|
TELMISARTAN 20 MG TABLET
|
Facility
|
OP
|
$85.78
|
|
|
Service Code
|
NDC 00378292093
|
| Hospital Charge Code |
29176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.31 |
| Max. Negotiated Rate |
$85.78 |
| Rate for Payer: Aetna Commercial |
$77.20
|
| Rate for Payer: Aetna Medicare |
$42.89
|
| Rate for Payer: ASR ASR |
$83.21
|
| Rate for Payer: ASR Commercial |
$83.21
|
| Rate for Payer: BCBS Complete |
$34.31
|
| Rate for Payer: BCBS Trust/PPO |
$70.25
|
| Rate for Payer: BCN Commercial |
$66.51
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cofinity Commercial |
$80.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.62
|
| Rate for Payer: Healthscope Commercial |
$85.78
|
| Rate for Payer: Healthscope Whirlpool |
$83.21
|
| Rate for Payer: Mclaren Commercial |
$77.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.91
|
| Rate for Payer: Nomi Health Commercial |
$70.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.16
|
| Rate for Payer: Priority Health Narrow Network |
$60.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.49
|
|
|
TELMISARTAN 20 MG TABLET
|
Facility
|
IP
|
$85.78
|
|
|
Service Code
|
NDC 00378292093
|
| Hospital Charge Code |
29176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.76 |
| Max. Negotiated Rate |
$85.78 |
| Rate for Payer: Aetna Commercial |
$77.20
|
| Rate for Payer: ASR ASR |
$83.21
|
| Rate for Payer: ASR Commercial |
$83.21
|
| Rate for Payer: BCBS Trust/PPO |
$69.90
|
| Rate for Payer: BCN Commercial |
$66.51
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cofinity Commercial |
$80.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.62
|
| Rate for Payer: Healthscope Commercial |
$85.78
|
| Rate for Payer: Healthscope Whirlpool |
$83.21
|
| Rate for Payer: Mclaren Commercial |
$77.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.91
|
| Rate for Payer: Nomi Health Commercial |
$70.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.49
|
|
|
TELMISARTAN 40 MG TABLET
|
Facility
|
IP
|
$483.52
|
|
|
Service Code
|
NDC 00597004037
|
| Hospital Charge Code |
24335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$314.29 |
| Max. Negotiated Rate |
$483.52 |
| Rate for Payer: Aetna Commercial |
$435.17
|
| Rate for Payer: ASR ASR |
$469.01
|
| Rate for Payer: ASR Commercial |
$469.01
|
| Rate for Payer: BCBS Trust/PPO |
$394.02
|
| Rate for Payer: BCN Commercial |
$374.87
|
| Rate for Payer: Cash Price |
$386.81
|
| Rate for Payer: Cofinity Commercial |
$454.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$386.82
|
| Rate for Payer: Healthscope Commercial |
$483.52
|
| Rate for Payer: Healthscope Whirlpool |
$469.01
|
| Rate for Payer: Mclaren Commercial |
$435.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$410.99
|
| Rate for Payer: Nomi Health Commercial |
$396.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$425.50
|
|
|
TELMISARTAN 40 MG TABLET
|
Facility
|
OP
|
$483.52
|
|
|
Service Code
|
NDC 00597004037
|
| Hospital Charge Code |
24335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.41 |
| Max. Negotiated Rate |
$483.52 |
| Rate for Payer: Aetna Commercial |
$435.17
|
| Rate for Payer: Aetna Medicare |
$241.76
|
| Rate for Payer: ASR ASR |
$469.01
|
| Rate for Payer: ASR Commercial |
$469.01
|
| Rate for Payer: BCBS Complete |
$193.41
|
| Rate for Payer: BCBS Trust/PPO |
$395.95
|
| Rate for Payer: BCN Commercial |
$374.87
|
| Rate for Payer: Cash Price |
$386.81
|
| Rate for Payer: Cofinity Commercial |
$454.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$386.82
|
| Rate for Payer: Healthscope Commercial |
$483.52
|
| Rate for Payer: Healthscope Whirlpool |
$469.01
|
| Rate for Payer: Mclaren Commercial |
$435.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$410.99
|
| Rate for Payer: Nomi Health Commercial |
$396.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$423.66
|
| Rate for Payer: Priority Health Narrow Network |
$338.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$425.50
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,932.37
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$29,932.37 |
| Rate for Payer: Aetna Commercial |
$26,939.13
|
| Rate for Payer: Aetna Medicare |
