|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
IP
|
$243.20
|
|
|
Service Code
|
NDC 68382-132-01
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.24 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$218.88
|
| Rate for Payer: ASR ASR |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$188.55
|
| Rate for Payer: BCN Commercial |
$188.55
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Commercial |
$228.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$243.20
|
| Rate for Payer: Healthscope Whirlpool |
$235.90
|
| Rate for Payer: Mclaren Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.02
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
IP
|
$192.85
|
|
|
Service Code
|
NDC 0904-6401-61
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: BCBS Trust/PPO |
$149.52
|
| Rate for Payer: BCN Commercial |
$149.52
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$192.85
|
| Rate for Payer: Healthscope Whirlpool |
$187.06
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
IP
|
$166.85
|
|
|
Service Code
|
NDC 65862-598-01
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.80 |
| Max. Negotiated Rate |
$166.85 |
| Rate for Payer: Aetna Commercial |
$150.16
|
| Rate for Payer: ASR ASR |
$161.84
|
| Rate for Payer: BCBS Trust/PPO |
$129.36
|
| Rate for Payer: BCN Commercial |
$129.36
|
| Rate for Payer: Cash Price |
$133.48
|
| Rate for Payer: Cofinity Commercial |
$156.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.48
|
| Rate for Payer: Healthscope Commercial |
$166.85
|
| Rate for Payer: Healthscope Whirlpool |
$161.84
|
| Rate for Payer: Mclaren Commercial |
$150.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$141.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$146.83
|
|
|
TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
IP
|
$657.25
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$460.08 |
| Max. Negotiated Rate |
$657.25 |
| Rate for Payer: Aetna Commercial |
$591.52
|
| Rate for Payer: ASR ASR |
$637.53
|
| Rate for Payer: BCBS Trust/PPO |
$509.57
|
| Rate for Payer: BCN Commercial |
$509.57
|
| Rate for Payer: Cash Price |
$525.80
|
| Rate for Payer: Cofinity Commercial |
$617.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$525.80
|
| Rate for Payer: Healthscope Commercial |
$657.25
|
| Rate for Payer: Healthscope Whirlpool |
$637.53
|
| Rate for Payer: Mclaren Commercial |
$591.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$558.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$460.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$578.38
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
IP
|
$1,051.94
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$736.36 |
| Max. Negotiated Rate |
$1,051.94 |
| Rate for Payer: Aetna Commercial |
$946.75
|
| Rate for Payer: ASR ASR |
$1,020.38
|
| Rate for Payer: BCBS Trust/PPO |
$815.57
|
| Rate for Payer: BCN Commercial |
$815.57
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cofinity Commercial |
$988.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$841.55
|
| Rate for Payer: Healthscope Commercial |
$1,051.94
|
| Rate for Payer: Healthscope Whirlpool |
$1,020.38
|
| Rate for Payer: Mclaren Commercial |
$946.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$894.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$736.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$925.71
|
|
|
TELMISARTAN 40 MG TABLET
|
Facility
IP
|
$482.63
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
24335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.84 |
| Max. Negotiated Rate |
$482.63 |
| Rate for Payer: Aetna Commercial |
$434.37
|
| Rate for Payer: ASR ASR |
$468.15
|
| Rate for Payer: BCBS Trust/PPO |
$374.18
|
| Rate for Payer: BCN Commercial |
$374.18
|
| Rate for Payer: Cash Price |
$386.10
|
| Rate for Payer: Cofinity Commercial |
$453.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$386.10
|
| Rate for Payer: Healthscope Commercial |
$482.63
|
| Rate for Payer: Healthscope Whirlpool |
$468.15
|
| Rate for Payer: Mclaren Commercial |
$434.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$410.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$337.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$424.71
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITH MCC
|
Facility
IP
|
$19,989.31
|
|
|
Service Code
|
MS-DRG 557
|
| Min. Negotiated Rate |
$14,118.37 |
| Max. Negotiated Rate |
$19,989.31 |
| Rate for Payer: Aetna Medicare |
