|
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS
|
Facility
|
IP
|
$13,996.31
|
|
|
Service Code
|
MSDRG 065
|
| Min. Negotiated Rate |
$8,578.39 |
| Max. Negotiated Rate |
$13,996.31 |
| Rate for Payer: Aetna Medicare |
$9,029.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,287.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,287.35
|
| Rate for Payer: BCBS MAPPO |
$9,029.88
|
| Rate for Payer: BCN Medicare Advantage |
$9,029.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,029.88
|
| Rate for Payer: Humana Choice PPO Medicare |
$9,029.88
|
| Rate for Payer: Mclaren Medicare |
$9,029.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,481.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,384.36
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,932.87
|
| Rate for Payer: PACE Medicare |
$8,578.39
|
| Rate for Payer: PACE SWMI |
$9,029.88
|
| Rate for Payer: PHP Commercial |
$9,932.87
|
| Rate for Payer: PHP Medicare Advantage |
$9,029.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13,880.31
|
| Rate for Payer: Priority Health Medicare |
$9,029.88
|
| Rate for Payer: Priority Health Narrow Network |
$11,104.25
|
| Rate for Payer: Railroad Medicare Medicare |
$9,029.88
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9,029.88
|
| Rate for Payer: UHC Exchange |
$13,996.31
|
| Rate for Payer: UHCCP DNSP |
$9,029.88
|
| Rate for Payer: VA VA |
$9,029.88
|
|
|
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC
|
Facility
|
IP
|
$27,628.73
|
|
|
Service Code
|
MSDRG 064
|
| Min. Negotiated Rate |
$15,424.34 |
| Max. Negotiated Rate |
$27,628.73 |
| Rate for Payer: Aetna Medicare |
$16,236.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,295.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,295.19
|
| Rate for Payer: BCBS MAPPO |
$16,236.15
|
| Rate for Payer: BCN Medicare Advantage |
$16,236.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,236.15
|
| Rate for Payer: Humana Choice PPO Medicare |
$16,236.15
|
| Rate for Payer: Mclaren Medicare |
$16,236.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17,047.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,671.57
|
| Rate for Payer: Molina Medicare/Medicaid |
$17,859.76
|
| Rate for Payer: PACE Medicare |
$15,424.34
|
| Rate for Payer: PACE SWMI |
$16,236.15
|
| Rate for Payer: PHP Commercial |
$17,859.76
|
| Rate for Payer: PHP Medicare Advantage |
$16,236.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$27,628.73
|
| Rate for Payer: Priority Health Medicare |
$16,236.15
|
| Rate for Payer: Priority Health Narrow Network |
$22,102.98
|
| Rate for Payer: Railroad Medicare Medicare |
$16,236.15
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$16,236.15
|
| Rate for Payer: UHC Exchange |
$25,166.03
|
| Rate for Payer: UHCCP DNSP |
$16,236.15
|
| Rate for Payer: VA VA |
$16,236.15
|
|
|
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC
|
Facility
|
IP
|
$10,358.63
|
|
|
Service Code
|
MSDRG 066
|
| Min. Negotiated Rate |
$6,348.84 |
| Max. Negotiated Rate |
$10,358.63 |
| Rate for Payer: Aetna Medicare |
$6,682.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,353.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,353.74
|
| Rate for Payer: BCBS MAPPO |
$6,682.99
|
| Rate for Payer: BCN Medicare Advantage |
$6,682.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,682.99
|
| Rate for Payer: Humana Choice PPO Medicare |
$6,682.99
|
| Rate for Payer: Mclaren Medicare |
$6,682.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,017.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,685.44
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,351.29
|
| Rate for Payer: PACE Medicare |
$6,348.84
|
| Rate for Payer: PACE SWMI |
$6,682.99
|
| Rate for Payer: PHP Commercial |
$7,351.29
|
| Rate for Payer: PHP Medicare Advantage |
$6,682.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$9,402.83
|
| Rate for Payer: Priority Health Medicare |
$6,682.99
|
| Rate for Payer: Priority Health Narrow Network |
$7,522.27
|
| Rate for Payer: Railroad Medicare Medicare |
$6,682.99
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,682.99
|
| Rate for Payer: UHC Exchange |
$10,358.63
|
| Rate for Payer: UHCCP DNSP |
$6,682.99
|
| Rate for Payer: VA VA |
$6,682.99
|
|
|
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC
|
Facility
|
IP
|
$72,730.46
|
|
|
Service Code
|
MSDRG 021
|
| Min. Negotiated Rate |
$37,882.59 |
| Max. Negotiated Rate |
$72,730.46 |
| Rate for Payer: Aetna Medicare |