$162.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$203.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$203.04
|
| Rate for Payer: ASR ASR |
$29,034.40
|
| Rate for Payer: ASR Commercial |
$29,034.40
|
| Rate for Payer: BCBS Complete |
$91.42
|
| Rate for Payer: BCBS MAPPO |
$162.43
|
| Rate for Payer: BCBS Trust/PPO |
$24,511.62
|
| Rate for Payer: BCN Commercial |
$23,206.57
|
| Rate for Payer: BCN Medicare Advantage |
$162.43
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cofinity Commercial |
$28,136.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,945.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$162.43
|
| Rate for Payer: Healthscope Commercial |
$29,932.37
|
| Rate for Payer: Healthscope Whirlpool |
$29,034.40
|
| Rate for Payer: Humana Choice PPO Medicare |
$162.43
|
| Rate for Payer: Mclaren Commercial |
$26,939.13
|
| Rate for Payer: Mclaren Medicaid |
$87.06
|
| Rate for Payer: Mclaren Medicare |
$162.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$170.55
|
| Rate for Payer: Meridian Medicaid |
$91.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$186.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,442.51
|
| Rate for Payer: Nomi Health Commercial |
$24,544.54
|
| Rate for Payer: PACE Medicare |
$154.31
|
| Rate for Payer: PACE SWMI |
$162.43
|
| Rate for Payer: PHP Commercial |
$178.67
|
| Rate for Payer: PHP Medicaid |
$87.06
|
| Rate for Payer: PHP Medicare Advantage |
$162.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$87.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,456.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$168.59
|
| Rate for Payer: Priority Health Medicare |
$162.43
|
| Rate for Payer: Priority Health Narrow Network |
$134.87
|
| Rate for Payer: Railroad Medicare Medicare |
$162.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26,340.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$162.43
|
| Rate for Payer: UHC Exchange |
$251.77
|
| Rate for Payer: UHC Medicare Advantage |
$162.43
|
| Rate for Payer: UHCCP DNSP |
$162.43
|
| Rate for Payer: UHCCP Medicaid |
$87.06
|
| Rate for Payer: VA VA |
$162.43
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29,932.37
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19,456.04 |
| Max. Negotiated Rate |
$29,932.37 |
| Rate for Payer: Aetna Commercial |
$26,939.13
|
| Rate for Payer: ASR ASR |
$29,034.40
|
| Rate for Payer: ASR Commercial |
$29,034.40
|
| Rate for Payer: BCBS Trust/PPO |
$24,391.89
|
| Rate for Payer: BCN Commercial |
$23,206.57
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cofinity Commercial |
$28,136.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,945.90
|
| Rate for Payer: Healthscope Commercial |
$29,932.37
|
| Rate for Payer: Healthscope Whirlpool |
$29,034.40
|
| Rate for Payer: Mclaren Commercial |
$26,939.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,442.51
|
| Rate for Payer: Nomi Health Commercial |
$24,544.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,456.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26,340.49
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$17.25
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Aetna Commercial |
$15.52
|
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: Aetna Commercial |
$19.19
|
| Rate for Payer: Aetna Medicare |
$12.02
|
| Rate for Payer: Aetna Medicare |
$8.62
|
| Rate for Payer: Aetna Medicare |
$10.66
|
| Rate for Payer: ASR ASR |
$20.68
|
| Rate for Payer: ASR ASR |
$16.73
|
| Rate for Payer: ASR ASR |
$23.32
|
| Rate for Payer: ASR Commercial |
$20.68
|
| Rate for Payer: ASR Commercial |
$16.73
|
| Rate for Payer: ASR Commercial |
$23.32
|
| Rate for Payer: BCBS Complete |
$6.90
|
| Rate for Payer: BCBS Complete |
$8.53
|
| Rate for Payer: BCBS Complete |
$9.62
|
| Rate for Payer: BCBS Trust/PPO |
$19.69
|
| Rate for Payer: BCBS Trust/PPO |
$14.13
|
| Rate for Payer: BCBS Trust/PPO |
$17.46
|
| Rate for Payer: BCN Commercial |
$16.53
|
| Rate for Payer: BCN Commercial |
$18.64
|
| Rate for Payer: BCN Commercial |
$13.37
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cash Price |
$19.23
|
| 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 |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.06
|
