|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,511.09
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
180872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$4,959.98 |
| Rate for Payer: Aetna Commercial |
$4,684.43
|
| Rate for Payer: Aetna Medicare |
$13.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,582.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.95
|
| Rate for Payer: BCBS Complete |
$7.18
|
| Rate for Payer: BCBS MAPPO |
$12.76
|
| Rate for Payer: BCBS Trust/PPO |
$36.62
|
| Rate for Payer: BCN Commercial |
$36.62
|
| Rate for Payer: BCN Medicare Advantage |
$12.76
|
| Rate for Payer: Cash Price |
$4,408.87
|
| Rate for Payer: Cash Price |
$4,408.87
|
| Rate for Payer: Cofinity Commercial |
$4,739.54
|
| Rate for Payer: Cofinity Commercial |
$3,857.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,857.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,408.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.76
|
| Rate for Payer: Healthscope Commercial |
$4,959.98
|
| Rate for Payer: Mclaren Medicaid |
$6.84
|
| Rate for Payer: Mclaren Medicare |
$12.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.40
|
| Rate for Payer: Meridian Medicaid |
$7.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,684.43
|
| Rate for Payer: Nomi Health Commercial |
$38.28
|
| Rate for Payer: PACE Medicare |
$12.12
|
| Rate for Payer: PACE SWMI |
$12.76
|
| Rate for Payer: PHP Commercial |
$4,684.43
|
| Rate for Payer: PHP Medicare Advantage |
$12.76
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,582.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.31
|
| Rate for Payer: Priority Health Medicare |
$12.76
|
| Rate for Payer: Priority Health Narrow Network |
$29.85
|
| Rate for Payer: Priority Health SBD |
$3,471.99
|
| Rate for Payer: Railroad Medicare Medicare |
$12.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.76
|
| Rate for Payer: UHC Medicare Advantage |
$12.76
|
| Rate for Payer: UHCCP Medicaid |
$7.18
|
| Rate for Payer: VA VA |
$12.76
|
|
|
USTEKINUMAB 45 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$36,949.51
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
119468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.55 |
| Max. Negotiated Rate |
$33,254.56 |
| Rate for Payer: Aetna Commercial |
$31,407.08
|
| Rate for Payer: Aetna Medicare |
$162.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24,017.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$194.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$194.85
|
| Rate for Payer: BCBS Complete |
$87.73
|
| Rate for Payer: BCBS MAPPO |
$155.88
|
| Rate for Payer: BCBS Trust/PPO |
$451.72
|
| Rate for Payer: BCN Commercial |
$451.72
|
| Rate for Payer: BCN Medicare Advantage |
$155.88
|
| Rate for Payer: Cash Price |
$29,559.61
|
| Rate for Payer: Cash Price |
$29,559.61
|
| Rate for Payer: Cofinity Commercial |
$31,776.58
|
| Rate for Payer: Cofinity Commercial |
$25,864.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$25,864.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29,559.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$155.88
|
| Rate for Payer: Healthscope Commercial |
$33,254.56
|
| Rate for Payer: Mclaren Medicaid |
$83.55
|
| Rate for Payer: Mclaren Medicare |
$155.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$163.67
|
| Rate for Payer: Meridian Medicaid |
$87.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$179.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31,407.08
|
| Rate for Payer: Nomi Health Commercial |
$467.64
|
| Rate for Payer: PACE Medicare |
$148.09
|
| Rate for Payer: PACE SWMI |
$155.88
|
| Rate for Payer: PHP Commercial |
$31,407.08
|
| Rate for Payer: PHP Medicare Advantage |
$155.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$83.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24,017.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$460.24
|
| Rate for Payer: Priority Health Medicare |
$155.88
|
| Rate for Payer: Priority Health Narrow Network |
$368.19
|
| Rate for Payer: Priority Health SBD |
$23,278.19
|
| Rate for Payer: Railroad Medicare Medicare |
$155.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$438.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$155.88
|
| Rate for Payer: UHC Medicare Advantage |
$155.88
|
| Rate for Payer: UHCCP Medicaid |
$87.76
|
| Rate for Payer: VA VA |
$155.88
|
