|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 68094-494-61
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Aetna Commercial |
$3.13
|
| Rate for Payer: ASR ASR |
$3.38
|
| Rate for Payer: BCBS Trust/PPO |
$2.70
|
| Rate for Payer: BCN Commercial |
$2.70
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cofinity Commercial |
$3.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.78
|
| Rate for Payer: Healthscope Commercial |
$3.48
|
| Rate for Payer: Healthscope Whirlpool |
$3.38
|
| Rate for Payer: Mclaren Commercial |
$3.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.06
|
|
|
IBUPROFEN 200 MG TABLET
|
Facility
|
IP
|
$19.60
|
|
|
Service Code
|
NDC 0904-7914-61
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$19.60 |
| Rate for Payer: Aetna Commercial |
$17.64
|
| Rate for Payer: ASR ASR |
$19.01
|
| Rate for Payer: BCBS Trust/PPO |
$15.20
|
| Rate for Payer: BCN Commercial |
$15.20
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cofinity Commercial |
$18.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.68
|
| Rate for Payer: Healthscope Commercial |
$19.60
|
| Rate for Payer: Healthscope Whirlpool |
$19.01
|
| Rate for Payer: Mclaren Commercial |
$17.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.25
|
|
|
IBUPROFEN 200 MG TABLET
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 47682-100-64
|
| Hospital Charge Code |
3841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Aetna Commercial |
$2.02
|
| Rate for Payer: ASR ASR |
$2.17
|
| Rate for Payer: BCBS Trust/PPO |
$1.74
|
| Rate for Payer: BCN Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.79
|
| Rate for Payer: Healthscope Commercial |
$2.24
|
| Rate for Payer: Healthscope Whirlpool |
$2.17
|
| Rate for Payer: Mclaren Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.97
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$4.04
|
|
|
Service Code
|
NDC 60687-457-11
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: ASR ASR |
$3.92
|
| Rate for Payer: BCBS Trust/PPO |
$3.13
|
| Rate for Payer: BCN Commercial |
$3.13
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Cofinity Commercial |
$3.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.23
|
| Rate for Payer: Healthscope Commercial |
$4.04
|
| Rate for Payer: Healthscope Whirlpool |
$3.92
|
| Rate for Payer: Mclaren Commercial |
$3.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.56
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 60687-457-01
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$282.94 |
| Max. Negotiated Rate |
$404.20 |
| Rate for Payer: Aetna Commercial |
$363.78
|
| Rate for Payer: ASR ASR |
$392.07
|
| Rate for Payer: BCBS Trust/PPO |
$313.38
|
| Rate for Payer: BCN Commercial |
$313.38
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$379.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$404.20
|
| Rate for Payer: Healthscope Whirlpool |
$392.07
|
| Rate for Payer: Mclaren Commercial |
$363.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$355.70
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$157.45
|
|
|
Service Code
|
NDC 49483-603-01
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.22 |
| Max. Negotiated Rate |
$157.45 |
| Rate for Payer: Aetna Commercial |
$141.70
|
| Rate for Payer: ASR ASR |
$152.73
|
| Rate for Payer: BCBS Trust/PPO |
$122.07
|
| Rate for Payer: BCN Commercial |
$122.07
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$148.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$157.45
|
| Rate for Payer: Healthscope Whirlpool |
$152.73
|
| Rate for Payer: Mclaren Commercial |
$141.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$138.56
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$164.50
|
|
|
Service Code
|
NDC 63739-684-10
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.15 |
| Max. Negotiated Rate |
$164.50 |
| Rate for Payer: Aetna Commercial |
$148.05
|
| Rate for Payer: ASR ASR |
$159.56
|
| Rate for Payer: BCBS Trust/PPO |
$127.54
|
| Rate for Payer: BCN Commercial |
$127.54
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$154.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.60
|
| Rate for Payer: Healthscope Commercial |
$164.50
|
| Rate for Payer: Healthscope Whirlpool |
$159.56
|
| Rate for Payer: Mclaren Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.76
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 67877-320-01
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.50 |
| Max. Negotiated Rate |
$162.15 |
| Rate for Payer: Aetna Commercial |
$145.94
|
| Rate for Payer: ASR ASR |
$157.29
|
| Rate for Payer: BCBS Trust/PPO |
$125.71
|
| Rate for Payer: BCN Commercial |
$125.71