| 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 |
$20.68
|
| Rate for Payer: Healthscope Whirlpool |
$16.73
|
| Rate for Payer: Mclaren Commercial |
$19.19
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: Mclaren Commercial |
$15.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.66
|
| Rate for Payer: Nomi Health Commercial |
$14.14
|
| Rate for Payer: Nomi Health Commercial |
$19.71
|
| Rate for Payer: Nomi Health Commercial |
$17.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.47
|
| Rate for Payer: Priority Health Narrow Network |
$1.18
|
| Rate for Payer: Priority Health Narrow Network |
$1.18
|
| Rate for Payer: Priority Health Narrow Network |
$1.18
|
| 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
|
|
|
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 |
$13.86 |
| 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 |
$23.32
|
| Rate for Payer: ASR ASR |
$16.73
|
| Rate for Payer: ASR ASR |
$20.68
|
| Rate for Payer: ASR Commercial |
$16.73
|
| Rate for Payer: ASR Commercial |
$23.32
|
| Rate for Payer: ASR Commercial |
$20.68
|
| Rate for Payer: BCBS Trust/PPO |
$17.37
|
| Rate for Payer: BCBS Trust/PPO |
$14.06
|
| Rate for Payer: BCBS Trust/PPO |
$19.59
|
| Rate for Payer: BCN Commercial |
$13.37
|
| Rate for Payer: BCN Commercial |
$16.53
|
| Rate for Payer: BCN Commercial |
$18.64
|
| Rate for Payer: Cash Price |
$17.05
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$19.23
|
| 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 |
$19.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.06
|
| Rate for Payer: Healthscope Commercial |
$21.32
|
| Rate for Payer: Healthscope Commercial |
$17.25
|
| Rate for Payer: Healthscope Commercial |
$24.04
|
| Rate for Payer: Healthscope Whirlpool |
$16.73
|
| Rate for Payer: Healthscope Whirlpool |
$20.68
|
| Rate for Payer: Healthscope Whirlpool |
$23.32
|
| Rate for Payer: Mclaren Commercial |
$21.64
|
| Rate for Payer: Mclaren Commercial |
$19.19
|
| Rate for Payer: Mclaren Commercial |
$15.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Nomi Health Commercial |
$14.14
|
| Rate for Payer: Nomi Health Commercial |
$17.48
|
| Rate for Payer: Nomi Health Commercial |
$19.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.76
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$110.40
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$99.36
|
| Rate for Payer: Aetna Commercial |
$58.59
|
| Rate for Payer: Aetna Commercial |
$91.76
|
| Rate for Payer: Aetna Commercial |
$87.88
|
| Rate for Payer: Aetna Commercial |
$511.83
|
| Rate for Payer: Aetna Medicare |
$284.35
|
| Rate for Payer: Aetna Medicare |
$50.98
|
| Rate for Payer: Aetna Medicare |
$55.20
|
| Rate for Payer: Aetna Medicare |
$32.55
|
| Rate for Payer: Aetna Medicare |
$48.82
|
| Rate for Payer: ASR ASR |
$98.89
|
| Rate for Payer: ASR ASR |
$63.15
|
| Rate for Payer: ASR ASR |
$107.09
|
| Rate for Payer: ASR ASR |
$551.64
|
| Rate for Payer: ASR ASR |
$94.72
|
| Rate for Payer: ASR Commercial |
$98.89
|
| Rate for Payer: ASR Commercial |
$107.09
|
| Rate for Payer: ASR Commercial |
$94.72
|
| Rate for Payer: ASR Commercial |
$63.15
|
| Rate for Payer: ASR Commercial |
$551.64
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: BCBS Complete |
$40.78
|
| Rate for Payer: BCBS Complete |
$44.16
|
| Rate for Payer: BCBS Complete |
$227.48
|
| Rate for Payer: BCBS Complete |
$26.04
|
| Rate for Payer: BCBS Trust/PPO |
$53.31
|
| Rate for Payer: BCBS Trust/PPO |
$465.71
|
| Rate for Payer: BCBS Trust/PPO |
$83.49
|
| Rate for Payer: BCBS Trust/PPO |
$90.41
|
| Rate for Payer: BCBS Trust/PPO |
$79.97
|
| Rate for Payer: BCN Commercial |
$50.47
|
| Rate for Payer: BCN Commercial |
$79.04
|
| Rate for Payer: BCN Commercial |
$85.59
|
| Rate for Payer: BCN Commercial |
$440.91
|
| Rate for Payer: BCN Commercial |
$75.71
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$81.56
|
| Rate for Payer: Cash Price |
$454.96
|
| Rate for Payer: Cash Price |
$454.96
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$81.56
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cofinity Commercial |
$103.78
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$91.79
|
| Rate for Payer: Cofinity Commercial |
$95.83