$14,861.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,576.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,576.80
|
| Rate for Payer: BCBS MAPPO |
$14,861.44
|
| Rate for Payer: BCN Medicare Advantage |
$14,861.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,861.44
|
| Rate for Payer: Humana Choice PPO Medicare |
$14,861.44
|
| Rate for Payer: Mclaren Medicare |
$14,861.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15,604.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,090.66
|
| Rate for Payer: PACE Medicare |
$14,118.37
|
| Rate for Payer: PACE SWMI |
$14,861.44
|
| Rate for Payer: PHP Commercial |
$16,347.58
|
| Rate for Payer: PHP Medicare Advantage |
$14,861.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,989.31
|
| Rate for Payer: Priority Health Medicare |
$14,861.44
|
| Rate for Payer: Priority Health Narrow Network |
$15,991.45
|
| Rate for Payer: Railroad Medicare Medicare |
$14,861.44
|
| Rate for Payer: UHC Medicare Advantage |
$15,307.28
|
| Rate for Payer: VA VA |
$14,861.44
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC
|
Facility
IP
|
$11,397.29
|
|
|
Service Code
|
MS-DRG 558
|
| Min. Negotiated Rate |
$8,661.94 |
| Max. Negotiated Rate |
$11,397.29 |
| Rate for Payer: Aetna Medicare |
$9,117.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,397.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,397.29
|
| Rate for Payer: BCBS MAPPO |
$9,117.83
|
| Rate for Payer: BCN Medicare Advantage |
$9,117.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,117.83
|
| Rate for Payer: Humana Choice PPO Medicare |
$9,117.83
|
| Rate for Payer: Mclaren Medicare |
$9,117.83
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,573.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,485.50
|
| Rate for Payer: PACE Medicare |
$8,661.94
|
| Rate for Payer: PACE SWMI |
$9,117.83
|
| Rate for Payer: PHP Commercial |
$10,029.61
|
| Rate for Payer: PHP Medicare Advantage |
$9,117.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,278.66
|
| Rate for Payer: Priority Health Medicare |
$9,117.83
|
| Rate for Payer: Priority Health Narrow Network |
$9,022.93
|
| Rate for Payer: Railroad Medicare Medicare |
$9,117.83
|
| Rate for Payer: UHC Medicare Advantage |
$9,391.36
|
| Rate for Payer: VA VA |
$9,117.83
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$26,150.27
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,305.19 |
| Max. Negotiated Rate |
$26,150.27 |
| Rate for Payer: Aetna Commercial |
$23,535.24
|
| Rate for Payer: ASR ASR |
$25,365.76
|
| Rate for Payer: BCBS Trust/PPO |
$20,274.30
|
| Rate for Payer: BCN Commercial |
$20,274.30
|
| Rate for Payer: Cash Price |
$20,920.21
|
| Rate for Payer: Cofinity Commercial |
$24,581.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20,920.22
|
| Rate for Payer: Healthscope Commercial |
$26,150.27
|
| Rate for Payer: Healthscope Whirlpool |
$25,365.76
|
| Rate for Payer: Mclaren Commercial |
$23,535.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22,227.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,305.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23,012.24
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
IP
|
$21.32
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.32 |
| Rate for Payer: Aetna Commercial |
$19.19
|
| Rate for Payer: Aetna Commercial |
$15.52
|
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: ASR ASR |
$16.73
|
| Rate for Payer: ASR ASR |
$23.32
|
| Rate for Payer: ASR ASR |
$20.68
|
| Rate for Payer: BCBS Trust/PPO |
$13.37
|
| Rate for Payer: BCBS Trust/PPO |
$18.64
|
| Rate for Payer: BCBS Trust/PPO |
$16.53
|
| Rate for Payer: BCN Commercial |
$16.53
|
| Rate for Payer: BCN Commercial |
$13.37
|
| Rate for Payer: BCN Commercial |
$18.64
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$16.22
|
| Rate for Payer: Cofinity Commercial |
$20.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.80
|
| Rate for Payer: Healthscope Commercial |
$24.04
|
| Rate for Payer: Healthscope Commercial |
$21.32
|
| Rate for Payer: Healthscope Commercial |
$17.25
|
| Rate for Payer: Healthscope Whirlpool |
$23.32
|
| Rate for Payer: Healthscope Whirlpool |
$16.73
|
| Rate for Payer: Healthscope Whirlpool |
$20.68
|
| Rate for Payer: Mclaren Commercial |
$19.19
|
| Rate for Payer: Mclaren Commercial |
$15.52
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.16
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
IP
|
$27,258.04
|
|
|
Service Code
|
MS-DRG 711
|
| Min. Negotiated Rate |
$18,671.54 |
| Max. Negotiated Rate |
$27,258.04 |
