|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$183.02
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.21 |
| Max. Negotiated Rate |
$164.72 |
| Rate for Payer: Aetna Commercial |
$155.57
|
| Rate for Payer: Aetna Medicare |
$91.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.96
|
| Rate for Payer: BCBS Complete |
$73.21
|
| Rate for Payer: Cash Price |
$146.42
|
| Rate for Payer: Cofinity Commercial |
$128.11
|
| Rate for Payer: Cofinity Commercial |
$157.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.42
|
| Rate for Payer: Healthscope Commercial |
$164.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.57
|
| Rate for Payer: PHP Commercial |
$155.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.96
|
| Rate for Payer: Priority Health SBD |
$115.30
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.02 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$18.93
|
| Rate for Payer: Aetna Commercial |
$13.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$13.06
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$11.79
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$11.42
|
| Rate for Payer: Cofinity Commercial |
$14.04
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$15.59
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$14.69
|
| Rate for Payer: Healthscope Commercial |
$20.04
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$13.87
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.45
|
| Rate for Payer: Priority Health SBD |
$10.28
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$14.03
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: Priority Health SBD |
$14.00
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$16.85
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$15.16 |
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$13.87
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.93
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna Medicare |
$8.43
|
| Rate for Payer: Aetna Medicare |
$8.16
|
| Rate for Payer: Aetna Medicare |
$11.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: BCBS Complete |
$6.53
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: BCBS Complete |
$8.91
|
| Rate for Payer: BCBS Complete |
$6.74
|
| Rate for Payer: BCBS Complete |
$8.89
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$13.06
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Commercial |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$11.79
|
| Rate for Payer: Cofinity Commercial |
$14.04
|
| Rate for Payer: Cofinity Commercial |
$11.42
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$15.59
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.82
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$20.04
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Healthscope Commercial |
$14.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$13.87
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$18.93
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health SBD |
$14.03
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: Priority Health SBD |
$10.28
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: Priority Health SBD |
$14.02
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.17 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Aetna Commercial |
$135.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.35
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cofinity Commercial |
$111.30
|
| Rate for Payer: Cofinity Commercial |
$136.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.20
|
| Rate for Payer: Healthscope Commercial |
$143.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.15
|
| Rate for Payer: PHP Commercial |
$135.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.35
|
| Rate for Payer: Priority Health SBD |
$100.17
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.60 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Aetna Commercial |
$135.15
|
| Rate for Payer: Aetna Medicare |
$79.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.35
|
| Rate for Payer: BCBS Complete |
$63.60
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cofinity Commercial |
$111.30
|
| Rate for Payer: Cofinity Commercial |
$136.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.20
|
| Rate for Payer: Healthscope Commercial |
$143.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.15
|
| Rate for Payer: PHP Commercial |
$135.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.35
|
| Rate for Payer: Priority Health SBD |
$100.17
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.41 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.01
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$176.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health SBD |
$158.41
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$108.10
|
|
|
Service Code
|
NDC 10702000301
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.24 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna Medicare |
$54.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: BCBS Complete |
$43.24
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.27
|
| Rate for Payer: Priority Health SBD |
$68.10
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 10702000301
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.27
|
| Rate for Payer: Priority Health SBD |
$68.10
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.58 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna Medicare |
$125.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: BCBS Complete |
$100.58
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.01
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$176.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health SBD |
$158.41
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$1,107.61
|
|
|
Service Code
|
NDC 00713013212
|
| Hospital Charge Code |
6624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$697.79 |
| Max. Negotiated Rate |
$996.85 |
| Rate for Payer: Aetna Commercial |
$941.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$719.95
|
| Rate for Payer: Cash Price |
$886.09
|
| Rate for Payer: Cofinity Commercial |
$775.33
|
| Rate for Payer: Cofinity Commercial |
$952.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$775.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$886.09
|
| Rate for Payer: Healthscope Commercial |
$996.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$941.47
|
| Rate for Payer: PHP Commercial |
$941.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$719.95
|
| Rate for Payer: Priority Health SBD |
$697.79
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$1,107.61
|
|
|
Service Code
|
NDC 00713013212
|
| Hospital Charge Code |
6624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$443.04 |
| Max. Negotiated Rate |
$996.85 |
| Rate for Payer: Aetna Commercial |
$941.47
|
| Rate for Payer: Aetna Medicare |
$553.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$719.95
|
| Rate for Payer: BCBS Complete |
$443.04
|
| Rate for Payer: Cash Price |
$886.09
|
| Rate for Payer: Cofinity Commercial |
$775.33
|
| Rate for Payer: Cofinity Commercial |
$952.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$775.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$886.09
|
| Rate for Payer: Healthscope Commercial |
$996.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$941.47
|
| Rate for Payer: PHP Commercial |
$941.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$719.95
|
| Rate for Payer: Priority Health SBD |
$697.79
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$389.05
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.10 |
