|
INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$5,238.48
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
36417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.81 |
| Max. Negotiated Rate |
$5,238.48 |
| Rate for Payer: Aetna Commercial |
$4,714.63
|
| Rate for Payer: Aetna Medicare |
$55.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$69.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$69.52
|
| Rate for Payer: ASR ASR |
$5,081.33
|
| Rate for Payer: ASR Commercial |
$5,081.33
|
| Rate for Payer: BCBS Complete |
$31.30
|
| Rate for Payer: BCBS MAPPO |
$55.62
|
| Rate for Payer: BCBS Trust/PPO |
$4,289.79
|
| Rate for Payer: BCN Commercial |
$4,061.39
|
| Rate for Payer: BCN Medicare Advantage |
$55.62
|
| Rate for Payer: Cash Price |
$4,190.78
|
| Rate for Payer: Cash Price |
$4,190.78
|
| Rate for Payer: Cofinity Commercial |
$4,924.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,190.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.62
|
| Rate for Payer: Healthscope Commercial |
$5,238.48
|
| Rate for Payer: Healthscope Whirlpool |
$5,081.33
|
| Rate for Payer: Humana Choice PPO Medicare |
$55.62
|
| Rate for Payer: Mclaren Commercial |
$4,714.63
|
| Rate for Payer: Mclaren Medicaid |
$29.81
|
| Rate for Payer: Mclaren Medicare |
$55.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.40
|
| Rate for Payer: Meridian Medicaid |
$31.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,452.71
|
| Rate for Payer: Nomi Health Commercial |
$4,295.55
|
| Rate for Payer: PACE Medicare |
$52.84
|
| Rate for Payer: PACE SWMI |
$55.62
|
| Rate for Payer: PHP Commercial |
$61.18
|
| Rate for Payer: PHP Medicaid |
$29.81
|
| Rate for Payer: PHP Medicare Advantage |
$55.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,405.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$73.42
|
| Rate for Payer: Priority Health Medicare |
$55.62
|
| Rate for Payer: Priority Health Narrow Network |
$58.74
|
| Rate for Payer: Railroad Medicare Medicare |
$55.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,609.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$55.62
|
| Rate for Payer: UHC Exchange |
$86.21
|
| Rate for Payer: UHC Medicare Advantage |
$55.62
|
| Rate for Payer: UHCCP DNSP |
$55.62
|
| Rate for Payer: UHCCP Medicaid |
$29.81
|
| Rate for Payer: VA VA |
$55.62
|
|
|
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 |
$1.75 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: Aetna Medicare |
$25.00
|
| Rate for Payer: ASR ASR |
$48.50
|
| Rate for Payer: ASR ASR |
$97.00
|
| Rate for Payer: ASR Commercial |
$97.00
|
| Rate for Payer: ASR Commercial |
$48.50
|
| Rate for Payer: BCBS Complete |
$20.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Trust/PPO |
$40.94
|
| Rate for Payer: BCBS Trust/PPO |
$81.89
|
| Rate for Payer: BCN Commercial |
$77.53
|
| Rate for Payer: BCN Commercial |
$38.76
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cash Price |
$40.00
|
| 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 |
$50.00
|
| Rate for Payer: Healthscope Commercial |
$100.00
|
| Rate for Payer: Healthscope Whirlpool |
$48.50
|
| Rate for Payer: Healthscope Whirlpool |
$97.00
|
| Rate for Payer: Mclaren Commercial |
$90.00
|
| Rate for Payer: Mclaren Commercial |
$45.00
|
| 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: Priority Health Cigna Priority Health |
$32.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| 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
|
$50.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
17595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: ASR ASR |
$48.50
|
| Rate for Payer: ASR ASR |
$97.00
|
| Rate for Payer: ASR Commercial |
$97.00
|
| Rate for Payer: ASR Commercial |
$48.50
|
| Rate for Payer: BCBS Trust/PPO |
$81.49
|
| Rate for Payer: BCBS Trust/PPO |
$40.74
|
| Rate for Payer: BCN Commercial |
$38.76
|
| Rate for Payer: BCN Commercial |
$77.53
|
| 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 |
$80.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.00
|
| Rate for Payer: Healthscope Commercial |
$100.00
|
| Rate for Payer: Healthscope Commercial |
$50.00
|
| Rate for Payer: Healthscope Whirlpool |
$97.00
|
| Rate for Payer: Healthscope Whirlpool |
$48.50
|
| Rate for Payer: Mclaren Commercial |
$90.00
|
| Rate for Payer: Mclaren Commercial |
$45.00
|
| 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: Priority Health Cigna Priority Health |