$39,876.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$49,845.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$49,845.51
|
| Rate for Payer: BCBS MAPPO |
$39,876.41
|
| Rate for Payer: BCN Medicare Advantage |
$39,876.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39,876.41
|
| Rate for Payer: Humana Choice PPO Medicare |
$39,876.41
|
| Rate for Payer: Mclaren Medicare |
$39,876.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$41,870.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45,857.87
|
| Rate for Payer: Molina Medicare/Medicaid |
$43,864.05
|
| Rate for Payer: PACE Medicare |
$37,882.59
|
| Rate for Payer: PACE SWMI |
$39,876.41
|
| Rate for Payer: PHP Commercial |
$43,864.05
|
| Rate for Payer: PHP Medicare Advantage |
$39,876.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$72,730.46
|
| Rate for Payer: Priority Health Medicare |
$39,876.41
|
| Rate for Payer: Priority Health Narrow Network |
$58,184.37
|
| Rate for Payer: Railroad Medicare Medicare |
$39,876.41
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$39,876.41
|
| Rate for Payer: UHC Exchange |
$61,808.44
|
| Rate for Payer: UHCCP DNSP |
$39,876.41
|
| Rate for Payer: VA VA |
$39,876.41
|
|
|
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$108,107.87
|
|
|
Service Code
|
MSDRG 020
|
| Min. Negotiated Rate |
$55,498.63 |
| Max. Negotiated Rate |
$108,107.87 |
| Rate for Payer: Aetna Medicare |
$58,419.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73,024.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73,024.51
|
| Rate for Payer: BCBS MAPPO |
$58,419.61
|
| Rate for Payer: BCN Medicare Advantage |
$58,419.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58,419.61
|
| Rate for Payer: Humana Choice PPO Medicare |
$58,419.61
|
| Rate for Payer: Mclaren Medicare |
$58,419.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61,340.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67,182.55
|
| Rate for Payer: Molina Medicare/Medicaid |
$64,261.57
|
| Rate for Payer: PACE Medicare |
$55,498.63
|
| Rate for Payer: PACE SWMI |
$58,419.61
|
| Rate for Payer: PHP Commercial |
$64,261.57
|
| Rate for Payer: PHP Medicare Advantage |
$58,419.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$108,107.87
|
| Rate for Payer: Priority Health Medicare |
$58,419.61
|
| Rate for Payer: Priority Health Narrow Network |
$86,486.30
|
| Rate for Payer: Railroad Medicare Medicare |
$58,419.61
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$58,419.61
|
| Rate for Payer: UHC Exchange |
$90,550.40
|
| Rate for Payer: UHCCP DNSP |
$58,419.61
|
| Rate for Payer: VA VA |
$58,419.61
|
|
|
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC
|
Facility
|
IP
|
$43,653.66
|
|
|
Service Code
|
MSDRG 022
|
| Min. Negotiated Rate |
$23,403.91 |
| Max. Negotiated Rate |
$43,653.66 |
| Rate for Payer: Aetna Medicare |
$24,635.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30,794.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30,794.61
|
| Rate for Payer: BCBS MAPPO |
$24,635.69
|
| Rate for Payer: BCN Medicare Advantage |
$24,635.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24,635.69
|
| Rate for Payer: Humana Choice PPO Medicare |
$24,635.69
|
| Rate for Payer: Mclaren Medicare |
$24,635.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25,867.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28,331.04
|
| Rate for Payer: Molina Medicare/Medicaid |
$27,099.26
|
| Rate for Payer: PACE Medicare |
$23,403.91
|
| Rate for Payer: PACE SWMI |
$24,635.69
|
| Rate for Payer: PHP Commercial |
$27,099.26
|
| Rate for Payer: PHP Medicare Advantage |
$24,635.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$43,653.66
|
| Rate for Payer: Priority Health Medicare |
$24,635.69
|
| Rate for Payer: Priority Health Narrow Network |
$34,922.93
|
| Rate for Payer: Railroad Medicare Medicare |
$24,635.69
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$24,635.69
|
| Rate for Payer: UHC Exchange |
$38,185.32
|
| Rate for Payer: UHCCP DNSP |
$24,635.69
|
| Rate for Payer: VA VA |
$24,635.69
|
|
|
INTRAOCULAR PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$24,841.12
|
|
|
Service Code
|
MSDRG 116
|
| Min. Negotiated Rate |
$14,036.28 |
| Max. Negotiated Rate |
$24,841.12 |
| Rate for Payer: Aetna Medicare |
$14,775.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,468.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,468.79
|
| Rate for Payer: BCBS MAPPO |
$14,775.03
|
| Rate for Payer: BCN Medicare Advantage |
$14,775.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,775.03
|
| Rate for Payer: Humana Choice PPO Medicare |