| Rate for Payer: Aetna Medicare |
$19,654.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,567.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,567.81
|
| Rate for Payer: BCBS MAPPO |
$19,654.25
|
| Rate for Payer: BCN Medicare Advantage |
$19,654.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,654.25
|
| Rate for Payer: Humana Choice PPO Medicare |
$19,654.25
|
| Rate for Payer: Mclaren Medicare |
$19,654.25
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,636.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,602.39
|
| Rate for Payer: PACE Medicare |
$18,671.54
|
| Rate for Payer: PACE SWMI |
$19,654.25
|
| Rate for Payer: PHP Commercial |
$21,619.68
|
| Rate for Payer: PHP Medicare Advantage |
$19,654.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27,258.04
|
| Rate for Payer: Priority Health Medicare |
$19,654.25
|
| Rate for Payer: Priority Health Narrow Network |
$21,806.43
|
| Rate for Payer: Railroad Medicare Medicare |
$19,654.25
|
| Rate for Payer: UHC Medicare Advantage |
$20,243.88
|
| Rate for Payer: VA VA |
$19,654.25
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$15,259.06
|
|
|
Service Code
|
MS-DRG 712
|
| Min. Negotiated Rate |
$11,155.28 |
| Max. Negotiated Rate |
$15,259.06 |
| Rate for Payer: Aetna Medicare |
$11,742.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,678.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,678.00
|
| Rate for Payer: BCBS MAPPO |
$11,742.40
|
| Rate for Payer: BCN Medicare Advantage |
$11,742.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,742.40
|
| Rate for Payer: Humana Choice PPO Medicare |
$11,742.40
|
| Rate for Payer: Mclaren Medicare |
$11,742.40
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,329.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,503.76
|
| Rate for Payer: PACE Medicare |
$11,155.28
|
| Rate for Payer: PACE SWMI |
$11,742.40
|
| Rate for Payer: PHP Commercial |
$12,916.64
|
| Rate for Payer: PHP Medicare Advantage |
$11,742.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,259.06
|
| Rate for Payer: Priority Health Medicare |
$11,742.40
|
| Rate for Payer: Priority Health Narrow Network |
$12,207.25
|
| Rate for Payer: Railroad Medicare Medicare |
$11,742.40
|
| Rate for Payer: UHC Medicare Advantage |
$12,094.67
|
| Rate for Payer: VA VA |
$11,742.40
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
IP
|
$65.10
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna Commercial |
$58.59
|
| Rate for Payer: Aetna Commercial |
$31.41
|
| Rate for Payer: Aetna Commercial |
$525.46
|
| Rate for Payer: ASR ASR |
$566.33
|
| Rate for Payer: ASR ASR |
$33.85
|
| Rate for Payer: ASR ASR |
$63.15
|
| Rate for Payer: BCBS Trust/PPO |
$50.47
|
| Rate for Payer: BCBS Trust/PPO |
$27.06
|
| Rate for Payer: BCBS Trust/PPO |
$452.66
|
| Rate for Payer: BCN Commercial |
$27.06
|
| Rate for Payer: BCN Commercial |
$452.66
|
| Rate for Payer: BCN Commercial |
$50.47
|
| Rate for Payer: Cash Price |
$27.92
|
| Rate for Payer: Cash Price |
$467.08
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$548.82
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$32.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$467.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.92
|
| Rate for Payer: Healthscope Commercial |
$583.85
|
| Rate for Payer: Healthscope Commercial |
$65.10
|
| Rate for Payer: Healthscope Commercial |
$34.90
|
| Rate for Payer: Healthscope Whirlpool |
$63.15
|
| Rate for Payer: Healthscope Whirlpool |
$33.85
|
| Rate for Payer: Healthscope Whirlpool |
$566.33
|
| Rate for Payer: Mclaren Commercial |
$58.59
|
| Rate for Payer: Mclaren Commercial |
$525.46
|
| Rate for Payer: Mclaren Commercial |
$31.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$496.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$408.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$513.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.71
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
IP
|
$1,676.77
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,173.74 |
| Max. Negotiated Rate |
$1,676.77 |
| Rate for Payer: Aetna Commercial |
$1,509.09
|
| Rate for Payer: ASR ASR |
$1,626.47
|
| Rate for Payer: BCBS Trust/PPO |
$1,300.00
|
| Rate for Payer: BCN Commercial |
$1,300.00
|
| Rate for Payer: Cash Price |
$1,341.41
|
| Rate for Payer: Cofinity Commercial |
$1,576.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,341.42
|
| Rate for Payer: Healthscope Commercial |
$1,676.77
|
| Rate for Payer: Healthscope Whirlpool |