$32.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| 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
|
OP
|
$15.68
|
|
|
Service Code
|
NDC 08080783200
|
| Hospital Charge Code |
110335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna Commercial |
$14.11
|
| Rate for Payer: Aetna Medicare |
$7.84
|
| Rate for Payer: ASR ASR |
$15.21
|
| Rate for Payer: ASR Commercial |
$15.21
|
| Rate for Payer: BCBS Complete |
$6.27
|
| Rate for Payer: BCBS Trust/PPO |
$12.84
|
| Rate for Payer: BCN Commercial |
$12.16
|
| 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 |
$15.68
|
| Rate for Payer: Healthscope Whirlpool |
$15.21
|
| 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: Priority Health Cigna Priority Health |
$10.19
|
| Rate for Payer: 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 1/2" X 5 YARD BANDAGE
|
Facility
|
IP
|
$15.68
|
|
|
Service Code
|
NDC 08080783200
|
| Hospital Charge Code |
110335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna Commercial |
$14.11
|
| Rate for Payer: ASR ASR |
$15.21
|
| Rate for Payer: ASR Commercial |
$15.21
|
| Rate for Payer: BCBS Trust/PPO |
$12.78
|
| Rate for Payer: BCN Commercial |
$12.16
|
| 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 |
$15.68
|
| Rate for Payer: Healthscope Whirlpool |
$15.21
|
| 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: Priority Health Cigna Priority Health |
$10.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.80
|
|
|
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 |
$4.70 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Aetna Commercial |
$10.58
|
| Rate for Payer: Aetna Medicare |
$5.88
|
| Rate for Payer: ASR ASR |
$11.41
|
| Rate for Payer: ASR Commercial |
$11.41
|
| Rate for Payer: BCBS Complete |
$4.70
|
| Rate for Payer: BCBS Trust/PPO |
$9.63
|
| Rate for Payer: BCN Commercial |
$9.12
|
| 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 |
$11.76
|
| Rate for Payer: Healthscope Whirlpool |
$11.41
|
| 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: Priority Health Cigna Priority Health |
$7.64
|
| Rate for Payer: 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 1/4" X 5 YARD BANDAGE
|
Facility
|
IP
|
$11.76
|
|
|
Service Code
|
NDC 80196073303
|
| Hospital Charge Code |
110336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Aetna Commercial |
$10.58
|
| Rate for Payer: ASR ASR |
$11.41
|
| Rate for Payer: ASR Commercial |
$11.41
|
| Rate for Payer: BCBS Trust/PPO |
$9.58
|
| Rate for Payer: BCN Commercial |
$9.12
|
| 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 |
$11.76
|
| Rate for Payer: Healthscope Whirlpool |
$11.41
|
| 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: Priority Health Cigna Priority Health |
$7.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.35
|
|
|
IODOFORM 1" X 5 YARD BANDAGE
|
Facility
|
OP
|
$18.84
|
|
|
Service Code
|
NDC 08080783300
|
| Hospital Charge Code |
110337
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.54 |
| Max. Negotiated Rate |
$18.84 |
| Rate for Payer: Aetna Commercial |
$16.96
|
| Rate for Payer: Aetna Medicare |
$9.42
|
| Rate for Payer: ASR ASR |
$18.27
|
| Rate for Payer: ASR Commercial |
$18.27
|
| Rate for Payer: BCBS Complete |
$7.54
|
| Rate for Payer: BCBS Trust/PPO |
$15.43
|
| Rate for Payer: BCN Commercial |
$14.61
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Cofinity Commercial |
$17.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.07
|
| Rate for Payer: Healthscope Commercial |
$18.84
|
| Rate for Payer: Healthscope Whirlpool |
$18.27
|
| Rate for Payer: Mclaren Commercial |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.01
|
| Rate for Payer: Nomi Health Commercial |
$15.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.51
|
| Rate for Payer: Priority Health Narrow Network |
$13.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.58
|
|
|
IODOFORM 1" X 5 YARD BANDAGE
|
Facility
|
IP
|
$18.84
|
|
|
Service Code
|
NDC 08080783300
|
| Hospital Charge Code |
110337
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$18.84 |
| Rate for Payer: Aetna Commercial |
$16.96
|
| Rate for Payer: ASR ASR |
$18.27
|
| Rate for Payer: ASR Commercial |
$18.27
|
| Rate for Payer: BCBS Trust/PPO |
$15.35
|
| Rate for Payer: BCN Commercial |
$14.61
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Cofinity Commercial |
$17.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.07
|
| Rate for Payer: Healthscope Commercial |
$18.84
|
| Rate for Payer: Healthscope Whirlpool |
