|
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$671.51
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
107671
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$423.05 |
| Max. Negotiated Rate |
$604.36 |
| Rate for Payer: Aetna Commercial |
$570.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$436.48
|
| Rate for Payer: Cash Price |
$537.21
|
| Rate for Payer: Cofinity Commercial |
$470.06
|
| Rate for Payer: Cofinity Commercial |
$577.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$470.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$537.21
|
| Rate for Payer: Healthscope Commercial |
$604.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$570.78
|
| Rate for Payer: PHP Commercial |
$570.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$436.48
|
| Rate for Payer: Priority Health SBD |
$423.05
|
|
|
CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$671.51
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
107671
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$604.36 |
| Rate for Payer: Aetna Commercial |
$570.78
|
| Rate for Payer: Aetna Medicare |
$4.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$436.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.29
|
| Rate for Payer: BCBS Complete |
$2.38
|
| Rate for Payer: BCBS MAPPO |
$4.23
|
| Rate for Payer: BCN Medicare Advantage |
$4.23
|
| Rate for Payer: Cash Price |
$537.21
|
| Rate for Payer: Cash Price |
$537.21
|
| Rate for Payer: Cofinity Commercial |
$577.50
|
| Rate for Payer: Cofinity Commercial |
$470.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$470.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$537.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.23
|
| Rate for Payer: Healthscope Commercial |
$604.36
|
| Rate for Payer: Mclaren Medicaid |
$2.27
|
| Rate for Payer: Mclaren Medicare |
$4.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.44
|
| Rate for Payer: Meridian Medicaid |
$2.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$570.78
|
| Rate for Payer: PACE Medicare |
$4.02
|
| Rate for Payer: PACE SWMI |
$4.23
|
| Rate for Payer: PHP Commercial |
$570.78
|
| Rate for Payer: PHP Medicare Advantage |
$4.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$436.48
|
| Rate for Payer: Priority Health Medicare |
$4.23
|
| Rate for Payer: Priority Health SBD |
$423.05
|
| Rate for Payer: Railroad Medicare Medicare |
$4.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.23
|
| Rate for Payer: UHC Medicare Advantage |
$4.23
|
| Rate for Payer: UHCCP Medicaid |
$2.38
|
| Rate for Payer: VA VA |
$4.23
|
|
|
CEFTAROLINE FOSAMIL 600 MG IV MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
OP
|
$671.51
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
301724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$604.36 |
| Rate for Payer: Aetna Commercial |
$570.78
|
| Rate for Payer: Aetna Medicare |
$4.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$436.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.29
|
| Rate for Payer: BCBS Complete |
$2.38
|
| Rate for Payer: BCBS MAPPO |
$4.23
|
| Rate for Payer: BCN Medicare Advantage |
$4.23
|
| Rate for Payer: Cash Price |
$537.21
|
| Rate for Payer: Cash Price |
$537.21
|
| Rate for Payer: Cofinity Commercial |
$577.50
|
| Rate for Payer: Cofinity Commercial |
$470.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$470.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$537.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.23
|
| Rate for Payer: Healthscope Commercial |
$604.36
|
| Rate for Payer: Mclaren Medicaid |
$2.27
|
| Rate for Payer: Mclaren Medicare |
$4.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.44
|
| Rate for Payer: Meridian Medicaid |
$2.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$570.78
|
| Rate for Payer: PACE Medicare |
$4.02
|
| Rate for Payer: PACE SWMI |
$4.23
|
| Rate for Payer: PHP Commercial |
$570.78
|
| Rate for Payer: PHP Medicare Advantage |
$4.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$436.48
|
| Rate for Payer: Priority Health Medicare |
$4.23
|
| Rate for Payer: Priority Health SBD |
$423.05
|
| Rate for Payer: Railroad Medicare Medicare |
$4.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.23
|
| Rate for Payer: UHC Medicare Advantage |
$4.23
|
| Rate for Payer: UHCCP Medicaid |
$2.38
|
| Rate for Payer: VA VA |
$4.23
|
|
|
CEFTAROLINE FOSAMIL 600 MG IV MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
IP
|
$671.51
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
301724