|
|
USTEKINUMAB 45 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$36,949.51
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
119468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23,278.19 |
| Max. Negotiated Rate |
$33,254.56 |
| Rate for Payer: Aetna Commercial |
$31,407.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24,017.18
|
| Rate for Payer: Cash Price |
$29,559.61
|
| Rate for Payer: Cofinity Commercial |
$25,864.66
|
| Rate for Payer: Cofinity Commercial |
$31,776.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$25,864.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29,559.61
|
| Rate for Payer: Healthscope Commercial |
$33,254.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31,407.08
|
| Rate for Payer: PHP Commercial |
$31,407.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24,017.18
|
| Rate for Payer: Priority Health SBD |
$23,278.19
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$73,898.95
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
119469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.55 |
| Max. Negotiated Rate |
$66,509.06 |
| Rate for Payer: Aetna Commercial |
$62,814.11
|
| Rate for Payer: Aetna Medicare |
$162.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48,034.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$194.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$194.85
|
| Rate for Payer: BCBS Complete |
$87.73
|
| Rate for Payer: BCBS MAPPO |
$155.88
|
| Rate for Payer: BCBS Trust/PPO |
$451.72
|
| Rate for Payer: BCN Commercial |
$451.72
|
| Rate for Payer: BCN Medicare Advantage |
$155.88
|
| Rate for Payer: Cash Price |
$59,119.16
|
| Rate for Payer: Cash Price |
$59,119.16
|
| Rate for Payer: Cofinity Commercial |
$63,553.10
|
| Rate for Payer: Cofinity Commercial |
$51,729.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$51,729.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59,119.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$155.88
|
| Rate for Payer: Healthscope Commercial |
$66,509.06
|
| Rate for Payer: Mclaren Medicaid |
$83.55
|
| Rate for Payer: Mclaren Medicare |
$155.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$163.67
|
| Rate for Payer: Meridian Medicaid |
$87.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$179.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62,814.11
|
| Rate for Payer: Nomi Health Commercial |
$467.64
|
| Rate for Payer: PACE Medicare |
$148.09
|
| Rate for Payer: PACE SWMI |
$155.88
|
| Rate for Payer: PHP Commercial |
$62,814.11
|
| Rate for Payer: PHP Medicare Advantage |
$155.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$83.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48,034.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$460.24
|
| Rate for Payer: Priority Health Medicare |
$155.88
|
| Rate for Payer: Priority Health Narrow Network |
$368.19
|
| Rate for Payer: Priority Health SBD |
$46,556.34
|
| Rate for Payer: Railroad Medicare Medicare |
$155.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$438.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$155.88
|
| Rate for Payer: UHC Medicare Advantage |
$155.88
|
| Rate for Payer: UHCCP Medicaid |
$87.76
|
| Rate for Payer: VA VA |
$155.88
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$73,898.95
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
119469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46,556.34 |
| Max. Negotiated Rate |
$66,509.06 |
| Rate for Payer: Aetna Commercial |
$62,814.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48,034.32
|
| Rate for Payer: Cash Price |
$59,119.16
|
| Rate for Payer: Cofinity Commercial |
$51,729.26
|
| Rate for Payer: Cofinity Commercial |
$63,553.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$51,729.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59,119.16
|
| Rate for Payer: Healthscope Commercial |
$66,509.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62,814.11
|
| Rate for Payer: PHP Commercial |
$62,814.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48,034.32
|
| Rate for Payer: Priority Health SBD |
$46,556.34
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
|
Facility
|
OP
|
$15,201.47
|
|
|
Service Code
|
CPT 58260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$898.23 |
| Max. Negotiated Rate |
$15,201.47 |
| Rate for Payer: Aetna Medicare |
