|
ROSUVASTATIN 5 MG TABLET
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 00781540092
|
| Hospital Charge Code |
36612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.05 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.50
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Advantage |
$155.61
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.72
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: Priority Health SBD |
$140.05
|
|
|
ROSUVASTATIN 5 MG TABLET
|
Facility
|
OP
|
$93.06
|
|
|
Service Code
|
NDC 68462026190
|
| Hospital Charge Code |
36612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.57 |
| Max. Negotiated Rate |
$83.75 |
| Rate for Payer: Aetna Commercial |
$79.10
|
| Rate for Payer: Aetna Medicare |
$46.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.49
|
| Rate for Payer: BCBS Complete |
$37.22
|
| Rate for Payer: Cash Price |
$74.45
|
| Rate for Payer: Cofinity Advantage |
$65.14
|
| Rate for Payer: Cofinity Commercial |
$80.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.45
|
| Rate for Payer: Healthscope Commercial |
$83.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$69.80
|
| Rate for Payer: PHP Commercial |
$79.10
|
| Rate for Payer: Priority Health SBD |
$58.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.49
|
| Rate for Payer: UHC Core |
$48.48
|
| Rate for Payer: UHC Exchange |
$36.57
|
|
|
ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH
|
Facility
|
OP
|
$3,050.17
|
|
|
Service Code
|
NDC 50474080203
|
| Hospital Charge Code |
82100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,198.72 |
| Max. Negotiated Rate |
$2,745.15 |
| Rate for Payer: Aetna Commercial |
$2,592.64
|
| Rate for Payer: Aetna Medicare |
$1,525.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,982.61
|
| Rate for Payer: BCBS Complete |
$1,220.07
|
| Rate for Payer: Cash Price |
$2,440.14
|
| Rate for Payer: Cofinity Advantage |
$2,135.12
|
| Rate for Payer: Cofinity Commercial |
$2,623.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,440.14
|
| Rate for Payer: Healthscope Commercial |
$2,745.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,440.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,592.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,287.63
|
| Rate for Payer: PHP Commercial |
$2,592.64
|
| Rate for Payer: Priority Health SBD |
$1,921.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,982.61
|
| Rate for Payer: UHC Core |
$1,589.14
|
| Rate for Payer: UHC Exchange |
$1,198.72
|
|
|
ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH
|
Facility
|
IP
|
$3,050.17
|
|
|
Service Code
|
NDC 50474080203
|
| Hospital Charge Code |
82100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,921.61 |
| Max. Negotiated Rate |
$2,745.15 |
| Rate for Payer: Aetna Commercial |
$2,592.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,982.61
|
| Rate for Payer: Cash Price |
$2,440.14
|
| Rate for Payer: Cofinity Advantage |
$2,135.12
|
| Rate for Payer: Cofinity Commercial |
$2,623.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,440.14
|
| Rate for Payer: Healthscope Commercial |
$2,745.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,592.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,287.63
|
| Rate for Payer: PHP Commercial |
$2,592.64
|
| Rate for Payer: Priority Health SBD |
$1,921.61
|
|
|
RUFINAMIDE 400 MG TABLET
|
Facility
|
OP
|
$1,394.61
|
|
|
Service Code
|
NDC 59651061708
|
| Hospital Charge Code |
95692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$548.08 |
| Max. Negotiated Rate |
$1,255.15 |
| Rate for Payer: Aetna Commercial |
$1,185.42
|
| Rate for Payer: Aetna Medicare |
$697.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$906.50
|
| Rate for Payer: BCBS Complete |
$557.84
|
| Rate for Payer: Cash Price |
$1,115.69
|
| Rate for Payer: Cofinity Advantage |
$976.23
|
| Rate for Payer: Cofinity Commercial |
$1,199.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,115.69
|
| Rate for Payer: Healthscope Commercial |
$1,255.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,115.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,185.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,045.96
|
| Rate for Payer: PHP Commercial |
$1,185.42
|
| Rate for Payer: Priority Health SBD |
$878.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$906.50
|
| Rate for Payer: UHC Core |
$726.59
|
| Rate for Payer: UHC Exchange |
$548.08
|
|
|
RUFINAMIDE 400 MG TABLET
|
Facility
|
IP
|
$1,394.61
|
