|
INSULIN SUBCUTANEOUS BASAL PUMP - REGULAR HUMAN (U-500)
|
Facility
|
OP
|
$5,065.60
|
|
|
Service Code
|
NDC 00002850101
|
| Hospital Charge Code |
180916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,026.24 |
| Max. Negotiated Rate |
$5,065.60 |
| Rate for Payer: Aetna Commercial |
$4,559.04
|
| Rate for Payer: Aetna Medicare |
$2,532.80
|
| Rate for Payer: ASR ASR |
$4,913.63
|
| Rate for Payer: ASR Commercial |
$4,913.63
|
| Rate for Payer: BCBS Complete |
$2,026.24
|
| Rate for Payer: BCBS Trust/PPO |
$4,148.22
|
| Rate for Payer: BCN Commercial |
$3,927.36
|
| Rate for Payer: Cash Price |
$4,052.48
|
| Rate for Payer: Cofinity Commercial |
$4,761.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,052.48
|
| Rate for Payer: Healthscope Commercial |
$5,065.60
|
| Rate for Payer: Healthscope Whirlpool |
$4,913.63
|
| Rate for Payer: Mclaren Commercial |
$4,559.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,305.76
|
| Rate for Payer: Nomi Health Commercial |
$4,153.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,292.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,438.48
|
| Rate for Payer: Priority Health Narrow Network |
$3,550.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,457.73
|
|
|
INSULIN SUBCUTANEOUS BOLUS PUMP - HUMAN (HUMULIN R)
|
Facility
|
OP
|
$141.16
|
|
|
Service Code
|
NDC 00169183311
|
| Hospital Charge Code |
180911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.46 |
| Max. Negotiated Rate |
$141.16 |
| Rate for Payer: Aetna Commercial |
$127.04
|
| Rate for Payer: Aetna Medicare |
$70.58
|
| Rate for Payer: ASR ASR |
$136.93
|
| Rate for Payer: ASR Commercial |
$136.93
|
| Rate for Payer: BCBS Complete |
$56.46
|
| Rate for Payer: BCBS Trust/PPO |
$115.60
|
| Rate for Payer: BCN Commercial |
$109.44
|
| Rate for Payer: Cash Price |
$112.92
|
| Rate for Payer: Cofinity Commercial |
$132.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.93
|
| Rate for Payer: Healthscope Commercial |
$141.16
|
| Rate for Payer: Healthscope Whirlpool |
$136.93
|
| Rate for Payer: Mclaren Commercial |
$127.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.99
|
| Rate for Payer: Nomi Health Commercial |
$115.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.68
|
| Rate for Payer: Priority Health Narrow Network |
$98.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.22
|
|
|
INSULIN SUBCUTANEOUS BOLUS PUMP - HUMAN (HUMULIN R)
|
Facility
|
IP
|
$141.16
|
|
|
Service Code
|
NDC 00169183311
|
| Hospital Charge Code |
180911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.75 |
| Max. Negotiated Rate |
$141.16 |
| Rate for Payer: Aetna Commercial |
$127.04
|
| Rate for Payer: ASR ASR |
$136.93
|
| Rate for Payer: ASR Commercial |
$136.93
|
| Rate for Payer: BCBS Trust/PPO |
$115.03
|
| Rate for Payer: BCN Commercial |
$109.44
|
| Rate for Payer: Cash Price |
$112.92
|
| Rate for Payer: Cofinity Commercial |
$132.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.93
|
| Rate for Payer: Healthscope Commercial |
$141.16
|
| Rate for Payer: Healthscope Whirlpool |
$136.93
|
| Rate for Payer: Mclaren Commercial |
$127.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.99
|
| Rate for Payer: Nomi Health Commercial |
$115.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.22
|
|
|
INSULIN SUBCUTANEOUS CONTINUOUS BASAL PUMP - ASPARTATE (NOVOLOG)
|
Facility
|
OP
|
$137.64
|
|
|
Service Code
|
NDC 00169750111
|
| Hospital Charge Code |
180912
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.06 |
| Max. Negotiated Rate |
$137.64 |
| Rate for Payer: Aetna Commercial |
$123.88
|
| Rate for Payer: Aetna Medicare |
$68.82
|
| Rate for Payer: ASR ASR |
$133.51
|
| Rate for Payer: ASR Commercial |
$133.51
|
| Rate for Payer: BCBS Complete |
$55.06
|
| Rate for Payer: BCBS Trust/PPO |
$112.71
|
| Rate for Payer: BCN Commercial |
$106.71
|
| Rate for Payer: Cash Price |
$110.11
|
| Rate for Payer: Cofinity Commercial |
$129.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.11
|
| Rate for Payer: Healthscope Commercial |
$137.64
|
| Rate for Payer: Healthscope Whirlpool |
$133.51
|
| Rate for Payer: Mclaren Commercial |
$123.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.99