$14,775.03
|
| Rate for Payer: Mclaren Medicare |
$14,775.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15,513.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,991.28
|
| Rate for Payer: Molina Medicare/Medicaid |
$16,252.53
|
| Rate for Payer: PACE Medicare |
$14,036.28
|
| Rate for Payer: PACE SWMI |
$14,775.03
|
| Rate for Payer: PHP Commercial |
$16,252.53
|
| Rate for Payer: PHP Medicare Advantage |
$14,775.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$24,841.12
|
| Rate for Payer: Priority Health Medicare |
$14,775.03
|
| Rate for Payer: Priority Health Narrow Network |
$19,872.90
|
| Rate for Payer: Railroad Medicare Medicare |
$14,775.03
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,775.03
|
| Rate for Payer: UHC Exchange |
$22,901.30
|
| Rate for Payer: UHCCP DNSP |
$14,775.03
|
| Rate for Payer: VA VA |
$14,775.03
|
|
|
INTRAOCULAR PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$14,905.22
|
|
|
Service Code
|
MSDRG 117
|
| Min. Negotiated Rate |
$9,088.74 |
| Max. Negotiated Rate |
$14,905.22 |
| Rate for Payer: Aetna Medicare |
$9,567.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,958.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,958.86
|
| Rate for Payer: BCBS MAPPO |
$9,567.09
|
| Rate for Payer: BCN Medicare Advantage |
$9,567.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,567.09
|
| Rate for Payer: Humana Choice PPO Medicare |
$9,567.09
|
| Rate for Payer: Mclaren Medicare |
$9,567.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10,045.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,002.15
|
| Rate for Payer: Molina Medicare/Medicaid |
$10,523.80
|
| Rate for Payer: PACE Medicare |
$9,088.74
|
| Rate for Payer: PACE SWMI |
$9,567.09
|
| Rate for Payer: PHP Commercial |
$10,523.80
|
| Rate for Payer: PHP Medicare Advantage |
$9,567.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$14,905.22
|
| Rate for Payer: Priority Health Medicare |
$9,567.09
|
| Rate for Payer: Priority Health Narrow Network |
$11,924.18
|
| Rate for Payer: Railroad Medicare Medicare |
$9,567.09
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9,567.09
|
| Rate for Payer: UHC Exchange |
$14,828.99
|
| Rate for Payer: UHCCP DNSP |
$9,567.09
|
| Rate for Payer: VA VA |
$9,567.09
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
17595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Medicare |
$37.00
|
| Rate for Payer: Aetna Medicare |
$18.50
|
| Rate for Payer: ASR ASR |
$48.50
|
| Rate for Payer: ASR ASR |
$97.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$20.00
|
| Rate for Payer: BCBS Trust/PPO |
$41.23
|
| Rate for Payer: BCBS Trust/PPO |
$82.45
|
| Rate for Payer: BCN Commercial |
$82.45
|
| Rate for Payer: BCN Commercial |
$41.23
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cofinity Commercial |
$94.00
|
| Rate for Payer: Cofinity Commercial |
$47.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.00
|
| Rate for Payer: Healthscope Commercial |
$48.50
|
| Rate for Payer: Healthscope Commercial |
$97.00
|
| Rate for Payer: Healthscope Whirlpool |
$50.00
|
| Rate for Payer: Healthscope Whirlpool |
$100.00
|
| Rate for Payer: Mclaren Commercial |
$45.00
|
| Rate for Payer: Mclaren Commercial |
$90.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.50
|
| Rate for Payer: Nomi Health Commercial |
$82.00
|
| Rate for Payer: Nomi Health Commercial |
$41.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.42
|
| Rate for Payer: Priority Health Narrow Network |
$1.93
|
| Rate for Payer: Priority Health Narrow Network |
$1.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$88.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.00
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
17595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: ASR ASR |
$48.50
|
| Rate for Payer: ASR ASR |
$97.00
|
| Rate for Payer: BCBS Trust/PPO |
$41.06
|
| Rate for Payer: BCBS Trust/PPO |
$82.12
|
| Rate for Payer: BCN Commercial |
$41.06
|
| Rate for Payer: BCN Commercial |
$82.12
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cofinity Commercial |
$94.00
|
| Rate for Payer: Cofinity Commercial |
$47.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.00
|
| Rate for Payer: Healthscope Commercial |
$97.00
|
| Rate for Payer: Healthscope Commercial |
$48.50
|
| Rate for Payer: Healthscope Whirlpool |
$50.00
|
| Rate for Payer: Healthscope Whirlpool |
$100.00
|
| Rate for Payer: Mclaren Commercial |
$45.00
|
| Rate for Payer: Mclaren Commercial |
$90.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.00