|
|
Service Code
|
NDC 59651061708
|
| Hospital Charge Code |
95692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$878.60 |
| Max. Negotiated Rate |
$1,255.15 |
| Rate for Payer: Aetna Commercial |
$1,185.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$906.50
|
| Rate for Payer: Cash Price |
$1,115.69
|
| Rate for Payer: Cofinity Advantage |
$976.23
|
| Rate for Payer: Cofinity Commercial |
$1,199.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,115.69
|
| Rate for Payer: Healthscope Commercial |
$1,255.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,185.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,045.96
|
| Rate for Payer: PHP Commercial |
$1,185.42
|
| Rate for Payer: Priority Health SBD |
$878.60
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$11,740.32
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$10,566.29 |
| Rate for Payer: Aetna Commercial |
$9,979.27
|
| Rate for Payer: Aetna Medicare |
$38.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,631.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.00
|
| Rate for Payer: BCBS Complete |
$20.21
|
| Rate for Payer: BCBS MAPPO |
$36.80
|
| Rate for Payer: BCBS Trust/PPO |
$92.76
|
| Rate for Payer: BCN Commercial |
$92.76
|
| Rate for Payer: BCN Medicare Advantage |
$36.80
|
| Rate for Payer: Cash Price |
$9,392.26
|
| Rate for Payer: Cash Price |
$9,392.26
|
| Rate for Payer: Cofinity Advantage |
$8,218.22
|
| Rate for Payer: Cofinity Commercial |
$10,096.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,392.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$36.80
|
| Rate for Payer: Healthscope Commercial |
$10,566.29
|
| Rate for Payer: Mclaren Medicaid |
$19.25
|
| Rate for Payer: Mclaren Medicare |
$36.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$38.64
|
| Rate for Payer: Meridian Medicaid |
$38.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.32
|
| Rate for Payer: Molina Medicare/Medicaid |
$40.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,979.27
|
| Rate for Payer: Nomi Health Commercial |
$110.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,805.24
|
| Rate for Payer: PACE Medicare |
$34.96
|
| Rate for Payer: PACE SWMI |
$36.80
|
| Rate for Payer: PHP Commercial |
$9,979.27
|
| Rate for Payer: PHP Medicare Advantage |
$36.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.25
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$114.41
|
| Rate for Payer: Priority Health Medicare |
$36.80
|
| Rate for Payer: Priority Health SBD |
$7,396.40
|
| Rate for Payer: Priority Health Tiered Network |
$91.53
|
| Rate for Payer: Railroad Medicare Medicare |
$36.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.02
|
| Rate for Payer: UHC Core |
$61.02
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$36.80
|
| Rate for Payer: UHC Exchange |
$61.02
|
| Rate for Payer: UHC Medicaid |
$19.25
|
| Rate for Payer: UHCCP Medicaid |
$19.25
|
| Rate for Payer: VA VA |
$36.80
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$11,740.32
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,396.40 |
| Max. Negotiated Rate |
$10,566.29 |
| Rate for Payer: Aetna Commercial |
$9,979.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,631.21
|
| Rate for Payer: Cash Price |
$9,392.26
|
| Rate for Payer: Cofinity Advantage |
$8,218.22
|
| Rate for Payer: Cofinity Commercial |
$10,096.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,392.26
|
| Rate for Payer: Healthscope Commercial |
$10,566.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,979.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,805.24
|
| Rate for Payer: PHP Commercial |
$9,979.27
|
| Rate for Payer: Priority Health SBD |
$7,396.40
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
OP
|
$1,138.76
|
|
|
Service Code
|
NDC 67877070751
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$447.53 |
| Max. Negotiated Rate |
$1,024.88 |
| Rate for Payer: Aetna Commercial |
$967.95
|
| Rate for Payer: Aetna Medicare |
$569.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$740.19
|
| Rate for Payer: BCBS Complete |
$455.50
|
| Rate for Payer: Cash Price |
$911.01
|
| Rate for Payer: Cofinity Advantage |
$797.13
|
| Rate for Payer: Cofinity Commercial |
$979.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$911.01
|
| Rate for Payer: Healthscope Commercial |
$1,024.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$911.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$967.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$854.07