|
| Rate for Payer: Nomi Health Commercial |
$112.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$120.60
|
| Rate for Payer: Priority Health Narrow Network |
$96.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$121.12
|
|
|
INSULIN SUBCUTANEOUS CONTINUOUS BASAL PUMP - ASPARTATE (NOVOLOG)
|
Facility
|
IP
|
$137.64
|
|
|
Service Code
|
NDC 00169750111
|
| Hospital Charge Code |
180912
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.47 |
| Max. Negotiated Rate |
$137.64 |
| Rate for Payer: Aetna Commercial |
$123.88
|
| Rate for Payer: ASR ASR |
$133.51
|
| Rate for Payer: ASR Commercial |
$133.51
|
| Rate for Payer: BCBS Trust/PPO |
$112.16
|
| Rate for Payer: BCN Commercial |
$106.71
|
| Rate for Payer: Cash Price |
$110.11
|
| Rate for Payer: Cofinity Commercial |
$129.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.11
|
| Rate for Payer: Healthscope Commercial |
$137.64
|
| Rate for Payer: Healthscope Whirlpool |
$133.51
|
| Rate for Payer: Mclaren Commercial |
$123.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.99
|
| Rate for Payer: Nomi Health Commercial |
$112.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$121.12
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION
|
Facility
|
OP
|
$60.35
|
|
|
Service Code
|
NDC 00002821501
|
| Hospital Charge Code |
10289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.14 |
| Max. Negotiated Rate |
$60.35 |
| Rate for Payer: Aetna Commercial |
$54.31
|
| Rate for Payer: Aetna Medicare |
$30.18
|
| Rate for Payer: ASR ASR |
$58.54
|
| Rate for Payer: ASR Commercial |
$58.54
|
| Rate for Payer: BCBS Complete |
$24.14
|
| Rate for Payer: BCBS Trust/PPO |
$49.42
|
| Rate for Payer: BCN Commercial |
$46.79
|
| Rate for Payer: Cash Price |
$48.28
|
| Rate for Payer: Cofinity Commercial |
$56.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.28
|
| Rate for Payer: Healthscope Commercial |
$60.35
|
| Rate for Payer: Healthscope Whirlpool |
$58.54
|
| Rate for Payer: Mclaren Commercial |
$54.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.30
|
| Rate for Payer: Nomi Health Commercial |
$49.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52.88
|
| Rate for Payer: Priority Health Narrow Network |
$42.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$53.11
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION
|
Facility
|
IP
|
$60.35
|
|
|
Service Code
|
NDC 00002821501
|
| Hospital Charge Code |
10289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.23 |
| Max. Negotiated Rate |
$60.35 |
| Rate for Payer: Aetna Commercial |
$54.31
|
| Rate for Payer: ASR ASR |
$58.54
|
| Rate for Payer: ASR Commercial |
$58.54
|
| Rate for Payer: BCBS Trust/PPO |
$49.18
|
| Rate for Payer: BCN Commercial |
$46.79
|
| Rate for Payer: Cash Price |
$48.28
|
| Rate for Payer: Cofinity Commercial |
$56.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.28
|
| Rate for Payer: Healthscope Commercial |
$60.35
|
| Rate for Payer: Healthscope Whirlpool |
$58.54
|
| Rate for Payer: Mclaren Commercial |
$54.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.30
|
| Rate for Payer: Nomi Health Commercial |
$49.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$53.11
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML SQ FOR INSULIN PUMP REFILL
|
Facility
|
IP
|
$141.16
|
|
|
Service Code
|
NDC 00169183311
|
| Hospital Charge Code |
301806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.75 |
| Max. Negotiated Rate |
$141.16 |
| Rate for Payer: Aetna Commercial |
$127.04
|
| Rate for Payer: ASR ASR |
$136.93
|
| Rate for Payer: ASR Commercial |
$136.93
|
| Rate for Payer: BCBS Trust/PPO |
$115.03
|
| Rate for Payer: BCN Commercial |
$109.44
|
| Rate for Payer: Cash Price |
$112.92
|
| Rate for Payer: Cofinity Commercial |
$132.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.93
|
| Rate for Payer: Healthscope Commercial |
$141.16
|
| Rate for Payer: Healthscope Whirlpool |
$136.93
|
| Rate for Payer: Mclaren Commercial |
$127.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.99
|
| Rate for Payer: Nomi Health Commercial |
$115.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.22
|
|
|