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$152.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$162.15
|
| Rate for Payer: Healthscope Whirlpool |
$157.29
|
| Rate for Payer: Mclaren Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.69
|
|
|
IBUPROFEN 600 MG TABLET
|
Facility
|
IP
|
$185.65
|
|
|
Service Code
|
NDC 0904-5854-61
|
| Hospital Charge Code |
3844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.96 |
| Max. Negotiated Rate |
$185.65 |
| Rate for Payer: Aetna Commercial |
$167.08
|
| Rate for Payer: ASR ASR |
$180.08
|
| Rate for Payer: BCBS Trust/PPO |
$143.93
|
| Rate for Payer: BCN Commercial |
$143.93
|
| Rate for Payer: Cash Price |
$148.52
|
| Rate for Payer: Cofinity Commercial |
$174.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.52
|
| Rate for Payer: Healthscope Commercial |
$185.65
|
| Rate for Payer: Healthscope Whirlpool |
$180.08
|
| Rate for Payer: Mclaren Commercial |
$167.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$163.37
|
|
|
IBUPROFEN 800 MG TABLET
|
Facility
|
IP
|
$185.65
|
|
|
Service Code
|
NDC 63739-691-10
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.96 |
| Max. Negotiated Rate |
$185.65 |
| Rate for Payer: Aetna Commercial |
$167.08
|
| Rate for Payer: ASR ASR |
$180.08
|
| Rate for Payer: BCBS Trust/PPO |
$143.93
|
| Rate for Payer: BCN Commercial |
$143.93
|
| Rate for Payer: Cash Price |
$148.52
|
| Rate for Payer: Cofinity Commercial |
$174.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.52
|
| Rate for Payer: Healthscope Commercial |
$185.65
|
| Rate for Payer: Healthscope Whirlpool |
$180.08
|
| Rate for Payer: Mclaren Commercial |
$167.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$163.37
|
|
|
IBUPROFEN 800 MG TABLET
|
Facility
|
IP
|
$16.22
|
|
|
Service Code
|
NDC 0904-5855-61
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.35 |
| Max. Negotiated Rate |
$16.22 |
| Rate for Payer: Aetna Commercial |
$14.60
|
| Rate for Payer: ASR ASR |
$15.73
|
| Rate for Payer: BCBS Trust/PPO |
$12.58
|
| Rate for Payer: BCN Commercial |
$12.58
|
| Rate for Payer: Cash Price |
$12.97
|
| Rate for Payer: Cofinity Commercial |
$15.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.98
|
| Rate for Payer: Healthscope Commercial |
$16.22
|
| Rate for Payer: Healthscope Whirlpool |
$15.73
|
| Rate for Payer: Mclaren Commercial |
$14.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.27
|
|
|
IBUPROFEN 800 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 67877-321-01
|
| Hospital Charge Code |
3845
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$150.40 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: ASR ASR |
$145.89
|
| Rate for Payer: BCBS Trust/PPO |
$116.61
|
| Rate for Payer: BCN Commercial |
$116.61
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$141.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$150.40
|
| Rate for Payer: Healthscope Whirlpool |
$145.89
|
| Rate for Payer: Mclaren Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.35
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN
|
Facility
|
IP
|
$16,456.74
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
172845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,519.72 |
| Max. Negotiated Rate |
$16,456.74 |
| Rate for Payer: Aetna Commercial |
$14,811.07
|
| Rate for Payer: ASR ASR |
$15,963.04
|
| Rate for Payer: BCBS Trust/PPO |
$12,758.91
|
| Rate for Payer: BCN Commercial |
$12,758.91
|
| Rate for Payer: Cash Price |
$13,165.40
|
| Rate for Payer: Cofinity Commercial |
$15,469.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,165.39
|
| Rate for Payer: Healthscope Commercial |
$16,456.74
|
| Rate for Payer: Healthscope Whirlpool |
$15,963.04
|
| Rate for Payer: Mclaren Commercial |
$14,811.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13,988.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,519.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14,481.93
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
171062
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,100.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,700.00
|
| Rate for Payer: Aetna Commercial |
$1,350.00
|
| Rate for Payer: Aetna Commercial |
$270.00
|
| Rate for Payer: ASR ASR |
$291.00
|
| Rate for Payer: ASR ASR |
$2,910.00
|
| Rate for Payer: ASR ASR |
$1,455.00
|
| Rate for Payer: BCBS Trust/PPO |
$1,162.95
|
| Rate for Payer: BCBS Trust/PPO |
$2,325.90
|
| Rate for Payer: BCBS Trust/PPO |
$232.59
|
| Rate for Payer: BCN Commercial |
$1,162.95
|
| Rate for Payer: BCN Commercial |
$232.59
|
| Rate for Payer: BCN Commercial |
$2,325.90
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cofinity Commercial |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$1,410.00
|
