Humana Choice PPO Medicare |
$10,451.28
|
| Rate for Payer: Mclaren Medicare |
$10,451.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,973.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,018.97
|
| Rate for Payer: PACE Medicare |
$9,928.72
|
| Rate for Payer: PACE SWMI |
$10,451.28
|
| Rate for Payer: PHP Commercial |
$11,496.41
|
| Rate for Payer: PHP Medicare Advantage |
$10,451.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,300.96
|
| Rate for Payer: Priority Health Medicare |
$10,451.28
|
| Rate for Payer: Priority Health Narrow Network |
$10,640.77
|
| Rate for Payer: Railroad Medicare Medicare |
$10,451.28
|
| Rate for Payer: UHC Medicare Advantage |
$10,764.82
|
| Rate for Payer: VA VA |
$10,451.28
|
|
|
DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$222.44
|
|
|
Service Code
|
CPT 97597
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$39.40 |
| Max. Negotiated Rate |
$222.44 |
| Rate for Payer: Aetna Medicare |
$177.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.44
|
| Rate for Payer: BCBS Complete |
$102.21
|
| Rate for Payer: BCBS MAPPO |
$177.95
|
| Rate for Payer: BCN Medicare Advantage |
$177.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$177.95
|
| Rate for Payer: Humana Choice PPO Medicare |
$177.95
|
| Rate for Payer: Mclaren Medicaid |
$97.34
|
| Rate for Payer: Mclaren Medicare |
$177.95
|
| Rate for Payer: Meridian Medicaid |
$102.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$186.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.64
|
| Rate for Payer: PACE Medicare |
$169.05
|
| Rate for Payer: PACE SWMI |
$177.95
|
| Rate for Payer: PHP Commercial |
$195.74
|
| Rate for Payer: PHP Medicaid |
$97.34
|
| Rate for Payer: PHP Medicare Advantage |
$177.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.25
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$39.40
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
|
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC
|
Facility
|
IP
|
$14,043.11
|
|
|
Service Code
|
MS-DRG 294
|
| Min. Negotiated Rate |
$10,393.61 |
| Max. Negotiated Rate |
$14,043.11 |
| Rate for Payer: Aetna Medicare |
$10,940.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,675.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,675.80
|
| Rate for Payer: BCBS MAPPO |
$10,940.64
|
| Rate for Payer: BCN Medicare Advantage |
$10,940.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,940.64
|
| Rate for Payer: Humana Choice PPO Medicare |
$10,940.64
|
| Rate for Payer: Mclaren Medicare |
$10,940.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,487.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,581.74
|
| Rate for Payer: PACE Medicare |
$10,393.61
|
| Rate for Payer: PACE SWMI |
$10,940.64
|
| Rate for Payer: PHP Commercial |
$12,034.70
|
| Rate for Payer: PHP Medicare Advantage |
$10,940.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14,043.11
|
| Rate for Payer: Priority Health Medicare |
$10,940.64
|
| Rate for Payer: Priority Health Narrow Network |
$11,234.49
|
| Rate for Payer: Railroad Medicare Medicare |
$10,940.64
|
| Rate for Payer: UHC Medicare Advantage |
$11,268.86
|
| Rate for Payer: VA VA |
$10,940.64
|
|
|
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$10,536.89
|
|
|
Service Code
|
MS-DRG 295
|
| Min. Negotiated Rate |
$6,486.77 |
| Max. Negotiated Rate |
$10,536.89 |
| Rate for Payer: Aetna Medicare |
$8,429.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,536.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,536.89
|
| Rate for Payer: BCBS MAPPO |
$8,429.51
|
| Rate for Payer: BCN Medicare Advantage |
$8,429.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,429.51
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,429.51
|
| Rate for Payer: Mclaren Medicare |
$8,429.51
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,850.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,693.94
|
| Rate for Payer: PACE Medicare |
$8,008.03
|
| Rate for Payer: PACE SWMI |
$8,429.51
|
| Rate for Payer: PHP Commercial |
$9,272.46
|
| Rate for Payer: PHP Medicare Advantage |
$8,429.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,108.46
|
| Rate for Payer: Priority Health Medicare |
$8,429.51
|
| Rate for Payer: Priority Health Narrow Network |
$6,486.77
|
| Rate for Payer: Railroad Medicare Medicare |
$8,429.51
|
| Rate for Payer: UHC Medicare Advantage |
$8,682.40
|
| Rate for Payer: VA VA |
$8,429.51
|
|