$5,030.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,045.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,045.79
|
| Rate for Payer: BCBS Complete |
$2,722.06
|
| Rate for Payer: BCBS MAPPO |
$4,836.63
|
| Rate for Payer: BCBS Trust/PPO |
$2,805.61
|
| Rate for Payer: BCN Commercial |
$2,805.61
|
| Rate for Payer: BCN Medicare Advantage |
$4,836.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,836.63
|
| Rate for Payer: Mclaren Medicaid |
$2,592.43
|
| Rate for Payer: Mclaren Medicare |
$4,836.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,078.46
|
| Rate for Payer: Meridian Medicaid |
$2,722.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,562.12
|
| Rate for Payer: Nomi Health Commercial |
$10,156.92
|
| Rate for Payer: PACE Medicare |
$4,594.80
|
| Rate for Payer: PACE SWMI |
$4,836.63
|
| Rate for Payer: PHP Medicare Advantage |
$4,836.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,592.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,201.47
|
| Rate for Payer: Priority Health Medicare |
$4,836.63
|
| Rate for Payer: Priority Health Narrow Network |
$12,161.18
|
| Rate for Payer: Railroad Medicare Medicare |
$4,836.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$898.23
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,836.63
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$4,836.63
|
| Rate for Payer: UHCCP Medicaid |
$2,723.02
|
| Rate for Payer: VA VA |
$4,836.63
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)
|
Facility
|
OP
|
$15,201.47
|
|
|
Service Code
|
CPT 58262
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$993.55 |
| Max. Negotiated Rate |
$15,201.47 |
| Rate for Payer: Aetna Medicare |
$5,030.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,045.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,045.79
|
| Rate for Payer: BCBS Complete |
$2,722.06
|
| Rate for Payer: BCBS MAPPO |
$4,836.63
|
| Rate for Payer: BCBS Trust/PPO |
$3,866.73
|
| Rate for Payer: BCN Commercial |
$3,866.73
|
| Rate for Payer: BCN Medicare Advantage |
$4,836.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,836.63
|
| Rate for Payer: Mclaren Medicaid |
$2,592.43
|
| Rate for Payer: Mclaren Medicare |
$4,836.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,078.46
|
| Rate for Payer: Meridian Medicaid |
$2,722.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,562.12
|
| Rate for Payer: Nomi Health Commercial |
$10,156.92
|
| Rate for Payer: PACE Medicare |
$4,594.80
|
| Rate for Payer: PACE SWMI |
$4,836.63
|
| Rate for Payer: PHP Medicare Advantage |
$4,836.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,592.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,201.47
|
| Rate for Payer: Priority Health Medicare |
$4,836.63
|
| Rate for Payer: Priority Health Narrow Network |
$12,161.18
|
| Rate for Payer: Railroad Medicare Medicare |
$4,836.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$993.55
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,836.63
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$4,836.63
|
| Rate for Payer: UHCCP Medicaid |
$2,723.02
|
| Rate for Payer: VA VA |
$4,836.63
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
IP
|
$494.88
|
|
|
Service Code
|
NDC 00904656561
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$311.77 |
| Max. Negotiated Rate |
$445.39 |
| Rate for Payer: Aetna Commercial |
$420.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$321.67
|
| Rate for Payer: Cash Price |
$395.90
|
| Rate for Payer: Cofinity Commercial |
$346.42
|
| Rate for Payer: Cofinity Commercial |
$425.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$346.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$395.90
|
| Rate for Payer: Healthscope Commercial |
$445.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$420.65
|
| Rate for Payer: PHP Commercial |
$420.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.67
|
| Rate for Payer: Priority Health SBD |
$311.77
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
IP
|
$316.91
|
|
|
Service Code
|
NDC 51079009303
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.65 |
| Max. Negotiated Rate |
$285.22 |
| Rate for Payer: Aetna Commercial |
$269.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$205.99
|
| Rate for Payer: Cash Price |
$253.53
|
| Rate for Payer: Cofinity Commercial |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$272.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$221.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.53