|
| Rate for Payer: PHP Commercial |
$967.95
|
| Rate for Payer: Priority Health SBD |
$717.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$740.19
|
| Rate for Payer: UHC Core |
$593.29
|
| Rate for Payer: UHC Exchange |
$447.53
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
OP
|
$2,499.50
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$982.30 |
| Max. Negotiated Rate |
$2,249.55 |
| Rate for Payer: Aetna Commercial |
$2,124.57
|
| Rate for Payer: Aetna Medicare |
$1,249.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.67
|
| Rate for Payer: BCBS Complete |
$999.80
|
| Rate for Payer: Cash Price |
$1,999.60
|
| Rate for Payer: Cofinity Advantage |
$1,749.65
|
| Rate for Payer: Cofinity Commercial |
$2,149.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.60
|
| Rate for Payer: Healthscope Commercial |
$2,249.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,999.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.62
|
| Rate for Payer: PHP Commercial |
$2,124.57
|
| Rate for Payer: Priority Health SBD |
$1,574.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,624.67
|
| Rate for Payer: UHC Core |
$1,302.24
|
| Rate for Payer: UHC Exchange |
$982.30
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$424.23
|
|
|
Service Code
|
NDC 72205028060
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.26 |
| Max. Negotiated Rate |
$381.81 |
| Rate for Payer: Aetna Commercial |
$360.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.75
|
| Rate for Payer: Cash Price |
$339.38
|
| Rate for Payer: Cofinity Advantage |
$296.96
|
| Rate for Payer: Cofinity Commercial |
$364.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.38
|
| Rate for Payer: Healthscope Commercial |
$381.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$318.17
|
| Rate for Payer: PHP Commercial |
$360.60
|
| Rate for Payer: Priority Health SBD |
$267.26
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$2,499.50
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,574.68 |
| Max. Negotiated Rate |
$2,249.55 |
| Rate for Payer: Aetna Commercial |
$2,124.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.67
|
| Rate for Payer: Cash Price |
$1,999.60
|
| Rate for Payer: Cofinity Advantage |
$1,749.65
|
| Rate for Payer: Cofinity Commercial |
$2,149.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.60
|
| Rate for Payer: Healthscope Commercial |
$2,249.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.62
|
| Rate for Payer: PHP Commercial |
$2,124.57
|
| Rate for Payer: Priority Health SBD |
$1,574.68
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
OP
|
$424.23
|
|
|
Service Code
|
NDC 72205028060
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.72 |
| Max. Negotiated Rate |
$381.81 |
| Rate for Payer: Aetna Commercial |
$360.60
|
| Rate for Payer: Aetna Medicare |
$212.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.75
|
| Rate for Payer: BCBS Complete |
$169.69
|
| Rate for Payer: Cash Price |
$339.38
|
| Rate for Payer: Cofinity Advantage |
$296.96
|
| Rate for Payer: Cofinity Commercial |
$364.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.38
|
| Rate for Payer: Healthscope Commercial |
$381.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$339.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$318.17
|
| Rate for Payer: PHP Commercial |
$360.60
|
| Rate for Payer: Priority Health SBD |
$267.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.75
|
| Rate for Payer: UHC Core |
$221.02
|
| Rate for Payer: UHC Exchange |
$166.72
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$1,138.76
|
|
|
Service Code
|
NDC 67877070751
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$717.42 |
| Max. Negotiated Rate |
$1,024.88 |
| Rate for Payer: Aetna Commercial |
$967.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$740.19
|
| Rate for Payer: Cash Price |
$911.01
|
| Rate for Payer: Cofinity Advantage |
$797.13
|
| Rate for Payer: Cofinity Commercial |
$979.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$911.01
|
| Rate for Payer: Healthscope Commercial |
$1,024.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$967.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$854.07
|
| Rate for Payer: PHP Commercial |
$967.95
|
| Rate for Payer: Priority Health SBD |
$717.42
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
IP
|
$2,499.50
|
|
|
Service Code
|
NDC 00078077720
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,574.68 |