INSULIN U-100 REGULAR HUMAN 100 UNIT/ML SQ FOR INSULIN PUMP REFILL
|
Facility
|
OP
|
$141.16
|
|
|
Service Code
|
NDC 00169183311
|
| Hospital Charge Code |
301806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.46 |
| Max. Negotiated Rate |
$141.16 |
| Rate for Payer: Aetna Commercial |
$127.04
|
| Rate for Payer: Aetna Medicare |
$70.58
|
| Rate for Payer: ASR ASR |
$136.93
|
| Rate for Payer: ASR Commercial |
$136.93
|
| Rate for Payer: BCBS Complete |
$56.46
|
| Rate for Payer: BCBS Trust/PPO |
$115.60
|
| Rate for Payer: BCN Commercial |
$109.44
|
| Rate for Payer: Cash Price |
$112.92
|
| Rate for Payer: Cofinity Commercial |
$132.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.93
|
| Rate for Payer: Healthscope Commercial |
$141.16
|
| Rate for Payer: Healthscope Whirlpool |
$136.93
|
| Rate for Payer: Mclaren Commercial |
$127.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.99
|
| Rate for Payer: Nomi Health Commercial |
$115.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.68
|
| Rate for Payer: Priority Health Narrow Network |
$98.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.22
|
|
|
INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR
|
Facility
|
IP
|
$3,496.74
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
159694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,272.88 |
| Max. Negotiated Rate |
$3,496.74 |
| Rate for Payer: Aetna Commercial |
$3,147.07
|
| Rate for Payer: ASR ASR |
$3,391.84
|
| Rate for Payer: ASR Commercial |
$3,391.84
|
| Rate for Payer: BCBS Trust/PPO |
$2,849.49
|
| Rate for Payer: BCN Commercial |
$2,711.02
|
| Rate for Payer: Cash Price |
$2,797.40
|
| Rate for Payer: Cofinity Commercial |
$3,286.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,797.39
|
| Rate for Payer: Healthscope Commercial |
$3,496.74
|
| Rate for Payer: Healthscope Whirlpool |
$3,391.84
|
| Rate for Payer: Mclaren Commercial |
$3,147.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,972.23
|
| Rate for Payer: Nomi Health Commercial |
$2,867.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,272.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,077.13
|
|
|
INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR
|
Facility
|
OP
|
$3,496.74
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
159694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.57 |
| Max. Negotiated Rate |
$3,496.74 |
| Rate for Payer: Aetna Commercial |
$3,147.07
|
| Rate for Payer: Aetna Medicare |
$58.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73.62
|
| Rate for Payer: ASR ASR |
$3,391.84
|
| Rate for Payer: ASR Commercial |
$3,391.84
|
| Rate for Payer: BCBS Complete |
$33.15
|
| Rate for Payer: BCBS MAPPO |
$58.90
|
| Rate for Payer: BCBS Trust/PPO |
$2,863.48
|
| Rate for Payer: BCN Commercial |
$2,711.02
|
| Rate for Payer: BCN Medicare Advantage |
$58.90
|
| Rate for Payer: Cash Price |
$2,797.40
|
| Rate for Payer: Cash Price |
$2,797.40
|
| Rate for Payer: Cofinity Commercial |
$3,286.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,797.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58.90
|
| Rate for Payer: Healthscope Commercial |
$3,496.74
|
| Rate for Payer: Healthscope Whirlpool |
$3,391.84
|
| Rate for Payer: Humana Choice PPO Medicare |
$58.90
|
| Rate for Payer: Mclaren Commercial |
$3,147.07
|
| Rate for Payer: Mclaren Medicaid |
$31.57
|
| Rate for Payer: Mclaren Medicare |
$58.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61.84
|
| Rate for Payer: Meridian Medicaid |
$33.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,972.23
|
| Rate for Payer: Nomi Health Commercial |
$2,867.33
|
| Rate for Payer: PACE Medicare |
$55.95
|
| Rate for Payer: PACE SWMI |
$58.90
|
| Rate for Payer: PHP Commercial |
$64.79
|
| Rate for Payer: PHP Medicaid |
$31.57
|
| Rate for Payer: PHP Medicare Advantage |
$58.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,272.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,063.84
|
| Rate for Payer: Priority Health Medicare |
$58.90
|
| Rate for Payer: Priority Health Narrow Network |
$2,451.21
|
| Rate for Payer: Railroad Medicare Medicare |
$58.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,077.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$58.90