| Max. Negotiated Rate |
$350.14 |
| Rate for Payer: Aetna Commercial |
$330.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.88
|
| Rate for Payer: Cash Price |
$311.24
|
| Rate for Payer: Cofinity Commercial |
$272.33
|
| Rate for Payer: Cofinity Commercial |
$334.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$272.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.24
|
| Rate for Payer: Healthscope Commercial |
$350.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.69
|
| Rate for Payer: PHP Commercial |
$330.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.88
|
| Rate for Payer: Priority Health SBD |
$245.10
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$206.94
|
|
|
Service Code
|
NDC 00121092716
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.78 |
| Max. Negotiated Rate |
$186.25 |
| Rate for Payer: Aetna Commercial |
$175.90
|
| Rate for Payer: Aetna Medicare |
$103.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.51
|
| Rate for Payer: BCBS Complete |
$82.78
|
| Rate for Payer: Cash Price |
$165.55
|
| Rate for Payer: Cofinity Commercial |
$144.86
|
| Rate for Payer: Cofinity Commercial |
$177.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.55
|
| Rate for Payer: Healthscope Commercial |
$186.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.90
|
| Rate for Payer: PHP Commercial |
$175.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.51
|
| Rate for Payer: Priority Health SBD |
$130.37
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$206.94
|
|
|
Service Code
|
NDC 00121092716
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.37 |
| Max. Negotiated Rate |
$186.25 |
| Rate for Payer: Aetna Commercial |
$175.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.51
|
| Rate for Payer: Cash Price |
$165.55
|
| Rate for Payer: Cofinity Commercial |
$144.86
|
| Rate for Payer: Cofinity Commercial |
$177.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.55
|
| Rate for Payer: Healthscope Commercial |
$186.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.90
|
| Rate for Payer: PHP Commercial |
$175.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.51
|
| Rate for Payer: Priority Health SBD |
$130.37
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$389.05
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.62 |
| Max. Negotiated Rate |
$350.14 |
| Rate for Payer: Aetna Commercial |
$330.69
|
| Rate for Payer: Aetna Medicare |
$194.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.88
|
| Rate for Payer: BCBS Complete |
$155.62
|
| Rate for Payer: Cash Price |
$311.24
|
| Rate for Payer: Cofinity Commercial |
$272.33
|
| Rate for Payer: Cofinity Commercial |
$334.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$272.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.24
|
| Rate for Payer: Healthscope Commercial |
$350.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.69
|
| Rate for Payer: PHP Commercial |
$330.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.88
|
| Rate for Payer: Priority Health SBD |
$245.10
|
|
|
PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$766.97
|
|
|
Service Code
|
NDC 60432060416
|
| Hospital Charge Code |
11145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$483.19 |
| Max. Negotiated Rate |
$690.27 |
| Rate for Payer: Aetna Commercial |
$651.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$498.53
|
| Rate for Payer: Cash Price |
$613.58
|
| Rate for Payer: Cofinity Commercial |
$536.88
|
| Rate for Payer: Cofinity Commercial |
$659.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$536.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$613.58
|
| Rate for Payer: Healthscope Commercial |
$690.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$651.92
|
| Rate for Payer: PHP Commercial |
$651.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$498.53
|
| Rate for Payer: Priority Health SBD |
$483.19
|
|
|
PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$766.97
|
|
|
Service Code
|
NDC 60432060416
|
| Hospital Charge Code |
11145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.79 |
| Max. Negotiated Rate |
$690.27 |
| Rate for Payer: Aetna Commercial |
$651.92
|
| Rate for Payer: Aetna Medicare |
$383.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$498.53
|
| Rate for Payer: BCBS Complete |
$306.79
|
| Rate for Payer: Cash Price |
$613.58
|
| Rate for Payer: Cofinity Commercial |
$536.88
|
| Rate for Payer: Cofinity Commercial |
$659.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$536.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$613.58
|
| Rate for Payer: Healthscope Commercial |
$690.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$651.92
|
| Rate for Payer: PHP Commercial |
$651.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$498.53
|
| Rate for Payer: Priority Health SBD |
$483.19
|
|
|
PR OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX
|
Professional
|
Both
|
$2,127.00
|
|
|
Service Code
|
HCPCS 49255
|
| Min. Negotiated Rate |
$767.78 |
| Max. Negotiated Rate |
$1,420.39 |
| Rate for Payer: Aetna Commercial |
$1,028.83
|
| Rate for Payer: Aetna Medicare |
$798.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,105.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,028.83
|
| Rate for Payer: BCBS Complete |
$850.80
|
| Rate for Payer: BCBS MAPPO |
$767.78
|
| Rate for Payer: BCN Medicare Advantage |
$767.78
|
| Rate for Payer: Cash Price |
$1,701.60
|
| Rate for Payer: Cash Price |
$1,701.60
|
| Rate for Payer: Cofinity Commercial |
$1,105.60
|
| Rate for Payer: Cofinity Commercial |
$1,028.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$767.78
|
| Rate for Payer: Healthscope Commercial |
$1,420.39
|
| Rate for Payer: Healthscope Commercial |
$1,228.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$806.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,382.55
|
| Rate for Payer: Nomi Health Commercial |
$921.34
|
| Rate for Payer: PACE SWMI |
$767.78
|
| Rate for Payer: PHP Medicare Advantage |
$767.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,382.55
|
| Rate for Payer: Priority Health Medicare |
$767.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$767.78
|
| Rate for Payer: UHC Medicare Advantage |
$767.78
|
|
|
PROMOTE BOLUS FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 98716026356
|
| Hospital Charge Code |
200092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: BCBS Complete |
$3.84
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
PROMOTE BOLUS FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 98716026356
|
| Hospital Charge Code |
200092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
PROMOTE BOLUS FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 98716016356
|
| Hospital Charge Code |
200092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
PROMOTE BOLUS FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 98716016356
|
| Hospital Charge Code |
200092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: BCBS Complete |
$3.84
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
PROMOTE CONTINUOUS FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 98716016356
|
| Hospital Charge Code |
180296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
PROMOTE CONTINUOUS FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 98716016356
|
| Hospital Charge Code |
180296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: BCBS Complete |
$3.84
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
PROMOTE CONTINUOUS FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 98716026356
|
| Hospital Charge Code |
180296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