|
| Rate for Payer: Cofinity Commercial |
$534.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$454.96
|
| Rate for Payer: Healthscope Commercial |
$65.10
|
| Rate for Payer: Healthscope Commercial |
$568.70
|
| Rate for Payer: Healthscope Commercial |
$110.40
|
| Rate for Payer: Healthscope Commercial |
$97.65
|
| Rate for Payer: Healthscope Commercial |
$101.95
|
| Rate for Payer: Healthscope Whirlpool |
$94.72
|
| Rate for Payer: Healthscope Whirlpool |
$107.09
|
| Rate for Payer: Healthscope Whirlpool |
$98.89
|
| Rate for Payer: Healthscope Whirlpool |
$63.15
|
| Rate for Payer: Healthscope Whirlpool |
$551.64
|
| Rate for Payer: Mclaren Commercial |
$58.59
|
| Rate for Payer: Mclaren Commercial |
$91.76
|
| Rate for Payer: Mclaren Commercial |
$99.36
|
| Rate for Payer: Mclaren Commercial |
$511.83
|
| Rate for Payer: Mclaren Commercial |
$87.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$483.40
|
| Rate for Payer: Nomi Health Commercial |
$83.60
|
| Rate for Payer: Nomi Health Commercial |
$90.53
|
| Rate for Payer: Nomi Health Commercial |
$80.07
|
| Rate for Payer: Nomi Health Commercial |
$53.38
|
| Rate for Payer: Nomi Health Commercial |
$466.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$369.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.03
|
| Rate for Payer: Priority Health Narrow Network |
$0.02
|
| Rate for Payer: Priority Health Narrow Network |
$0.02
|
| Rate for Payer: Priority Health Narrow Network |
$0.02
|
| Rate for Payer: Priority Health Narrow Network |
$0.02
|
| Rate for Payer: Priority Health Narrow Network |
$0.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$97.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$85.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$500.46
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$110.40
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$99.36
|
| Rate for Payer: Aetna Commercial |
$58.59
|
| Rate for Payer: Aetna Commercial |
$87.88
|
| Rate for Payer: Aetna Commercial |
$511.83
|
| Rate for Payer: Aetna Commercial |
$91.76
|
| Rate for Payer: ASR ASR |
$94.72
|
| Rate for Payer: ASR ASR |
$63.15
|
| Rate for Payer: ASR ASR |
$551.64
|
| Rate for Payer: ASR ASR |
$107.09
|
| Rate for Payer: ASR ASR |
$98.89
|
| Rate for Payer: ASR Commercial |
$551.64
|
| Rate for Payer: ASR Commercial |
$94.72
|
| Rate for Payer: ASR Commercial |
$63.15
|
| Rate for Payer: ASR Commercial |
$107.09
|
| Rate for Payer: ASR Commercial |
$98.89
|
| Rate for Payer: BCBS Trust/PPO |
$79.57
|
| Rate for Payer: BCBS Trust/PPO |
$83.08
|
| Rate for Payer: BCBS Trust/PPO |
$89.96
|
| Rate for Payer: BCBS Trust/PPO |
$53.05
|
| Rate for Payer: BCBS Trust/PPO |
$463.43
|
| Rate for Payer: BCN Commercial |
$85.59
|
| Rate for Payer: BCN Commercial |
$75.71
|
| Rate for Payer: BCN Commercial |
$79.04
|
| Rate for Payer: BCN Commercial |
$440.91
|
| Rate for Payer: BCN Commercial |
$50.47
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$454.96
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$81.56
|
| Rate for Payer: Cofinity Commercial |
$103.78
|
| Rate for Payer: Cofinity Commercial |
$534.58
|
| Rate for Payer: Cofinity Commercial |
$95.83
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$91.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$454.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Healthscope Commercial |
$568.70
|
| Rate for Payer: Healthscope Commercial |
$65.10
|
| Rate for Payer: Healthscope Commercial |
$110.40
|
| Rate for Payer: Healthscope Commercial |
$101.95
|
| Rate for Payer: Healthscope Commercial |
$97.65
|
| Rate for Payer: Healthscope Whirlpool |
$94.72
|
| Rate for Payer: Healthscope Whirlpool |
$98.89
|
| Rate for Payer: Healthscope Whirlpool |
$551.64
|
| Rate for Payer: Healthscope Whirlpool |
$107.09
|
| Rate for Payer: Healthscope Whirlpool |
$63.15
|
| Rate for Payer: Mclaren Commercial |
$99.36
|
| Rate for Payer: Mclaren Commercial |
$511.83
|
| Rate for Payer: Mclaren Commercial |
$91.76
|
| Rate for Payer: Mclaren Commercial |
$58.59
|
| Rate for Payer: Mclaren Commercial |
$87.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$483.40
|
| Rate for Payer: Nomi Health Commercial |
$466.33
|
