|
IMPACT PEPTIDE/VITAL 1.5 BOLUS FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
150765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE/VITAL 1.5 CONTINUOUS FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
168957
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE/VITAL 1.5 CONTINUOUS FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
168957
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE/VITAL 1.5 CYCLIC FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
200091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE/VITAL 1.5 CYCLIC FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
200091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE/VITAL 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
200090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
IMPACT PEPTIDE/VITAL 1.5 INTERMITTENT FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900097399
|
| Hospital Charge Code |
200090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| 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 Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE
|
Facility
|
OP
|
$300.37
|
|
|
Service Code
|
CPT 10060
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$103.87 |
| Max. Negotiated Rate |
$300.37 |
| Rate for Payer: Aetna Medicare |
$193.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$242.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$242.24
|
| Rate for Payer: BCBS Complete |
$109.07
|
| Rate for Payer: BCBS MAPPO |
$193.79
|
| Rate for Payer: BCN Medicare Advantage |
$193.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$193.79
|
| Rate for Payer: Humana Choice PPO Medicare |
$193.79
|
| Rate for Payer: Mclaren Medicaid |
$103.87
|
| Rate for Payer: Mclaren Medicare |
$193.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$203.48
|
| Rate for Payer: Meridian Medicaid |
$109.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$222.86
|
| Rate for Payer: PACE Medicare |
$184.10
|
| Rate for Payer: PACE SWMI |
$193.79
|
| Rate for Payer: PHP Commercial |
$213.17
|
| Rate for Payer: PHP Medicaid |
$103.87
|
| Rate for Payer: PHP Medicare Advantage |
$193.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$103.87
|
| Rate for Payer: Priority Health Medicare |
$193.79
|
| Rate for Payer: Railroad Medicare Medicare |
$193.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$193.79
|
| Rate for Payer: UHC Exchange |
$300.37
|
| Rate for Payer: UHC Medicare Advantage |
$193.79
|
| Rate for Payer: UHCCP DNSP |
$193.79
|
| Rate for Payer: UHCCP Medicaid |
$103.87
|
| Rate for Payer: VA VA |
$193.79
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$8,880.51
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,772.33 |
| Max. Negotiated Rate |
$8,880.51 |
| Rate for Payer: Aetna Commercial |
$7,992.46
|
| Rate for Payer: ASR ASR |
$8,614.09
|
| Rate for Payer: ASR Commercial |
$8,614.09
|
| Rate for Payer: BCBS Trust/PPO |
$7,236.73
|
| Rate for Payer: BCN Commercial |
$6,885.06
|
| Rate for Payer: Cash Price |
$7,104.41
|
| Rate for Payer: Cofinity Commercial |
$8,347.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,104.41
|
| Rate for Payer: Healthscope Commercial |
$8,880.51
|
| Rate for Payer: Healthscope Whirlpool |
$8,614.09
|
| Rate for Payer: Mclaren Commercial |
$7,992.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,548.43
|
| Rate for Payer: Nomi Health Commercial |
$7,282.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,772.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7,814.85
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$8,880.51
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$8,880.51 |
| Rate for Payer: Aetna Commercial |
$7,992.46
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.40
|
| Rate for Payer: ASR ASR |
$8,614.09
|
| Rate for Payer: ASR Commercial |
$8,614.09
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: BCBS MAPPO |
$12.32
|
| Rate for Payer: BCBS Trust/PPO |
$7,272.25
|
| Rate for Payer: BCN Commercial |
$6,885.06
|
| Rate for Payer: BCN Medicare Advantage |
$12.32
|
| Rate for Payer: Cash Price |
$7,104.41
|
| Rate for Payer: Cash Price |
$7,104.41
|
| Rate for Payer: Cofinity Commercial |
$8,347.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,104.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.32
|
| Rate for Payer: Healthscope Commercial |
$8,880.51
|
| Rate for Payer: Healthscope Whirlpool |
$8,614.09
|
| Rate for Payer: Humana Choice PPO Medicare |
$12.32
|
| Rate for Payer: Mclaren Commercial |
$7,992.46
|
| Rate for Payer: Mclaren Medicaid |
$6.60
|
| Rate for Payer: Mclaren Medicare |
$12.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.94
|
| Rate for Payer: Meridian Medicaid |