|
| Rate for Payer: UHC Exchange |
$91.30
|
| Rate for Payer: UHC Medicare Advantage |
$58.90
|
| Rate for Payer: UHCCP DNSP |
$58.90
|
| Rate for Payer: UHCCP Medicaid |
$31.57
|
| Rate for Payer: VA VA |
$58.90
|
|
|
INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$5,993.30
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
161584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.57 |
| Max. Negotiated Rate |
$5,993.30 |
| Rate for Payer: Aetna Commercial |
$5,393.97
|
| Rate for Payer: Aetna Medicare |
$58.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73.62
|
| Rate for Payer: ASR ASR |
$5,813.50
|
| Rate for Payer: ASR Commercial |
$5,813.50
|
| Rate for Payer: BCBS Complete |
$33.15
|
| Rate for Payer: BCBS MAPPO |
$58.90
|
| Rate for Payer: BCBS Trust/PPO |
$4,907.91
|
| Rate for Payer: BCN Commercial |
$4,646.61
|
| Rate for Payer: BCN Medicare Advantage |
$58.90
|
| Rate for Payer: Cash Price |
$4,794.64
|
| Rate for Payer: Cash Price |
$4,794.64
|
| Rate for Payer: Cofinity Commercial |
$5,633.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,794.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58.90
|
| Rate for Payer: Healthscope Commercial |
$5,993.30
|
| Rate for Payer: Healthscope Whirlpool |
$5,813.50
|
| Rate for Payer: Humana Choice PPO Medicare |
$58.90
|
| Rate for Payer: Mclaren Commercial |
$5,393.97
|
| Rate for Payer: Mclaren Medicaid |
$31.57
|
| Rate for Payer: Mclaren Medicare |
$58.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61.84
|
| Rate for Payer: Meridian Medicaid |
$33.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,094.31
|
| Rate for Payer: Nomi Health Commercial |
$4,914.51
|
| Rate for Payer: PACE Medicare |
$55.95
|
| Rate for Payer: PACE SWMI |
$58.90
|
| Rate for Payer: PHP Commercial |
$64.79
|
| Rate for Payer: PHP Medicaid |
$31.57
|
| Rate for Payer: PHP Medicare Advantage |
$58.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,895.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,251.33
|
| Rate for Payer: Priority Health Medicare |
$58.90
|
| Rate for Payer: Priority Health Narrow Network |
$4,201.30
|
| Rate for Payer: Railroad Medicare Medicare |
$58.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,274.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$58.90
|
| Rate for Payer: UHC Exchange |
$91.30
|
| Rate for Payer: UHC Medicare Advantage |
$58.90
|
| Rate for Payer: UHCCP DNSP |
$58.90
|
| Rate for Payer: UHCCP Medicaid |
$31.57
|
| Rate for Payer: VA VA |
$58.90
|
|
|
INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$5,993.30
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
161584
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,895.64 |
| Max. Negotiated Rate |
$5,993.30 |
| Rate for Payer: Aetna Commercial |
$5,393.97
|
| Rate for Payer: ASR ASR |
$5,813.50
|
| Rate for Payer: ASR Commercial |
$5,813.50
|
| Rate for Payer: BCBS Trust/PPO |
$4,883.94
|
| Rate for Payer: BCN Commercial |
$4,646.61
|
| Rate for Payer: Cash Price |
$4,794.64
|
| Rate for Payer: Cofinity Commercial |
$5,633.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,794.64
|
| Rate for Payer: Healthscope Commercial |
$5,993.30
|
| Rate for Payer: Healthscope Whirlpool |
$5,813.50
|
| Rate for Payer: Mclaren Commercial |
$5,393.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,094.31
|
| Rate for Payer: Nomi Health Commercial |
$4,914.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,895.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,274.10
|
|
|
INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$5,238.48
|
|
|
Service Code
|
HCPCS Q3027
|
| Hospital Charge Code |
36417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,405.01 |
| Max. Negotiated Rate |
$5,238.48 |
| Rate for Payer: Aetna Commercial |
$4,714.63
|
| Rate for Payer: ASR ASR |
$5,081.33
|
| Rate for Payer: ASR Commercial |
$5,081.33
|
| Rate for Payer: BCBS Trust/PPO |
$4,268.84
|
| Rate for Payer: BCN Commercial |
$4,061.39
|
| 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: Healthscope Commercial |
$5,238.48
|
| Rate for Payer: Healthscope Whirlpool |
$5,081.33
|