|
| Rate for Payer: Nomi Health Commercial |
$41.00
|
| Rate for Payer: Nomi Health Commercial |
$82.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$88.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.00
|
|
|
IODOFORM 1/2" X 5 YARD BANDAGE
|
Facility
|
IP
|
$15.68
|
|
|
Service Code
|
NDC 8080783200
|
| Hospital Charge Code |
110335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna Commercial |
$14.11
|
| Rate for Payer: ASR ASR |
$15.21
|
| Rate for Payer: BCBS Trust/PPO |
$12.88
|
| Rate for Payer: BCN Commercial |
$12.88
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: Cofinity Commercial |
$14.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.54
|
| Rate for Payer: Healthscope Commercial |
$15.21
|
| Rate for Payer: Healthscope Whirlpool |
$15.68
|
| Rate for Payer: Mclaren Commercial |
$14.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.33
|
| Rate for Payer: Nomi Health Commercial |
$12.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.80
|
|
|
IODOFORM 1/2" X 5 YARD BANDAGE
|
Facility
|
OP
|
$15.68
|
|
|
Service Code
|
NDC 8080783200
|
| Hospital Charge Code |
110335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna Commercial |
$14.11
|
| Rate for Payer: Aetna Medicare |
$5.80
|
| Rate for Payer: ASR ASR |
$15.21
|
| Rate for Payer: BCBS Complete |
$6.27
|
| Rate for Payer: BCBS Trust/PPO |
$12.93
|
| Rate for Payer: BCN Commercial |
$12.93
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: Cofinity Commercial |
$14.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.54
|
| Rate for Payer: Healthscope Commercial |
$15.21
|
| Rate for Payer: Healthscope Whirlpool |
$15.68
|
| Rate for Payer: Mclaren Commercial |
$14.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.33
|
| Rate for Payer: Nomi Health Commercial |
$12.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13.74
|
| Rate for Payer: Priority Health Narrow Network |
$10.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.80
|
|
|
IODOFORM 1/4" X 5 YARD BANDAGE
|
Facility
|
IP
|
$11.76
|
|
|
Service Code
|
NDC 80196073303
|
| Hospital Charge Code |
110336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Aetna Commercial |
$10.58
|
| Rate for Payer: ASR ASR |
$11.41
|
| Rate for Payer: BCBS Trust/PPO |
$9.66
|
| Rate for Payer: BCN Commercial |
$9.66
|
| Rate for Payer: Cash Price |
$9.41
|
| Rate for Payer: Cofinity Commercial |
$11.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.41
|
| Rate for Payer: Healthscope Commercial |
$11.41
|
| Rate for Payer: Healthscope Whirlpool |
$11.76
|
| Rate for Payer: Mclaren Commercial |
$10.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.00
|
| Rate for Payer: Nomi Health Commercial |
$9.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.35
|
|
|
IODOFORM 1/4" X 5 YARD BANDAGE
|
Facility
|
OP
|
$11.76
|
|
|
Service Code
|
NDC 80196073303
|
| Hospital Charge Code |
110336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Aetna Commercial |
$10.58
|
| Rate for Payer: Aetna Medicare |
$4.35
|
| Rate for Payer: ASR ASR |
$11.41
|
| Rate for Payer: BCBS Complete |
$4.70
|
| Rate for Payer: BCBS Trust/PPO |
$9.70
|
| Rate for Payer: BCN Commercial |
$9.70
|
| Rate for Payer: Cash Price |
$9.41
|
| Rate for Payer: Cofinity Commercial |
$11.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.41
|
| Rate for Payer: Healthscope Commercial |
$11.41
|
| Rate for Payer: Healthscope Whirlpool |
$11.76
|
| Rate for Payer: Mclaren Commercial |
$10.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.00
|
| Rate for Payer: Nomi Health Commercial |
$9.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$10.30
|
| Rate for Payer: Priority Health Narrow Network |
$8.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.35
|
|
|
IODOFORM 1" X 5 YARD BANDAGE
|
Facility
|
OP
|
$16.76
|
|
|
Service Code
|
NDC 8080783300
|
| Hospital Charge Code |
110337
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.20 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna Commercial |
$15.08
|
| Rate for Payer: Aetna Medicare |
$6.20
|
| Rate for Payer: ASR ASR |
$16.26
|
| Rate for Payer: BCBS Complete |
$6.70
|
| Rate for Payer: BCBS Trust/PPO |
$13.82
|
| Rate for Payer: BCN Commercial |
$13.82
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cofinity Commercial |
$15.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.41
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Healthscope Whirlpool |
$16.76
|
| Rate for Payer: Mclaren Commercial |
$15.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.25