| Rate for Payer: Nomi Health Commercial |
$83.60
|
| Rate for Payer: Nomi Health Commercial |
$90.53
|
| Rate for Payer: Nomi Health Commercial |
$80.07
|
| Rate for Payer: Nomi Health Commercial |
$53.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$369.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$500.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$97.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$85.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.29
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$1,678.14
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$1,678.14 |
| Rate for Payer: Aetna Commercial |
$1,510.33
|
| Rate for Payer: ASR ASR |
$1,627.80
|
| Rate for Payer: ASR Commercial |
$1,627.80
|
| Rate for Payer: BCBS Trust/PPO |
$1,367.52
|
| Rate for Payer: BCN Commercial |
$1,301.06
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,577.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.51
|
| Rate for Payer: Healthscope Commercial |
$1,678.14
|
| Rate for Payer: Healthscope Whirlpool |
$1,627.80
|
| Rate for Payer: Mclaren Commercial |
$1,510.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.42
|
| Rate for Payer: Nomi Health Commercial |
$1,376.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,476.76
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$1,678.14
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$306.63 |
| Max. Negotiated Rate |
$1,678.14 |
| Rate for Payer: Aetna Commercial |
$1,510.33
|
| Rate for Payer: Aetna Medicare |
$572.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$715.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$715.09
|
| Rate for Payer: ASR ASR |
$1,627.80
|
| Rate for Payer: ASR Commercial |
$1,627.80
|
| Rate for Payer: BCBS Complete |
$321.96
|
| Rate for Payer: BCBS MAPPO |
$572.07
|
| Rate for Payer: BCBS Trust/PPO |
$1,374.23
|
| Rate for Payer: BCN Commercial |
$1,301.06
|
| Rate for Payer: BCN Medicare Advantage |
$572.07
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,577.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$572.07
|
| Rate for Payer: Healthscope Commercial |
$1,678.14
|
| Rate for Payer: Healthscope Whirlpool |
$1,627.80
|
| Rate for Payer: Humana Choice PPO Medicare |
$572.07
|
| Rate for Payer: Mclaren Commercial |
$1,510.33
|
| Rate for Payer: Mclaren Medicaid |
$306.63
|
| Rate for Payer: Mclaren Medicare |
$572.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$600.67
|
| Rate for Payer: Meridian Medicaid |
$321.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$657.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.42
|
| Rate for Payer: Nomi Health Commercial |
$1,376.07
|
| Rate for Payer: PACE Medicare |
$543.47
|
| Rate for Payer: PACE SWMI |
$572.07
|
| Rate for Payer: PHP Commercial |
$629.28
|
| Rate for Payer: PHP Medicaid |
$306.63
|
| Rate for Payer: PHP Medicare Advantage |
$572.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$306.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$597.49
|
| Rate for Payer: Priority Health Medicare |
$572.07
|
| Rate for Payer: Priority Health Narrow Network |
$477.99
|
| Rate for Payer: Railroad Medicare Medicare |
$572.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,476.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$572.07
|
| Rate for Payer: UHC Exchange |
$886.71
|
| Rate for Payer: UHC Medicare Advantage |
$572.07
|
| Rate for Payer: UHCCP DNSP |
$572.07
|
| Rate for Payer: UHCCP Medicaid |
$306.63
|
| Rate for Payer: VA VA |
$572.07
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
IP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.86 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Aetna Commercial |
$34.42
|
| Rate for Payer: ASR ASR |
$37.10
|
| Rate for Payer: ASR Commercial |
$37.10
|
| Rate for Payer: BCBS Trust/PPO |
$31.17
|
| Rate for Payer: BCN Commercial |
$29.66
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$35.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$38.25
|
| Rate for Payer: Healthscope Whirlpool |
$37.10
|
| Rate for Payer: Mclaren Commercial |
$34.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: Nomi Health Commercial |
$31.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.66