| Rate for Payer: Mclaren Commercial |
$4,714.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,452.71
|
| Rate for Payer: Nomi Health Commercial |
$4,295.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,405.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,609.86
|
|
|
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 |
$31.57 |
| Max. Negotiated Rate |
$5,238.48 |
| Rate for Payer: Aetna Commercial |
$4,714.63
|
| Rate for Payer: Aetna Medicare |
$58.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73.62
|
| Rate for Payer: ASR ASR |
$5,081.33
|
| Rate for Payer: ASR Commercial |
$5,081.33
|
| Rate for Payer: BCBS Complete |
$33.15
|
| Rate for Payer: BCBS MAPPO |
$58.90
|
| Rate for Payer: BCBS Trust/PPO |
$4,289.79
|
| Rate for Payer: BCN Commercial |
$4,061.39
|
| Rate for Payer: BCN Medicare Advantage |
$58.90
|
| 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 |
$58.90
|
| Rate for Payer: Healthscope Commercial |
$5,238.48
|
| Rate for Payer: Healthscope Whirlpool |
$5,081.33
|
| Rate for Payer: Humana Choice PPO Medicare |
$58.90
|
| Rate for Payer: Mclaren Commercial |
$4,714.63
|
| Rate for Payer: Mclaren Medicaid |
$31.57
|
| Rate for Payer: Mclaren Medicare |
$58.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61.84
|
| Rate for Payer: Meridian Medicaid |
$33.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.73
|
| 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 |
$55.95
|
| Rate for Payer: PACE SWMI |
$58.90
|
| Rate for Payer: PHP Commercial |
$64.79
|
| Rate for Payer: PHP Medicaid |
$31.57
|
| Rate for Payer: PHP Medicare Advantage |
$58.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,405.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,589.96
|
| Rate for Payer: Priority Health Medicare |
$58.90
|
| Rate for Payer: Priority Health Narrow Network |
$3,672.17
|
| Rate for Payer: Railroad Medicare Medicare |
$58.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,609.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$58.90
|
| Rate for Payer: UHC Exchange |
$91.30
|
| Rate for Payer: UHC Medicare Advantage |
$58.90
|
| Rate for Payer: UHCCP DNSP |
$58.90
|
| Rate for Payer: UHCCP Medicaid |
$31.57
|
| Rate for Payer: VA VA |
$58.90
|
|
|
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 |
$97.00
|
| Rate for Payer: ASR ASR |
$48.50
|
| 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 |
$38.77
|
| 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 |
$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 |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.50
|
| 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
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
17595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: Aetna Medicare |
$25.00
|
| Rate for Payer: ASR ASR |
$97.00
|
| Rate for Payer: ASR ASR |
$48.50
|
| Rate for Payer: ASR Commercial |
$48.50
|
| Rate for Payer: ASR Commercial |
$97.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$20.00
|
| Rate for Payer: BCBS Trust/PPO |
$81.89
|
| Rate for Payer: BCBS Trust/PPO |
$40.95
|
| Rate for Payer: BCN Commercial |
$38.77
|
| Rate for Payer: BCN Commercial |
$77.53
|
| Rate for Payer: Cash Price |
$80.00
|
| 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 |
$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 |
$42.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.00
|
| 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: Priority Health HMO/PPO/Tiered Network |
$87.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$43.81
|
| Rate for Payer: Priority Health Narrow Network |
$35.05
|
| Rate for Payer: Priority Health Narrow Network |
$70.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$88.00
|
|
|
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 1/2" 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 1/4" 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 1/4" 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" 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 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 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
|
|
|
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
|
|