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$423.05 |
| Max. Negotiated Rate |
$604.36 |
| Rate for Payer: Aetna Commercial |
$570.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$436.48
|
| Rate for Payer: Cash Price |
$537.21
|
| Rate for Payer: Cofinity Commercial |
$470.06
|
| Rate for Payer: Cofinity Commercial |
$577.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$470.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$537.21
|
| Rate for Payer: Healthscope Commercial |
$604.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$570.78
|
| Rate for Payer: PHP Commercial |
$570.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$436.48
|
| Rate for Payer: Priority Health SBD |
$423.05
|
|
|
CEFTAROLINE FOSAMIL 60 MCG CUSTOM IV FOR DESENSITIZATION
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 09900000954
|
| Hospital Charge Code |
168966
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna Commercial |
$0.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.23
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cofinity Commercial |
$0.25
|
| Rate for Payer: Cofinity Commercial |
$0.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.28
|
| Rate for Payer: Healthscope Commercial |
$0.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.30
|
| Rate for Payer: PHP Commercial |
$0.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.23
|
| Rate for Payer: Priority Health SBD |
$0.22
|
|
|
CEFTAROLINE FOSAMIL 60 MCG CUSTOM IV FOR DESENSITIZATION
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 09900000954
|
| Hospital Charge Code |
168966
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna Commercial |
$0.30
|
| Rate for Payer: Aetna Medicare |
$0.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.23
|
| Rate for Payer: BCBS Complete |
$0.14
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cofinity Commercial |
$0.25
|
| Rate for Payer: Cofinity Commercial |
$0.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.28
|
| Rate for Payer: Healthscope Commercial |
$0.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.30
|
| Rate for Payer: PHP Commercial |
$0.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.23
|
| Rate for Payer: Priority Health SBD |
$0.22
|
|
|
CEFTAROLINE FOSAMIL 6 MCG CUSTOM IV FOR DESENSITIZATION
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 09900000957
|
| Hospital Charge Code |
180578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cofinity Commercial |
$0.04
|
| Rate for Payer: Cofinity Commercial |
$0.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.04
|
| Rate for Payer: Healthscope Commercial |
$0.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.04
|
| Rate for Payer: PHP Commercial |
$0.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.03
|
| Rate for Payer: Priority Health SBD |
$0.03
|
|
|
CEFTAROLINE FOSAMIL 6 MCG CUSTOM IV FOR DESENSITIZATION
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 09900000957
|
| Hospital Charge Code |
180578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Aetna Medicare |
$0.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.03
|
| Rate for Payer: BCBS Complete |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cofinity Commercial |
$0.04
|
| Rate for Payer: Cofinity Commercial |
$0.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.04
|
| Rate for Payer: Healthscope Commercial |
$0.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.04
|
| Rate for Payer: PHP Commercial |
$0.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.03
|
| Rate for Payer: Priority Health SBD |
$0.03
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$20.65
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
9474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.01 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health SBD |
$13.01
|
|
|
CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
9474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health SBD |
$13.01
|
|
|
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$37.25
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
9476
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.90 |
| Max. Negotiated Rate |
$33.52 |
| Rate for Payer: Aetna Commercial |
$31.66
|
| Rate for Payer: Aetna Commercial |
$24.51
|
| Rate for Payer: Aetna Medicare |
$14.42
|
| Rate for Payer: Aetna Medicare |
$18.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.75
|
| Rate for Payer: BCBS Complete |
$14.90
|
| Rate for Payer: BCBS Complete |
$11.54
|