$6.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,548.43
|
| Rate for Payer: Nomi Health Commercial |
$7,282.02
|
| Rate for Payer: PACE Medicare |
$11.70
|
| Rate for Payer: PACE SWMI |
$12.32
|
| Rate for Payer: PHP Commercial |
$13.55
|
| Rate for Payer: PHP Medicaid |
$6.60
|
| Rate for Payer: PHP Medicare Advantage |
$12.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,772.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,781.10
|
| Rate for Payer: Priority Health Medicare |
$12.32
|
| Rate for Payer: Priority Health Narrow Network |
$6,225.24
|
| Rate for Payer: Railroad Medicare Medicare |
$12.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7,814.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.32
|
| Rate for Payer: UHC Exchange |
$19.10
|
| Rate for Payer: UHC Medicare Advantage |
$12.32
|
| Rate for Payer: UHCCP DNSP |
$12.32
|
| Rate for Payer: UHCCP Medicaid |
$6.60
|
| Rate for Payer: VA VA |
$12.32
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$253.80
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.97 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$228.42
|
| Rate for Payer: ASR ASR |
$246.19
|
| Rate for Payer: ASR Commercial |
$246.19
|
| Rate for Payer: BCBS Trust/PPO |
$206.82
|
| Rate for Payer: BCN Commercial |
$196.77
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$238.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Healthscope Whirlpool |
$246.19
|
| Rate for Payer: Mclaren Commercial |
$228.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: Nomi Health Commercial |
$208.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.34
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$253.80
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$228.42
|
| Rate for Payer: Aetna Medicare |
$126.90
|
| Rate for Payer: ASR ASR |
$246.19
|
| Rate for Payer: ASR Commercial |
$246.19
|
| Rate for Payer: BCBS Complete |
$101.52
|
| Rate for Payer: BCBS Trust/PPO |
$207.84
|
| Rate for Payer: BCN Commercial |
$196.77
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$238.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Healthscope Whirlpool |
$246.19
|
| Rate for Payer: Mclaren Commercial |
$228.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: Nomi Health Commercial |
$208.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$222.38
|
| Rate for Payer: Priority Health Narrow Network |
$177.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.34
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 43975030410
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$227.60 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.13
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: ASR Commercial |
$339.65
|
| Rate for Payer: BCBS Trust/PPO |
$285.34
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Nomi Health Commercial |
$287.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$350.15
|
|
|
Service Code
|
NDC 43975030410
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.06 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.13
|
| Rate for Payer: Aetna Medicare |
$175.07
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: ASR Commercial |
$339.65
|
| Rate for Payer: BCBS Complete |
$140.06
|
| Rate for Payer: BCBS Trust/PPO |
$286.74
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Nomi Health Commercial |
$287.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$306.80
|
| Rate for Payer: Priority Health Narrow Network |
$245.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$420.65 |
| Rate for Payer: Aetna Commercial |
$378.58
|
| Rate for Payer: ASR ASR |
$408.03
|
| Rate for Payer: ASR Commercial |
$408.03
|
| Rate for Payer: BCBS Trust/PPO |
$342.79
|
| Rate for Payer: BCN Commercial |
$326.13
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$395.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$420.65
|
| Rate for Payer: Healthscope Whirlpool |
$408.03
|
| Rate for Payer: Mclaren Commercial |
$378.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Nomi Health Commercial |
$344.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$370.17
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$120.17
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.07 |
| Max. Negotiated Rate |
$120.17 |
| Rate for Payer: Aetna Commercial |
$108.15
|
| Rate for Payer: Aetna Medicare |
$60.09
|
| Rate for Payer: ASR ASR |
$116.56
|
| Rate for Payer: ASR Commercial |
$116.56
|
| Rate for Payer: BCBS Complete |
$48.07
|
| Rate for Payer: BCBS Trust/PPO |
$98.41
|
| Rate for Payer: BCN Commercial |
$93.17
|
| Rate for Payer: Cash Price |
$96.14
|
| Rate for Payer: Cofinity Commercial |
$112.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.14
|
| Rate for Payer: Healthscope Commercial |