| Rate for Payer: Cofinity Commercial |
$2,820.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,200.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,400.00
|
| Rate for Payer: Healthscope Commercial |
$1,500.00
|
| Rate for Payer: Healthscope Commercial |
$3,000.00
|
| Rate for Payer: Healthscope Commercial |
$300.00
|
| Rate for Payer: Healthscope Whirlpool |
$291.00
|
| Rate for Payer: Healthscope Whirlpool |
$2,910.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,455.00
|
| Rate for Payer: Mclaren Commercial |
$270.00
|
| Rate for Payer: Mclaren Commercial |
$1,350.00
|
| Rate for Payer: Mclaren Commercial |
$2,700.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,550.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,275.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,100.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,050.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,320.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$264.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,640.00
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-GLY-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,463.20
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
171060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,024.24 |
| Max. Negotiated Rate |
$1,463.20 |
| Rate for Payer: Aetna Commercial |
$1,316.88
|
| Rate for Payer: ASR ASR |
$1,419.30
|
| Rate for Payer: BCBS Trust/PPO |
$1,134.42
|
| Rate for Payer: BCN Commercial |
$1,134.42
|
| Rate for Payer: Cash Price |
$1,170.56
|
| Rate for Payer: Cofinity Commercial |
$1,375.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,170.56
|
| Rate for Payer: Healthscope Commercial |
$1,463.20
|
| Rate for Payer: Healthscope Whirlpool |
$1,419.30
|
| Rate for Payer: Mclaren Commercial |
$1,316.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,243.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,024.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,287.62
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$6,828.12
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
172293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,779.68 |
| Max. Negotiated Rate |
$6,828.12 |
| Rate for Payer: Aetna Commercial |
$6,145.31
|
| Rate for Payer: ASR ASR |
$6,623.28
|
| Rate for Payer: BCBS Trust/PPO |
$5,293.84
|
| Rate for Payer: BCN Commercial |
$5,293.84
|
| Rate for Payer: Cash Price |
$5,462.50
|
| Rate for Payer: Cofinity Commercial |
$6,418.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,462.50
|
| Rate for Payer: Healthscope Commercial |
$6,828.12
|
| Rate for Payer: Healthscope Whirlpool |
$6,623.28
|
| Rate for Payer: Mclaren Commercial |
$6,145.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,803.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,779.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6,008.75
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$7,960.27
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
171063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,572.19 |
| Max. Negotiated Rate |
$7,960.27 |
| Rate for Payer: Aetna Commercial |
$7,164.24
|
| Rate for Payer: Aetna Commercial |
$1,791.06
|
| Rate for Payer: Aetna Commercial |
$3,582.13
|
| Rate for Payer: ASR ASR |
$7,721.46
|
| Rate for Payer: ASR ASR |
$1,930.37
|
| Rate for Payer: ASR ASR |
$3,860.74
|
| Rate for Payer: BCBS Trust/PPO |
$3,085.80
|
| Rate for Payer: BCBS Trust/PPO |
$1,542.90
|
| Rate for Payer: BCBS Trust/PPO |
$6,171.60
|
| Rate for Payer: BCN Commercial |
$6,171.60
|
| Rate for Payer: BCN Commercial |
$1,542.90
|
| Rate for Payer: BCN Commercial |
$3,085.80
|
| Rate for Payer: Cash Price |
$6,368.22
|
| Rate for Payer: Cash Price |
$1,592.05
|
| Rate for Payer: Cash Price |
$3,184.11
|
| Rate for Payer: Cofinity Commercial |
$3,741.33
|
| Rate for Payer: Cofinity Commercial |
$1,870.67
|
| Rate for Payer: Cofinity Commercial |
$7,482.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,592.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,184.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,368.22
|
| Rate for Payer: Healthscope Commercial |
$7,960.27
|
| Rate for Payer: Healthscope Commercial |
$3,980.14
|
| Rate for Payer: Healthscope Commercial |
$1,990.07
|
| Rate for Payer: Healthscope Whirlpool |
$3,860.74
|
| Rate for Payer: Healthscope Whirlpool |
$1,930.37
|
| Rate for Payer: Healthscope Whirlpool |
$7,721.46
|
| Rate for Payer: Mclaren Commercial |
$3,582.13
|
| Rate for Payer: Mclaren Commercial |
$1,791.06
|
| Rate for Payer: Mclaren Commercial |