| Rate for Payer: Cash Price |
$29.80
|
| Rate for Payer: Cash Price |
$23.07
|
| Rate for Payer: Cofinity Commercial |
$32.03
|
| Rate for Payer: Cofinity Commercial |
$20.19
|
| Rate for Payer: Cofinity Commercial |
$24.80
|
| Rate for Payer: Cofinity Commercial |
$26.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.80
|
| Rate for Payer: Healthscope Commercial |
$33.52
|
| Rate for Payer: Healthscope Commercial |
$25.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.51
|
| Rate for Payer: PHP Commercial |
$31.66
|
| Rate for Payer: PHP Commercial |
$24.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.21
|
| Rate for Payer: Priority Health SBD |
$18.17
|
| Rate for Payer: Priority Health SBD |
$23.47
|
|
|
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$37.25
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
9476
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.47 |
| Max. Negotiated Rate |
$33.52 |
| Rate for Payer: Aetna Commercial |
$31.66
|
| Rate for Payer: Aetna Commercial |
$24.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.21
|
| Rate for Payer: Cash Price |
$23.07
|
| Rate for Payer: Cash Price |
$29.80
|
| Rate for Payer: Cofinity Commercial |
$32.03
|
| Rate for Payer: Cofinity Commercial |
$26.07
|
| Rate for Payer: Cofinity Commercial |
$20.19
|
| Rate for Payer: Cofinity Commercial |
$24.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.80
|
| Rate for Payer: Healthscope Commercial |
$33.52
|
| Rate for Payer: Healthscope Commercial |
$25.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.66
|
| Rate for Payer: PHP Commercial |
$31.66
|
| Rate for Payer: PHP Commercial |
$24.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.21
|
| Rate for Payer: Priority Health SBD |
$18.17
|
| Rate for Payer: Priority Health SBD |
$23.47
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,174.32
|
|
|
Service Code
|
HCPCS J0714
|
| Hospital Charge Code |
161545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.14 |
| Max. Negotiated Rate |
$1,056.89 |
| Rate for Payer: Aetna Commercial |
$998.17
|
| Rate for Payer: Aetna Medicare |
$108.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$763.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$130.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$130.91
|
| Rate for Payer: BCBS Complete |
$58.94
|
| Rate for Payer: BCBS MAPPO |
$104.73
|
| Rate for Payer: BCN Medicare Advantage |
$104.73
|
| Rate for Payer: Cash Price |
$939.46
|
| Rate for Payer: Cash Price |
$939.46
|
| Rate for Payer: Cofinity Commercial |
$1,009.92
|
| Rate for Payer: Cofinity Commercial |
$822.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$822.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$939.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.73
|
| Rate for Payer: Healthscope Commercial |
$1,056.89
|
| Rate for Payer: Mclaren Medicaid |
$56.14
|
| Rate for Payer: Mclaren Medicare |
$104.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.97
|
| Rate for Payer: Meridian Medicaid |
$58.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$998.17
|
| Rate for Payer: PACE Medicare |
$99.49
|
| Rate for Payer: PACE SWMI |
$104.73
|
| Rate for Payer: PHP Commercial |
$998.17
|
| Rate for Payer: PHP Medicare Advantage |
$104.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$56.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$763.31
|
| Rate for Payer: Priority Health Medicare |
$104.73
|
| Rate for Payer: Priority Health SBD |
$739.82
|
| Rate for Payer: Railroad Medicare Medicare |
$104.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$294.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$104.73
|
| Rate for Payer: UHC Medicare Advantage |
$104.73
|
| Rate for Payer: UHCCP Medicaid |
$58.96
|
| Rate for Payer: VA VA |
$104.73
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,174.32
|
|
|
Service Code
|
HCPCS J0714
|
| Hospital Charge Code |
161545
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$739.82 |
| Max. Negotiated Rate |
$1,056.89 |
| Rate for Payer: Aetna Commercial |
$998.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$763.31
|
| Rate for Payer: Cash Price |
$939.46
|
| Rate for Payer: Cofinity Commercial |
$1,009.92
|
| Rate for Payer: Cofinity Commercial |
$822.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$822.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$939.46
|
| Rate for Payer: Healthscope Commercial |
$1,056.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$998.17
|
| Rate for Payer: PHP Commercial |