$120.17
|
| Rate for Payer: Healthscope Whirlpool |
$116.56
|
| Rate for Payer: Mclaren Commercial |
$108.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.14
|
| Rate for Payer: Nomi Health Commercial |
$98.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.29
|
| Rate for Payer: Priority Health Narrow Network |
$84.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.75
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 68462040601
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.11 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna Commercial |
$200.93
|
| Rate for Payer: ASR ASR |
$216.55
|
| Rate for Payer: ASR Commercial |
$216.55
|
| Rate for Payer: BCBS Trust/PPO |
$181.93
|
| Rate for Payer: BCN Commercial |
$173.09
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$209.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$223.25
|
| Rate for Payer: Healthscope Whirlpool |
$216.55
|
| Rate for Payer: Mclaren Commercial |
$200.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: Nomi Health Commercial |
$183.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$196.46
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: Aetna Medicare |
$1.20
|
| Rate for Payer: ASR ASR |
$2.33
|
| Rate for Payer: ASR Commercial |
$2.33
|
| Rate for Payer: BCBS Complete |
$0.96
|
| Rate for Payer: BCBS Trust/PPO |
$1.97
|
| Rate for Payer: BCN Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.92
|
| Rate for Payer: Healthscope Commercial |
$2.40
|
| Rate for Payer: Healthscope Whirlpool |
$2.33
|
| Rate for Payer: Mclaren Commercial |
$2.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.04
|
| Rate for Payer: Nomi Health Commercial |
$1.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.10
|
| Rate for Payer: Priority Health Narrow Network |
$1.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.11
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.26 |
| Max. Negotiated Rate |
$420.65 |
| Rate for Payer: Aetna Commercial |
$378.58
|
| Rate for Payer: Aetna Medicare |
$210.32
|
| Rate for Payer: ASR ASR |
$408.03
|
| Rate for Payer: ASR Commercial |
$408.03
|
| Rate for Payer: BCBS Complete |
$168.26
|
| Rate for Payer: BCBS Trust/PPO |
$344.47
|
| Rate for Payer: BCN Commercial |
$326.13
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$395.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$420.65
|
| Rate for Payer: Healthscope Whirlpool |
$408.03
|
| Rate for Payer: Mclaren Commercial |
$378.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Nomi Health Commercial |
$344.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$368.57
|
| Rate for Payer: Priority Health Narrow Network |
$294.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$370.17
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: ASR ASR |
$2.33
|
| Rate for Payer: ASR Commercial |
$2.33
|
| Rate for Payer: BCBS Trust/PPO |
$1.96
|
| Rate for Payer: BCN Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.92
|
| Rate for Payer: Healthscope Commercial |
$2.40
|
| Rate for Payer: Healthscope Whirlpool |
$2.33
|
| Rate for Payer: Mclaren Commercial |
$2.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.04
|
| Rate for Payer: Nomi Health Commercial |
$1.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.11
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$223.25
|
|
|
Service Code
|
NDC 68462040601
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.30 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna Commercial |
$200.93
|
| Rate for Payer: Aetna Medicare |
$111.62
|
| Rate for Payer: ASR ASR |
$216.55
|
| Rate for Payer: ASR Commercial |
$216.55
|
| Rate for Payer: BCBS Complete |
$89.30
|
| Rate for Payer: BCBS Trust/PPO |
$182.82
|
| Rate for Payer: BCN Commercial |
$173.09
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$209.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$223.25
|
| Rate for Payer: Healthscope Whirlpool |
$216.55
|
| Rate for Payer: Mclaren Commercial |
$200.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: Nomi Health Commercial |
$183.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$195.61
|
| Rate for Payer: Priority Health Narrow Network |
$156.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$196.46
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$120.17
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.11 |
| Max. Negotiated Rate |
$120.17 |
| Rate for Payer: Aetna Commercial |
$108.15
|
| Rate for Payer: ASR ASR |
$116.56
|
| Rate for Payer: ASR Commercial |
$116.56
|
| Rate for Payer: BCBS Trust/PPO |
$97.93
|
| Rate for Payer: BCN Commercial |
$93.17
|
| Rate for Payer: Cash Price |
$96.14
|
| Rate for Payer: Cofinity Commercial |