|
| Rate for Payer: Nomi Health Commercial |
$13.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.57
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$14.69
|
| Rate for Payer: Priority Health Narrow Network |
$11.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.75
|
|
|
IODOFORM 1" X 5 YARD BANDAGE
|
Facility
|
IP
|
$16.76
|
|
|
Service Code
|
NDC 8080783300
|
| Hospital Charge Code |
110337
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.57 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna Commercial |
$15.08
|
| Rate for Payer: ASR ASR |
$16.26
|
| Rate for Payer: BCBS Trust/PPO |
$13.76
|
| Rate for Payer: BCN Commercial |
$13.76
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cofinity Commercial |
$15.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.41
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Healthscope Whirlpool |
$16.76
|
| Rate for Payer: Mclaren Commercial |
$15.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.25
|
| Rate for Payer: Nomi Health Commercial |
$13.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.75
|
|
|
IODOFORM 2" X 5 YARD BANDAGE
|
Facility
|
OP
|
$13.88
|
|
|
Service Code
|
NDC 8080783400
|
| Hospital Charge Code |
110338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Aetna Commercial |
$12.49
|
| Rate for Payer: Aetna Medicare |
$5.14
|
| Rate for Payer: ASR ASR |
$13.46
|
| Rate for Payer: BCBS Complete |
$5.55
|
| Rate for Payer: BCBS Trust/PPO |
$11.44
|
| Rate for Payer: BCN Commercial |
$11.44
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cofinity Commercial |
$13.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.10
|
| Rate for Payer: Healthscope Commercial |
$13.46
|
| Rate for Payer: Healthscope Whirlpool |
$13.88
|
| Rate for Payer: Mclaren Commercial |
$12.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.80
|
| Rate for Payer: Nomi Health Commercial |
$11.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$12.16
|
| Rate for Payer: Priority Health Narrow Network |
$9.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.21
|
|
|
IODOFORM 2" X 5 YARD BANDAGE
|
Facility
|
IP
|
$13.88
|
|
|
Service Code
|
NDC 8080783400
|
| Hospital Charge Code |
110338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Aetna Commercial |
$12.49
|
| Rate for Payer: ASR ASR |
$13.46
|
| Rate for Payer: BCBS Trust/PPO |
$11.40
|
| Rate for Payer: BCN Commercial |
$11.40
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cofinity Commercial |
$13.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.10
|
| Rate for Payer: Healthscope Commercial |
$13.46
|
| Rate for Payer: Healthscope Whirlpool |
$13.88
|
| Rate for Payer: Mclaren Commercial |
$12.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.80
|
| Rate for Payer: Nomi Health Commercial |
$11.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.21
|
|
|
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Medicare |
$99.90
|
| Rate for Payer: ASR ASR |
$261.90
|
| Rate for Payer: BCBS Complete |
$108.00
|
| Rate for Payer: BCBS Trust/PPO |
$222.62
|
| Rate for Payer: BCN Commercial |
$222.62
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cofinity Commercial |
$253.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.00
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Whirlpool |
$270.00
|
| Rate for Payer: Mclaren Commercial |
$243.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$216.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.50
|
| Rate for Payer: Nomi Health Commercial |
$221.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$202.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.42
|
| Rate for Payer: Priority Health Narrow Network |
$1.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$237.60
|
|
|
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.50 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: ASR ASR |
$261.90
|
| Rate for Payer: BCBS Trust/PPO |
$221.72
|
| Rate for Payer: BCN Commercial |
$221.72
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cofinity Commercial |
$253.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.00
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Whirlpool |
$270.00
|
| Rate for Payer: Mclaren Commercial |
$243.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.50
|
| Rate for Payer: Nomi Health Commercial |
$221.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$202.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$237.60
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$360.00
|
| Rate for Payer: Aetna Medicare |