$998.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$763.31
|
| Rate for Payer: Priority Health SBD |
$739.82
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM IV MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
OP
|
$1,174.32
|
|
|
Service Code
|
HCPCS J0714
|
| Hospital Charge Code |
301756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.14 |
| Max. Negotiated Rate |
$1,056.89 |
| Rate for Payer: Aetna Commercial |
$998.17
|
| Rate for Payer: Aetna Medicare |
$108.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$763.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$130.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$130.91
|
| Rate for Payer: BCBS Complete |
$58.94
|
| Rate for Payer: BCBS MAPPO |
$104.73
|
| Rate for Payer: BCN Medicare Advantage |
$104.73
|
| Rate for Payer: Cash Price |
$939.46
|
| Rate for Payer: Cash Price |
$939.46
|
| Rate for Payer: Cofinity Commercial |
$822.02
|
| Rate for Payer: Cofinity Commercial |
$1,009.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$822.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$939.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.73
|
| Rate for Payer: Healthscope Commercial |
$1,056.89
|
| Rate for Payer: Mclaren Medicaid |
$56.14
|
| Rate for Payer: Mclaren Medicare |
$104.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.97
|
| Rate for Payer: Meridian Medicaid |
$58.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$998.17
|
| Rate for Payer: PACE Medicare |
$99.49
|
| Rate for Payer: PACE SWMI |
$104.73
|
| Rate for Payer: PHP Commercial |
$998.17
|
| Rate for Payer: PHP Medicare Advantage |
$104.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$56.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$763.31
|
| Rate for Payer: Priority Health Medicare |
$104.73
|
| Rate for Payer: Priority Health SBD |
$739.82
|
| Rate for Payer: Railroad Medicare Medicare |
$104.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$294.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$104.73
|
| Rate for Payer: UHC Medicare Advantage |
$104.73
|
| Rate for Payer: UHCCP Medicaid |
$58.96
|
| Rate for Payer: VA VA |
$104.73
|
|
|
CEFTAZIDIME-AVIBACTAM 2.5 GRAM IV MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
IP
|
$1,174.32
|
|
|
Service Code
|
HCPCS J0714
|
| Hospital Charge Code |
301756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$739.82 |
| Max. Negotiated Rate |
$1,056.89 |
| Rate for Payer: Aetna Commercial |
$998.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$763.31
|
| Rate for Payer: Cash Price |
$939.46
|
| Rate for Payer: Cofinity Commercial |
$1,009.92
|
| Rate for Payer: Cofinity Commercial |
$822.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$822.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$939.46
|
| Rate for Payer: Healthscope Commercial |
$1,056.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$998.17
|
| Rate for Payer: PHP Commercial |
$998.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$763.31
|
| Rate for Payer: Priority Health SBD |
$739.82
|
|
|
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$523.77
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
173413
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$471.39 |
| Rate for Payer: Aetna Commercial |
$445.20
|
| Rate for Payer: Aetna Medicare |
$9.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.34
|
| Rate for Payer: BCBS Complete |
$5.10
|
| Rate for Payer: BCBS MAPPO |
$9.07
|
| Rate for Payer: BCN Medicare Advantage |
$9.07
|
| Rate for Payer: Cash Price |
$419.02
|
| Rate for Payer: Cash Price |
$419.02
|
| Rate for Payer: Cofinity Commercial |
$450.44
|
| Rate for Payer: Cofinity Commercial |
$366.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.07
|
| Rate for Payer: Healthscope Commercial |
$471.39
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicare |
$9.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.52
|
| Rate for Payer: Meridian Medicaid |
$5.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.20
|
| Rate for Payer: PACE Medicare |
$8.62
|
| Rate for Payer: PACE SWMI |
$9.07
|
| Rate for Payer: PHP Commercial |
$445.20
|
| Rate for Payer: PHP Medicare Advantage |
$9.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.45
|
| Rate for Payer: Priority Health Medicare |
$9.07
|
| Rate for Payer: Priority Health SBD |
$329.98
|
| Rate for Payer: Railroad Medicare Medicare |
$9.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.07
|
| Rate for Payer: UHC Medicare Advantage |
$9.07
|