$112.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.14
|
| Rate for Payer: Healthscope Commercial |
$120.17
|
| Rate for Payer: Healthscope Whirlpool |
$116.56
|
| Rate for Payer: Mclaren Commercial |
$108.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.14
|
| Rate for Payer: Nomi Health Commercial |
$98.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.75
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$3,641.79
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
23796
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$3,641.79 |
| Rate for Payer: Aetna Commercial |
$3,277.61
|
| Rate for Payer: Aetna Medicare |
$31.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$38.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$38.86
|
| Rate for Payer: ASR ASR |
$3,532.54
|
| Rate for Payer: ASR Commercial |
$3,532.54
|
| Rate for Payer: BCBS Complete |
$17.50
|
| Rate for Payer: BCBS MAPPO |
$31.09
|
| Rate for Payer: BCBS Trust/PPO |
$2,982.26
|
| Rate for Payer: BCN Commercial |
$2,823.48
|
| Rate for Payer: BCN Medicare Advantage |
$31.09
|
| Rate for Payer: Cash Price |
$2,913.43
|
| Rate for Payer: Cash Price |
$2,913.43
|
| Rate for Payer: Cofinity Commercial |
$3,423.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,913.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$31.09
|
| Rate for Payer: Healthscope Commercial |
$3,641.79
|
| Rate for Payer: Healthscope Whirlpool |
$3,532.54
|
| Rate for Payer: Humana Choice PPO Medicare |
$31.09
|
| Rate for Payer: Mclaren Commercial |
$3,277.61
|
| Rate for Payer: Mclaren Medicaid |
$16.66
|
| Rate for Payer: Mclaren Medicare |
$31.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$32.64
|
| Rate for Payer: Meridian Medicaid |
$17.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,095.52
|
| Rate for Payer: Nomi Health Commercial |
$2,986.27
|
| Rate for Payer: PACE Medicare |
$29.54
|
| Rate for Payer: PACE SWMI |
$31.09
|
| Rate for Payer: PHP Commercial |
$34.20
|
| Rate for Payer: PHP Medicaid |
$16.66
|
| Rate for Payer: PHP Medicare Advantage |
$31.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$16.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,367.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,190.94
|
| Rate for Payer: Priority Health Medicare |
$31.09
|
| Rate for Payer: Priority Health Narrow Network |
$2,552.89
|
| Rate for Payer: Railroad Medicare Medicare |
$31.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,204.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$31.09
|
| Rate for Payer: UHC Exchange |
$48.19
|
| Rate for Payer: UHC Medicare Advantage |
$31.09
|
| Rate for Payer: UHCCP DNSP |
$31.09
|
| Rate for Payer: UHCCP Medicaid |
$16.66
|
| Rate for Payer: VA VA |
$31.09
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$3,641.79
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
23796
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,367.16 |
| Max. Negotiated Rate |
$3,641.79 |
| Rate for Payer: Aetna Commercial |
$3,277.61
|
| Rate for Payer: ASR ASR |
$3,532.54
|
| Rate for Payer: ASR Commercial |
$3,532.54
|
| Rate for Payer: BCBS Trust/PPO |
$2,967.69
|
| Rate for Payer: BCN Commercial |
$2,823.48
|
| Rate for Payer: Cash Price |
$2,913.43
|
| Rate for Payer: Cofinity Commercial |
$3,423.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,913.43
|
| Rate for Payer: Healthscope Commercial |
$3,641.79
|
| Rate for Payer: Healthscope Whirlpool |
$3,532.54
|
| Rate for Payer: Mclaren Commercial |
$3,277.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,095.52
|
| Rate for Payer: Nomi Health Commercial |
$2,986.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,367.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,204.78
|
|
|
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,818.98
|
|
|
Service Code
|
HCPCS Q5103
|
| Hospital Charge Code |
181037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,182.34 |
| Max. Negotiated Rate |
$1,818.98 |
| Rate for Payer: Aetna Commercial |
$1,637.08
|
| Rate for Payer: ASR ASR |
$1,764.41
|
| Rate for Payer: ASR Commercial |
$1,764.41
|
| Rate for Payer: BCBS Trust/PPO |
$1,482.29
|
| Rate for Payer: BCN Commercial |
$1,410.26
|
| Rate for Payer: Cash Price |
$1,455.18
|
| Rate for Payer: Cofinity Commercial |
$1,709.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,455.18
|
| Rate for Payer: Healthscope Commercial |
$1,818.98
|
| Rate for Payer: Healthscope Whirlpool |
$1,764.41
|
| Rate for Payer: Mclaren Commercial |
$1,637.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,546.13
|
| Rate for Payer: Nomi Health Commercial |
$1,491.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,182.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,600.70
|
|