$1,626.47
|
| Rate for Payer: Mclaren Commercial |
$1,509.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,425.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,173.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,475.56
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
IP
|
$36.43
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$36.43 |
| Rate for Payer: Aetna Commercial |
$32.79
|
| Rate for Payer: ASR ASR |
$35.34
|
| Rate for Payer: BCBS Trust/PPO |
$28.24
|
| Rate for Payer: BCN Commercial |
$28.24
|
| Rate for Payer: Cash Price |
$29.14
|
| Rate for Payer: Cofinity Commercial |
$34.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.14
|
| Rate for Payer: Healthscope Commercial |
$36.43
|
| Rate for Payer: Healthscope Whirlpool |
$35.34
|
| Rate for Payer: Mclaren Commercial |
$32.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.06
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
IP
|
$250.72
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$250.72 |
| Rate for Payer: Aetna Commercial |
$225.65
|
| Rate for Payer: ASR ASR |
$243.20
|
| Rate for Payer: BCBS Trust/PPO |
$194.38
|
| Rate for Payer: BCN Commercial |
$194.38
|
| Rate for Payer: Cash Price |
$200.58
|
| Rate for Payer: Cofinity Commercial |
$235.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.58
|
| Rate for Payer: Healthscope Commercial |
$250.72
|
| Rate for Payer: Healthscope Whirlpool |
$243.20
|
| Rate for Payer: Mclaren Commercial |
$225.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$220.63
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
IP
|
$882.45
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$617.72 |
| Max. Negotiated Rate |
$882.45 |
| Rate for Payer: Aetna Commercial |
$794.20
|
| Rate for Payer: ASR ASR |
$855.98
|
| Rate for Payer: BCBS Trust/PPO |
$684.16
|
| Rate for Payer: BCN Commercial |
$684.16
|
| Rate for Payer: Cash Price |
$705.96
|
| Rate for Payer: Cofinity Commercial |
$829.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$705.96
|
| Rate for Payer: Healthscope Commercial |
$882.45
|
| Rate for Payer: Healthscope Whirlpool |
$855.98
|
| Rate for Payer: Mclaren Commercial |
$794.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$750.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$617.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$776.56
|
|
|
THERMAGE
|
Professional
|
$1,000.00
|
|
|
Service Code
|
HCPCS 00167
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$400.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Complete |
$400.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$700.00
|
|
|
THERMAGE ABDOMEN - ENTIRE
|
Professional
|
$3,100.00
|
|
|
Service Code
|
HCPCS 00150
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,240.00 |
| Max. Negotiated Rate |
$2,170.00 |
| Rate for Payer: BCBS Complete |
$1,240.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,170.00
|
|
|
THERMAGE ABDOMEN - LOWER
|
Professional
|
$2,000.00
|
|
|
Service Code
|
HCPCS 00149
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$800.00 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: BCBS Complete |
$800.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,400.00
|
|
|
THERMAGE ARMS - 1 ARM
|
Professional
|
$1,200.00
|
|
|
Service Code
|
HCPCS 00145
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
|
|
THERMAGE ARMS - BILATERAL
|
Professional
|
$2,100.00
|
|
|
Service Code
|
HCPCS 00146
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,470.00 |
| Rate for Payer: BCBS Complete |
$840.00
|
| Rate for Payer: Cash Price |
$1,680.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,470.00
|
|
|
THERMAGE EYES
|
Professional
|
$950.00
|
|
|
Service Code
|
HCPCS 00140
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$380.00 |
| Max. Negotiated Rate |
$665.00 |
| Rate for Payer: BCBS Complete |
$380.00
|
| Rate for Payer: Cash Price |
$760.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$665.00
|
|
|
THERMAGE FACE
|
Professional
|
$2,000.00
|
|
|
Service Code
|
HCPCS 00139
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$800.00 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: BCBS Complete |
$800.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,400.00
|
|
|
THERMAGE FACE & EYES
|
Professional
|
$2,700.00
|
|
|
Service Code
|
HCPCS 00142
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,080.00 |
| Max. Negotiated Rate |
$1,890.00 |
| Rate for Payer: BCBS Complete |
$1,080.00
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,890.00
|
|