| Rate for Payer: UHCCP Medicaid |
$5.11
|
| Rate for Payer: VA VA |
$9.07
|
|
|
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$523.77
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
173413
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$471.39 |
| Rate for Payer: Aetna Commercial |
$445.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.45
|
| Rate for Payer: Cash Price |
$419.02
|
| Rate for Payer: Cofinity Commercial |
$366.64
|
| Rate for Payer: Cofinity Commercial |
$450.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.02
|
| Rate for Payer: Healthscope Commercial |
$471.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.20
|
| Rate for Payer: PHP Commercial |
$445.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.45
|
| Rate for Payer: Priority Health SBD |
$329.98
|
|
|
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM IV MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
OP
|
$523.77
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
301725
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$471.39 |
| Rate for Payer: Aetna Commercial |
$445.20
|
| Rate for Payer: Aetna Medicare |
$9.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.34
|
| Rate for Payer: BCBS Complete |
$5.10
|
| Rate for Payer: BCBS MAPPO |
$9.07
|
| Rate for Payer: BCN Medicare Advantage |
$9.07
|
| Rate for Payer: Cash Price |
$419.02
|
| Rate for Payer: Cash Price |
$419.02
|
| Rate for Payer: Cofinity Commercial |
$450.44
|
| Rate for Payer: Cofinity Commercial |
$366.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.07
|
| Rate for Payer: Healthscope Commercial |
$471.39
|
| Rate for Payer: Mclaren Medicaid |
$4.86
|
| Rate for Payer: Mclaren Medicare |
$9.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.52
|
| Rate for Payer: Meridian Medicaid |
$5.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.20
|
| Rate for Payer: PACE Medicare |
$8.62
|
| Rate for Payer: PACE SWMI |
$9.07
|
| Rate for Payer: PHP Commercial |
$445.20
|
| Rate for Payer: PHP Medicare Advantage |
$9.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.45
|
| Rate for Payer: Priority Health Medicare |
$9.07
|
| Rate for Payer: Priority Health SBD |
$329.98
|
| Rate for Payer: Railroad Medicare Medicare |
$9.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.07
|
| Rate for Payer: UHC Medicare Advantage |
$9.07
|
| Rate for Payer: UHCCP Medicaid |
$5.11
|
| Rate for Payer: VA VA |
$9.07
|
|
|
CEFTOLOZANE-TAZOBACTAM 1.5 GRAM IV MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
IP
|
$523.77
|
|
|
Service Code
|
HCPCS J0695
|
| Hospital Charge Code |
301725
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$471.39 |
| Rate for Payer: Aetna Commercial |
$445.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.45
|
| Rate for Payer: Cash Price |
$419.02
|
| Rate for Payer: Cofinity Commercial |
$366.64
|
| Rate for Payer: Cofinity Commercial |
$450.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.02
|
| Rate for Payer: Healthscope Commercial |
$471.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.20
|
| Rate for Payer: PHP Commercial |
$445.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.45
|
| Rate for Payer: Priority Health SBD |
$329.98
|
|
|
CEFTRIAXONE 100 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$2,175.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
78580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$870.00 |
| Max. Negotiated Rate |
$1,957.50 |
| Rate for Payer: Aetna Commercial |
$1,848.75
|
| Rate for Payer: Aetna Medicare |
$1,087.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,413.75
|
| Rate for Payer: BCBS Complete |
$870.00
|
| Rate for Payer: Cash Price |
$1,740.00
|
| Rate for Payer: Cofinity Commercial |
$1,522.50
|
| Rate for Payer: Cofinity Commercial |
$1,870.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,522.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,740.00
|
| Rate for Payer: Healthscope Commercial |
$1,957.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,848.75
|
| Rate for Payer: PHP Commercial |
$1,848.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,413.75
|
| Rate for Payer: Priority Health SBD |
$1,370.25
|
|
|
CEFTRIAXONE 100 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$2,175.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
78580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,370.25 |
| Max. Negotiated Rate |
$1,957.50 |
| Rate for Payer: Aetna Commercial |
$1,848.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,413.75
|