$18.27
|
| Rate for Payer: Mclaren Commercial |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.01
|
| Rate for Payer: Nomi Health Commercial |
$15.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.58
|
|
|
IODOFORM 2" X 5 YARD BANDAGE
|
Facility
|
OP
|
$13.88
|
|
|
Service Code
|
NDC 08080783400
|
| Hospital Charge Code |
110338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Aetna Commercial |
$12.49
|
| Rate for Payer: Aetna Medicare |
$6.94
|
| Rate for Payer: ASR ASR |
$13.46
|
| Rate for Payer: ASR Commercial |
$13.46
|
| Rate for Payer: BCBS Complete |
$5.55
|
| Rate for Payer: BCBS Trust/PPO |
$11.37
|
| Rate for Payer: BCN Commercial |
$10.76
|
| 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 |
$13.88
|
| Rate for Payer: Healthscope Whirlpool |
$13.46
|
| 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: Priority Health Cigna Priority Health |
$9.02
|
| Rate for Payer: 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 08080783400
|
| Hospital Charge Code |
110338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Aetna Commercial |
$12.49
|
| Rate for Payer: ASR ASR |
$13.46
|
| Rate for Payer: ASR Commercial |
$13.46
|
| Rate for Payer: BCBS Trust/PPO |
$11.31
|
| Rate for Payer: BCN Commercial |
$10.76
|
| 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 |
$13.88
|
| Rate for Payer: Healthscope Whirlpool |
$13.46
|
| 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: Priority Health Cigna Priority Health |
$9.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.21
|
|
|
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 |
$1.75 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: ASR ASR |
$40.74
|
| Rate for Payer: ASR Commercial |
$40.74
|
| Rate for Payer: BCBS Complete |
$16.80
|
| Rate for Payer: BCBS Trust/PPO |
$34.39
|
| Rate for Payer: BCN Commercial |
$32.56
|
| 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 |
$42.00
|
| Rate for Payer: Healthscope Whirlpool |
$40.74
|
| 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: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.96
|
|
|
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 |
$27.30 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: ASR ASR |
$40.74
|
| Rate for Payer: ASR Commercial |
$40.74
|
| Rate for Payer: BCBS Trust/PPO |
$34.23
|
| Rate for Payer: BCN Commercial |
$32.56
|
| 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 |
$42.00
|
| Rate for Payer: Healthscope Whirlpool |
$40.74
|
| 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: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.96
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$252.00
|
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Commercial |
$630.00
|
| Rate for Payer: ASR ASR |
$135.80
|
| Rate for Payer: ASR ASR |
$271.60
|
| Rate for Payer: ASR ASR |
$679.00
|
| Rate for Payer: ASR Commercial |
$271.60
|
| Rate for Payer: ASR Commercial |
$135.80
|
| Rate for Payer: ASR Commercial |
$679.00
|
| Rate for Payer: BCBS Trust/PPO |
$570.43
|
| Rate for Payer: BCBS Trust/PPO |
$114.09
|
| Rate for Payer: BCBS Trust/PPO |
$228.17
|
| Rate for Payer: BCN Commercial |
$108.54
|
| Rate for Payer: BCN Commercial |
$542.71
|
| Rate for Payer: BCN Commercial |
$217.08
|
| Rate for Payer: Cash Price |
$224.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cofinity Commercial |
$658.00
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$263.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$560.00
|
| Rate for Payer: Healthscope Commercial |
$140.00
|
| Rate for Payer: Healthscope Commercial |
$280.00
|
| Rate for Payer: Healthscope Commercial |
$700.00
|
| Rate for Payer: Healthscope Whirlpool |
$271.60
|
| Rate for Payer: Healthscope Whirlpool |
$135.80
|
| Rate for Payer: Healthscope Whirlpool |
$679.00
|
| 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 |
$595.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.00
|
| 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: Priority Health Cigna Priority Health |
$91.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$455.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$616.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$123.20
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.75 |
| 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: Aetna Medicare |
$350.00
|
| Rate for Payer: Aetna Medicare |
$70.00
|
| Rate for Payer: Aetna Medicare |
$140.00
|
| Rate for Payer: ASR ASR |