$7,164.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,766.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,383.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,691.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,393.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,786.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,572.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,502.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,751.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7,005.04
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$3,414.06
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
171059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,389.84 |
| Max. Negotiated Rate |
$3,414.06 |
| Rate for Payer: Aetna Commercial |
$3,072.65
|
| Rate for Payer: Aetna Commercial |
$768.17
|
| Rate for Payer: ASR ASR |
$3,311.64
|
| Rate for Payer: ASR ASR |
$827.91
|
| Rate for Payer: BCBS Trust/PPO |
$661.73
|
| Rate for Payer: BCBS Trust/PPO |
$2,646.92
|
| Rate for Payer: BCN Commercial |
$2,646.92
|
| Rate for Payer: BCN Commercial |
$661.73
|
| Rate for Payer: Cash Price |
$682.81
|
| Rate for Payer: Cash Price |
$2,731.25
|
| Rate for Payer: Cofinity Commercial |
$802.31
|
| Rate for Payer: Cofinity Commercial |
$3,209.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$682.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,731.25
|
| Rate for Payer: Healthscope Commercial |
$3,414.06
|
| Rate for Payer: Healthscope Commercial |
$853.52
|
| Rate for Payer: Healthscope Whirlpool |
$3,311.64
|
| Rate for Payer: Healthscope Whirlpool |
$827.91
|
| Rate for Payer: Mclaren Commercial |
$3,072.65
|
| Rate for Payer: Mclaren Commercial |
$768.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,901.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$725.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,389.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$597.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$751.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,004.37
|
|
|
IMPACT PEPTIDE 1.5 BOLUS FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 4390097399
|
| Hospital Charge Code |
150765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.19
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE 1.5 CONTINUOUS FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 4390097399
|
| Hospital Charge Code |
168957
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.19
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE 1.5 CYCLIC FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 4390097399
|
| Hospital Charge Code |
200091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.19
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 4390097399
|
| Hospital Charge Code |
200090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.19
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPLANTABLE TISSUE MARKER
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS A4648
|
| Min. Negotiated Rate |
$102.14 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: Aetna Commercial |
$102.14
|
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: BCN Commercial |
$136.96
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
|
|
INBORN AND OTHER DISORDERS OF METABOLISM
|
Facility
|
IP
|
$16,734.37
|
|
|
Service Code
|
MS-DRG 642
|
| Min. Negotiated Rate |
$12,079.43 |
| Max. Negotiated Rate |
$16,734.37 |
| Rate for Payer: Aetna Medicare |
$12,715.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,893.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,893.99
|
| Rate for Payer: BCBS MAPPO |
$12,715.19
|
| Rate for Payer: BCN Medicare Advantage |
$12,715.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,715.19
|
| Rate for Payer: Humana Choice PPO Medicare |
$12,715.19
|
| Rate for Payer: Mclaren Medicare |
$12,715.19
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,350.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,622.47
|
| Rate for Payer: PACE Medicare |
$12,079.43
|
| Rate for Payer: PACE SWMI |
$12,715.19
|
| Rate for Payer: PHP Commercial |
$13,986.71
|
| Rate for Payer: PHP Medicare Advantage |
$12,715.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,734.37
|
| Rate for Payer: Priority Health Medicare |
$12,715.19
|
| Rate for Payer: Priority Health Narrow Network |
$13,387.50
|
| Rate for Payer: Railroad Medicare Medicare |
$12,715.19
|
| Rate for Payer: UHC Medicare Advantage |
$13,096.65
|
| Rate for Payer: VA VA |
$12,715.19
|
|
|
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE
|
Facility
|
OP
|
$222.44
|
|
|
Service Code
|
CPT 10060
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$97.34 |
| 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 |
$217.86
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$174.29
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