|
| Rate for Payer: Healthscope Commercial |
$285.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.37
|
| Rate for Payer: PHP Commercial |
$269.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$205.99
|
| Rate for Payer: Priority Health SBD |
$199.65
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
OP
|
$316.91
|
|
|
Service Code
|
NDC 51079009303
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.76 |
| Max. Negotiated Rate |
$285.22 |
| Rate for Payer: Aetna Commercial |
$269.37
|
| Rate for Payer: Aetna Medicare |
$158.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$205.99
|
| Rate for Payer: BCBS Complete |
$126.76
|
| Rate for Payer: Cash Price |
$253.53
|
| Rate for Payer: Cofinity Commercial |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$272.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$221.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.53
|
| Rate for Payer: Healthscope Commercial |
$285.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.37
|
| Rate for Payer: PHP Commercial |
$269.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$205.99
|
| Rate for Payer: Priority Health SBD |
$199.65
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
OP
|
$494.88
|
|
|
Service Code
|
NDC 00904656561
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.95 |
| Max. Negotiated Rate |
$445.39 |
| Rate for Payer: Aetna Commercial |
$420.65
|
| Rate for Payer: Aetna Medicare |
$247.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$321.67
|
| Rate for Payer: BCBS Complete |
$197.95
|
| Rate for Payer: Cash Price |
$395.90
|
| Rate for Payer: Cofinity Commercial |
$346.42
|
| Rate for Payer: Cofinity Commercial |
$425.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$346.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$395.90
|
| Rate for Payer: Healthscope Commercial |
$445.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$420.65
|
| Rate for Payer: PHP Commercial |
$420.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.67
|
| Rate for Payer: Priority Health SBD |
$311.77
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
OP
|
$3,184.93
|
|
|
Service Code
|
NDC 00904679604
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,273.97 |
| Max. Negotiated Rate |
$2,866.44 |
| Rate for Payer: Aetna Commercial |
$2,707.19
|
| Rate for Payer: Aetna Medicare |
$1,592.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,070.20
|
| Rate for Payer: BCBS Complete |
$1,273.97
|
| Rate for Payer: Cash Price |
$2,547.94
|
| Rate for Payer: Cofinity Commercial |
$2,229.45
|
| Rate for Payer: Cofinity Commercial |
$2,739.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,229.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,547.94
|
| Rate for Payer: Healthscope Commercial |
$2,866.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,707.19
|
| Rate for Payer: PHP Commercial |
$2,707.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,070.20
|
| Rate for Payer: Priority Health SBD |
$2,006.51
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
IP
|
$1,645.47
|
|
|
Service Code
|
NDC 68084096525
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,036.65 |
| Max. Negotiated Rate |
$1,480.92 |
| Rate for Payer: Aetna Commercial |
$1,398.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,069.56
|
| Rate for Payer: Cash Price |
$1,316.38
|
| Rate for Payer: Cofinity Commercial |
$1,151.83
|
| Rate for Payer: Cofinity Commercial |
$1,415.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,151.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,316.38
|
| Rate for Payer: Healthscope Commercial |
$1,480.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,398.65
|
| Rate for Payer: PHP Commercial |
$1,398.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,069.56
|
| Rate for Payer: Priority Health SBD |
$1,036.65
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
OP
|
$54.85
|
|
|
Service Code
|
NDC 68084096595
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$49.36 |
| Rate for Payer: Aetna Commercial |
$46.62
|
| Rate for Payer: Aetna Medicare |
$27.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.65
|
| Rate for Payer: BCBS Complete |
$21.94
|
| Rate for Payer: Cash Price |
$43.88
|
| Rate for Payer: Cofinity Commercial |
$38.40
|