| Max. Negotiated Rate |
$2,249.55 |
| Rate for Payer: Aetna Commercial |
$2,124.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.67
|
| Rate for Payer: Cash Price |
$1,999.60
|
| Rate for Payer: Cofinity Advantage |
$1,749.65
|
| Rate for Payer: Cofinity Commercial |
$2,149.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.60
|
| Rate for Payer: Healthscope Commercial |
$2,249.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.62
|
| Rate for Payer: PHP Commercial |
$2,124.57
|
| Rate for Payer: Priority Health SBD |
$1,574.68
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
OP
|
$2,499.50
|
|
|
Service Code
|
NDC 00078077720
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$982.30 |
| Max. Negotiated Rate |
$2,249.55 |
| Rate for Payer: Aetna Commercial |
$2,124.57
|
| Rate for Payer: Aetna Medicare |
$1,249.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.67
|
| Rate for Payer: BCBS Complete |
$999.80
|
| Rate for Payer: Cash Price |
$1,999.60
|
| Rate for Payer: Cofinity Advantage |
$1,749.65
|
| Rate for Payer: Cofinity Commercial |
$2,149.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.60
|
| Rate for Payer: Healthscope Commercial |
$2,249.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,999.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.62
|
| Rate for Payer: PHP Commercial |
$2,124.57
|
| Rate for Payer: Priority Health SBD |
$1,574.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,624.67
|
| Rate for Payer: UHC Core |
$1,302.24
|
| Rate for Payer: UHC Exchange |
$982.30
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
OP
|
$424.23
|
|
|
Service Code
|
NDC 72205028160
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.72 |
| Max. Negotiated Rate |
$381.81 |
| Rate for Payer: Aetna Commercial |
$360.60
|
| Rate for Payer: Aetna Medicare |
$212.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.75
|
| Rate for Payer: BCBS Complete |
$169.69
|
| Rate for Payer: Cash Price |
$339.38
|
| Rate for Payer: Cofinity Advantage |
$296.96
|
| Rate for Payer: Cofinity Commercial |
$364.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.38
|
| Rate for Payer: Healthscope Commercial |
$381.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$339.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$318.17
|
| Rate for Payer: PHP Commercial |
$360.60
|
| Rate for Payer: Priority Health SBD |
$267.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.75
|
| Rate for Payer: UHC Core |
$221.02
|
| Rate for Payer: UHC Exchange |
$166.72
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
IP
|
$424.23
|
|
|
Service Code
|
NDC 72205028160
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.26 |
| Max. Negotiated Rate |
$381.81 |
| Rate for Payer: Aetna Commercial |
$360.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.75
|
| Rate for Payer: Cash Price |
$339.38
|
| Rate for Payer: Cofinity Advantage |
$296.96
|
| Rate for Payer: Cofinity Commercial |
$364.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.38
|
| Rate for Payer: Healthscope Commercial |
$381.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$318.17
|
| Rate for Payer: PHP Commercial |
$360.60
|
| Rate for Payer: Priority Health SBD |
$267.26
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
OP
|
$2,499.50
|
|
|
Service Code
|
NDC 00078069620
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$982.30 |
| Max. Negotiated Rate |
$2,249.55 |
| Rate for Payer: Aetna Commercial |
$2,124.57
|
| Rate for Payer: Aetna Medicare |
$1,249.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.67
|
| Rate for Payer: BCBS Complete |
$999.80
|
| Rate for Payer: Cash Price |
$1,999.60
|
| Rate for Payer: Cofinity Advantage |
$1,749.65
|
| Rate for Payer: Cofinity Commercial |
$2,149.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.60
|
| Rate for Payer: Healthscope Commercial |
$2,249.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,999.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.62
|
| Rate for Payer: PHP Commercial |
$2,124.57
|
| Rate for Payer: Priority Health SBD |
$1,574.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,624.67
|
| Rate for Payer: UHC Core |
$1,302.24
|
| Rate for Payer: UHC Exchange |
$982.30
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
IP
|
$424.23
|
|
|
Service Code
|
NDC 72205028260
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.26 |
| Max. Negotiated Rate |
$381.81 |
| Rate for Payer: Aetna Commercial |