$271.60
|
| Rate for Payer: ASR ASR |
$135.80
|
| Rate for Payer: ASR ASR |
$679.00
|
| Rate for Payer: ASR Commercial |
$271.60
|
| Rate for Payer: ASR Commercial |
$135.80
|
| Rate for Payer: ASR Commercial |
$679.00
|
| Rate for Payer: BCBS Complete |
$56.00
|
| Rate for Payer: BCBS Complete |
$112.00
|
| Rate for Payer: BCBS Complete |
$280.00
|
| Rate for Payer: BCBS Trust/PPO |
$573.23
|
| Rate for Payer: BCBS Trust/PPO |
$114.65
|
| Rate for Payer: BCBS Trust/PPO |
$229.29
|
| Rate for Payer: BCN Commercial |
$217.08
|
| Rate for Payer: BCN Commercial |
$542.71
|
| Rate for Payer: BCN Commercial |
$108.54
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$224.00
|
| Rate for Payer: Cash Price |
$224.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cofinity Commercial |
$658.00
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$263.20
|
| 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 |
$700.00
|
| Rate for Payer: Healthscope Commercial |
$280.00
|
| Rate for Payer: Healthscope Commercial |
$140.00
|
| Rate for Payer: Healthscope Whirlpool |
$679.00
|
| Rate for Payer: Healthscope Whirlpool |
$271.60
|
| Rate for Payer: Healthscope Whirlpool |
$135.80
|
| Rate for Payer: Mclaren Commercial |
$252.00
|
| Rate for Payer: Mclaren Commercial |
$630.00
|
| Rate for Payer: Mclaren Commercial |
$126.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$595.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.00
|
| Rate for Payer: Nomi Health Commercial |
$114.80
|
| Rate for Payer: Nomi Health Commercial |
$574.00
|
| Rate for Payer: Nomi Health Commercial |
$229.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$455.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$123.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$616.00
|
|
|
IPL CHEEKS FIRST
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
HCPCS 00126
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$83.20 |
| Rate for Payer: Aetna Medicare |
$64.00
|
| Rate for Payer: BCBS Complete |
$51.20
|
| Rate for Payer: Cash Price |
$102.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.20
|
|
|
IPL CHEST FIRST
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00128
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
|
|
IPL CHEST SECOND
|
Professional
|
Both
|
$204.00
|
|
|
Service Code
|
HCPCS 00129
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Aetna Medicare |
$102.00
|
| Rate for Payer: BCBS Complete |
$81.60
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.60
|
|
|
IPL FACE FIRST
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 00130
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$92.00 |
| Max. Negotiated Rate |
$149.50 |
| Rate for Payer: Aetna Medicare |
$115.00
|
| Rate for Payer: BCBS Complete |
$92.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.50
|
|
|
IPL FACE, NECK, CHEST FIRST
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 00132
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Aetna Medicare |
$204.00
|
| Rate for Payer: BCBS Complete |
$163.20
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.20
|
|
|
IPL FACE, NECK, CHEST SECOND
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
HCPCS 00133
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$182.65 |
| Rate for Payer: Aetna Medicare |
$140.50
|
| Rate for Payer: BCBS Complete |
$112.40
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.65
|
|
|
IPL FACE & NECK FIRST
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 00134
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
|
|
IPL FACE & NECK SECOND
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 00135
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$71.60 |
| Max. Negotiated Rate |
$116.35 |
| Rate for Payer: Aetna Medicare |
$89.50
|
| Rate for Payer: BCBS Complete |
$71.60
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.35
|
|
|
IPL FACE SECOND
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS 00131
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$66.30 |
| Rate for Payer: Aetna Medicare |
$51.00
|
| Rate for Payer: BCBS Complete |
$40.80
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.30
|
|
|
IPL HANDS & ARMS FIRST
|
Professional
|
Both
|
$357.00
|
|
|
Service Code
|
HCPCS 00136
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$232.05 |
| Rate for Payer: Aetna Medicare |
$178.50
|
| Rate for Payer: BCBS Complete |
$142.80
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.05
|
|