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
OP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Aetna Commercial |
$34.42
|
| Rate for Payer: Aetna Medicare |
$19.12
|
| Rate for Payer: ASR ASR |
$37.10
|
| Rate for Payer: ASR Commercial |
$37.10
|
| Rate for Payer: BCBS Complete |
$15.30
|
| Rate for Payer: BCBS Trust/PPO |
$31.32
|
| Rate for Payer: BCN Commercial |
$29.66
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$35.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$38.25
|
| Rate for Payer: Healthscope Whirlpool |
$37.10
|
| Rate for Payer: Mclaren Commercial |
$34.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: Nomi Health Commercial |
$31.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.51
|
| Rate for Payer: Priority Health Narrow Network |
$26.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.66
|
|
|
THERMAGE
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00167
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
THERMAGE ABDOMEN - ENTIRE
|
Professional
|
Both
|
$3,162.00
|
|
|
Service Code
|
HCPCS 00150
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,264.80 |
| Max. Negotiated Rate |
$2,055.30 |
| Rate for Payer: Aetna Medicare |
$1,581.00
|
| Rate for Payer: BCBS Complete |
$1,264.80
|
| Rate for Payer: Cash Price |
$2,529.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,055.30
|
|
|
THERMAGE ABDOMEN - LOWER
|
Professional
|
Both
|
$2,040.00
|
|
|
Service Code
|
HCPCS 00149
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$1,326.00 |
| Rate for Payer: Aetna Medicare |
$1,020.00
|
| Rate for Payer: BCBS Complete |
$816.00
|
| Rate for Payer: Cash Price |
$1,632.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,326.00
|
|
|
THERMAGE ARMS - 1 ARM
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00145
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
|
|
THERMAGE ARMS - BILATERAL
|
Professional
|
Both
|
$2,142.00
|
|
|
Service Code
|
HCPCS 00146
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$856.80 |
| Max. Negotiated Rate |
$1,392.30 |
| Rate for Payer: Aetna Medicare |
$1,071.00
|
| Rate for Payer: BCBS Complete |
$856.80
|
| Rate for Payer: Cash Price |
$1,713.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,392.30
|
|
|
THERMAGE EYES
|
Professional
|
Both
|
$969.00
|
|
|
Service Code
|
HCPCS 00140
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$387.60 |
| Max. Negotiated Rate |
$629.85 |
| Rate for Payer: Aetna Medicare |
$484.50
|
| Rate for Payer: BCBS Complete |
$387.60
|
| Rate for Payer: Cash Price |
$775.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$629.85
|
|
|
THERMAGE FACE
|
Professional
|
Both
|
$2,040.00
|
|
|
Service Code
|
HCPCS 00139
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$1,326.00 |
| Rate for Payer: Aetna Medicare |
$1,020.00
|
| Rate for Payer: BCBS Complete |
$816.00
|
| Rate for Payer: Cash Price |
$1,632.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,326.00
|
|
|
THERMAGE FACE & EYES
|
Professional
|
Both
|
$2,754.00
|
|
|
Service Code
|
HCPCS 00142
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,101.60 |
| Max. Negotiated Rate |
$1,790.10 |
| Rate for Payer: Aetna Medicare |
$1,377.00
|
| Rate for Payer: BCBS Complete |
$1,101.60
|
| Rate for Payer: Cash Price |
$2,203.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,790.10
|
|
|
THERMAGE FACE & NECK
|
Professional
|
Both
|
$2,856.00
|
|
|
Service Code
|
HCPCS 00143
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,142.40 |
| Max. Negotiated Rate |
$1,856.40 |
| Rate for Payer: Aetna Medicare |
$1,428.00
|
| Rate for Payer: BCBS Complete |
$1,142.40
|
| Rate for Payer: Cash Price |
$2,284.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,856.40
|
|
|
THERMAGE FACE, NECK, & EYES
|
Professional
|
Both
|
$3,570.00
|
|
|
Service Code
|
HCPCS 00144
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,428.00 |
| Max. Negotiated Rate |
$2,320.50 |
| Rate for Payer: Aetna Medicare |
$1,785.00
|
| Rate for Payer: BCBS Complete |
$1,428.00
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,320.50
|
|
|
THERMAGE KNEES - BILATERAL
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00151
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
|