$360.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.75
|
| Rate for Payer: Cash Price |
$339.38
|
| Rate for Payer: Cofinity Advantage |
$296.96
|
| Rate for Payer: Cofinity Commercial |
$364.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.38
|
| Rate for Payer: Healthscope Commercial |
$381.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$318.17
|
| Rate for Payer: PHP Commercial |
$360.60
|
| Rate for Payer: Priority Health SBD |
$267.26
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
IP
|
$2,499.50
|
|
|
Service Code
|
NDC 00078069620
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,574.68 |
| Max. Negotiated Rate |
$2,249.55 |
| Rate for Payer: Aetna Commercial |
$2,124.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.67
|
| Rate for Payer: Cash Price |
$1,999.60
|
| Rate for Payer: Cofinity Advantage |
$1,749.65
|
| Rate for Payer: Cofinity Commercial |
$2,149.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.60
|
| Rate for Payer: Healthscope Commercial |
$2,249.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.62
|
| Rate for Payer: PHP Commercial |
$2,124.57
|
| Rate for Payer: Priority Health SBD |
$1,574.68
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
OP
|
$424.23
|
|
|
Service Code
|
NDC 72205028260
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.72 |
| Max. Negotiated Rate |
$381.81 |
| Rate for Payer: Aetna Commercial |
$360.60
|
| Rate for Payer: Aetna Medicare |
$212.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.75
|
| Rate for Payer: BCBS Complete |
$169.69
|
| Rate for Payer: Cash Price |
$339.38
|
| Rate for Payer: Cofinity Advantage |
$296.96
|
| Rate for Payer: Cofinity Commercial |
$364.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.38
|
| Rate for Payer: Healthscope Commercial |
$381.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$339.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$318.17
|
| Rate for Payer: PHP Commercial |
$360.60
|
| Rate for Payer: Priority Health SBD |
$267.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.75
|
| Rate for Payer: UHC Core |
$221.02
|
| Rate for Payer: UHC Exchange |
$166.72
|
|
|
SALIVARY GLAND PROCEDURES
|
Facility
|
IP
|
$22,787.69
|
|
|
Service Code
|
MSDRG 139
|
| Min. Negotiated Rate |
$9,622.33 |
| Max. Negotiated Rate |
$22,787.69 |
| Rate for Payer: Aetna Medicare |
$10,533.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,660.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,660.96
|
| Rate for Payer: BCBS MAPPO |
$10,128.77
|
| Rate for Payer: BCBS Trust/PPO |
$22,787.69
|
| Rate for Payer: BCN Commercial |
$22,787.69
|
| Rate for Payer: BCN Medicare Advantage |
$10,128.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,128.77
|
| Rate for Payer: Mclaren Medicare |
$10,128.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10,635.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,648.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$11,141.65
|
| Rate for Payer: Nomi Health Commercial |
$15,590.94
|
| Rate for Payer: PACE Medicare |
$9,622.33
|
| Rate for Payer: PACE SWMI |
$10,128.77
|
| Rate for Payer: PHP Medicare Advantage |
$10,128.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$19,922.13
|
| Rate for Payer: Priority Health Medicare |
$10,128.77
|
| Rate for Payer: Priority Health Tiered Network |
$15,937.70
|
| Rate for Payer: Railroad Medicare Medicare |
$10,128.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,700.18
|
| Rate for Payer: UHC Core |
$16,481.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$10,128.77
|
| Rate for Payer: UHC Exchange |
$13,460.18
|
| Rate for Payer: VA VA |
$10,128.77
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
IP
|
$24.97
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Advantage |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.73
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health SBD |
$15.73
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
OP
|
$24.97
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.81 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna Medicare |
$12.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: BCBS Complete |
$9.99
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Advantage |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.73
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health SBD |
$15.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.23
|
| Rate for Payer: UHC Core |
$13.01
|
| Rate for Payer: UHC Exchange |
$9.81
|
|