$148.00
|
| Rate for Payer: ASR ASR |
$388.00
|
| Rate for Payer: BCBS Complete |
$160.00
|
| Rate for Payer: BCBS Trust/PPO |
$329.80
|
| Rate for Payer: BCN Commercial |
$329.80
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cofinity Commercial |
$376.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.00
|
| Rate for Payer: Healthscope Commercial |
$388.00
|
| Rate for Payer: Healthscope Whirlpool |
$400.00
|
| Rate for Payer: Mclaren Commercial |
$360.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$320.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.00
|
| Rate for Payer: Nomi Health Commercial |
$328.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$300.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.42
|
| Rate for Payer: Priority Health Narrow Network |
$1.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$352.00
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$360.00
|
| Rate for Payer: ASR ASR |
$388.00
|
| Rate for Payer: BCBS Trust/PPO |
$328.48
|
| Rate for Payer: BCN Commercial |
$328.48
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cofinity Commercial |
$376.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.00
|
| Rate for Payer: Healthscope Commercial |
$388.00
|
| Rate for Payer: Healthscope Whirlpool |
$400.00
|
| Rate for Payer: Mclaren Commercial |
$360.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.00
|
| Rate for Payer: Nomi Health Commercial |
$328.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$300.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$352.00
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: ASR ASR |
$40.74
|
| Rate for Payer: BCBS Trust/PPO |
$34.49
|
| Rate for Payer: BCN Commercial |
$34.49
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$39.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$40.74
|
| Rate for Payer: Healthscope Whirlpool |
$42.00
|
| Rate for Payer: Mclaren Commercial |
$37.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: Nomi Health Commercial |
$34.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.96
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Medicare |
$15.54
|
| Rate for Payer: ASR ASR |
$40.74
|
| Rate for Payer: BCBS Complete |
$16.80
|
| Rate for Payer: BCBS Trust/PPO |
$34.63
|
| Rate for Payer: BCN Commercial |
$34.63
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$39.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$40.74
|
| Rate for Payer: Healthscope Whirlpool |
$42.00
|
| Rate for Payer: Mclaren Commercial |
$37.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: Nomi Health Commercial |
$34.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.42
|
| Rate for Payer: Priority Health Narrow Network |
$1.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.96
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Commercial |
$630.00
|
| Rate for Payer: Aetna Commercial |
$252.00
|
| Rate for Payer: ASR ASR |
$679.00
|
| Rate for Payer: ASR ASR |
$135.80
|
| Rate for Payer: ASR ASR |
$271.60
|
| Rate for Payer: BCBS Trust/PPO |
$574.84
|
| Rate for Payer: BCBS Trust/PPO |
$114.97
|
| Rate for Payer: BCBS Trust/PPO |
$229.94
|
| Rate for Payer: BCN Commercial |
$229.94
|
| Rate for Payer: BCN Commercial |
$114.97
|
| Rate for Payer: BCN Commercial |
$574.84
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$224.00
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$658.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$560.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.00
|
| Rate for Payer: Healthscope Commercial |
$271.60
|
| Rate for Payer: Healthscope Commercial |
$135.80
|
| Rate for Payer: Healthscope Commercial |
$679.00
|
| Rate for Payer: Healthscope Whirlpool |
$280.00
|
| Rate for Payer: Healthscope Whirlpool |
$700.00
|
| Rate for Payer: Healthscope Whirlpool |
$140.00
|
| Rate for Payer: Mclaren Commercial |
$252.00
|
| Rate for Payer: Mclaren Commercial |
$126.00
|
| Rate for Payer: Mclaren Commercial |
$630.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$595.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.00
|
| Rate for Payer: Nomi Health Commercial |
$229.60
|
| Rate for Payer: Nomi Health Commercial |
$114.80
|
| Rate for Payer: Nomi Health Commercial |
$574.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$105.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$525.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$210.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$616.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$123.20
|
|