| Rate for Payer: Cash Price |
$1,740.00
|
| Rate for Payer: Cofinity Commercial |
$1,870.50
|
| Rate for Payer: Cofinity Commercial |
$1,522.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,522.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,740.00
|
| Rate for Payer: Healthscope Commercial |
$1,957.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,848.75
|
| Rate for Payer: PHP Commercial |
$1,848.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,413.75
|
| Rate for Payer: Priority Health SBD |
$1,370.25
|
|
|
CEFTRIAXONE 10 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$40.72
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
9491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.65 |
| Max. Negotiated Rate |
$36.65 |
| Rate for Payer: Aetna Commercial |
$34.61
|
| Rate for Payer: Aetna Commercial |
$33.78
|
| Rate for Payer: Aetna Commercial |
$58.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.01
|
| Rate for Payer: Cash Price |
$31.79
|
| Rate for Payer: Cash Price |
$55.40
|
| Rate for Payer: Cash Price |
$32.58
|
| Rate for Payer: Cofinity Commercial |
$27.82
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Cofinity Commercial |
$28.50
|
| Rate for Payer: Cofinity Commercial |
$35.02
|
| Rate for Payer: Cofinity Commercial |
$48.48
|
| Rate for Payer: Cofinity Commercial |
$59.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$28.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.40
|
| Rate for Payer: Healthscope Commercial |
$35.77
|
| Rate for Payer: Healthscope Commercial |
$36.65
|
| Rate for Payer: Healthscope Commercial |
$62.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.86
|
| Rate for Payer: PHP Commercial |
$34.61
|
| Rate for Payer: PHP Commercial |
$58.86
|
| Rate for Payer: PHP Commercial |
$33.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.83
|
| Rate for Payer: Priority Health SBD |
$43.63
|
| Rate for Payer: Priority Health SBD |
$25.65
|
| Rate for Payer: Priority Health SBD |
$25.04
|
|
|
CEFTRIAXONE 10 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$39.74
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
9491
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$35.77 |
| Rate for Payer: Aetna Commercial |
$33.78
|
| Rate for Payer: Aetna Commercial |
$58.86
|
| Rate for Payer: Aetna Commercial |
$34.61
|
| Rate for Payer: Aetna Medicare |
$34.62
|
| Rate for Payer: Aetna Medicare |
$19.87
|
| Rate for Payer: Aetna Medicare |
$20.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.47
|
| Rate for Payer: BCBS Complete |
$16.29
|
| Rate for Payer: BCBS Complete |
$15.90
|
| Rate for Payer: BCBS Complete |
$27.70
|
| Rate for Payer: Cash Price |
$55.40
|
| Rate for Payer: Cash Price |
$31.79
|
| Rate for Payer: Cash Price |
$32.58
|
| Rate for Payer: Cofinity Commercial |
$59.55
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Cofinity Commercial |
$27.82
|
| Rate for Payer: Cofinity Commercial |
$35.02
|
| Rate for Payer: Cofinity Commercial |
$28.50
|
| Rate for Payer: Cofinity Commercial |
$48.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$28.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.79
|
| Rate for Payer: Healthscope Commercial |
$36.65
|
| Rate for Payer: Healthscope Commercial |
$35.77
|
| Rate for Payer: Healthscope Commercial |
$62.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.78
|
| Rate for Payer: PHP Commercial |
$34.61
|
| Rate for Payer: PHP Commercial |
$33.78
|
| Rate for Payer: PHP Commercial |
$58.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.47
|
| Rate for Payer: Priority Health SBD |
$43.63
|
| Rate for Payer: Priority Health SBD |
$25.65
|
| Rate for Payer: Priority Health SBD |
$25.04
|
|
|
CEFTRIAXONE 1 GM IV SYRINGE
|
Facility
|
OP
|
$17.98
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
500542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.19 |
| Max. Negotiated Rate |
$16.18 |
| Rate for Payer: Aetna Commercial |
$15.28
|
| Rate for Payer: Aetna Medicare |
$8.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.69
|
| Rate for Payer: BCBS Complete |
$7.19
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cofinity Commercial |
$12.59
|
| Rate for Payer: Cofinity Commercial |
$15.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.38
|
| Rate for Payer: Healthscope Commercial |
$16.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.28
|
| Rate for Payer: PHP Commercial |
$15.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.69
|
| Rate for Payer: Priority Health SBD |
$11.33
|
|