| Rate for Payer: Cofinity Commercial |
$47.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$38.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.88
|
| Rate for Payer: Healthscope Commercial |
$49.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.62
|
| Rate for Payer: PHP Commercial |
$46.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.65
|
| Rate for Payer: Priority Health SBD |
$34.56
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
IP
|
$3,184.93
|
|
|
Service Code
|
NDC 00904679604
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,006.51 |
| Max. Negotiated Rate |
$2,866.44 |
| Rate for Payer: Aetna Commercial |
$2,707.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,070.20
|
| Rate for Payer: Cash Price |
$2,547.94
|
| Rate for Payer: Cofinity Commercial |
$2,229.45
|
| Rate for Payer: Cofinity Commercial |
$2,739.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,229.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,547.94
|
| Rate for Payer: Healthscope Commercial |
$2,866.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,707.19
|
| Rate for Payer: PHP Commercial |
$2,707.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,070.20
|
| Rate for Payer: Priority Health SBD |
$2,006.51
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
OP
|
$18,251.51
|
|
|
Service Code
|
NDC 00004003822
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,300.60 |
| Max. Negotiated Rate |
$16,426.36 |
| Rate for Payer: Aetna Commercial |
$15,513.78
|
| Rate for Payer: Aetna Medicare |
$9,125.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,863.48
|
| Rate for Payer: BCBS Complete |
$7,300.60
|
| Rate for Payer: Cash Price |
$14,601.21
|
| Rate for Payer: Cofinity Commercial |
$12,776.06
|
| Rate for Payer: Cofinity Commercial |
$15,696.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,776.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,601.21
|
| Rate for Payer: Healthscope Commercial |
$16,426.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,513.78
|
| Rate for Payer: PHP Commercial |
$15,513.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,863.48
|
| Rate for Payer: Priority Health SBD |
$11,498.45
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
IP
|
$18,251.51
|
|
|
Service Code
|
NDC 00004003822
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11,498.45 |
| Max. Negotiated Rate |
$16,426.36 |
| Rate for Payer: Aetna Commercial |
$15,513.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,863.48
|
| Rate for Payer: Cash Price |
$14,601.21
|
| Rate for Payer: Cofinity Commercial |
$12,776.06
|
| Rate for Payer: Cofinity Commercial |
$15,696.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,776.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,601.21
|
| Rate for Payer: Healthscope Commercial |
$16,426.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,513.78
|
| Rate for Payer: PHP Commercial |
$15,513.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,863.48
|
| Rate for Payer: Priority Health SBD |
$11,498.45
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
OP
|
$1,645.47
|
|
|
Service Code
|
NDC 68084096525
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$658.19 |
| Max. Negotiated Rate |
$1,480.92 |
| Rate for Payer: Aetna Commercial |
$1,398.65
|
| Rate for Payer: Aetna Medicare |
$822.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,069.56
|
| Rate for Payer: BCBS Complete |
$658.19
|
| Rate for Payer: Cash Price |
$1,316.38
|
| Rate for Payer: Cofinity Commercial |
$1,151.83
|
| Rate for Payer: Cofinity Commercial |
$1,415.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,151.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,316.38
|
| Rate for Payer: Healthscope Commercial |
$1,480.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,398.65
|
| Rate for Payer: PHP Commercial |
$1,398.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,069.56
|
| Rate for Payer: Priority Health SBD |
$1,036.65
|
|
|
VALGANCICLOVIR 450 MG TABLET
|
Facility
|
IP
|
$54.85
|
|
|
Service Code
|
NDC 68084096595
|
| Hospital Charge Code |
30148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.56 |
| Max. Negotiated Rate |
$49.36 |
| Rate for Payer: Aetna Commercial |
$46.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.65
|
| Rate for Payer: Cash Price |
$43.88
|
| Rate for Payer: Cofinity Commercial |
$38.40
|
| Rate for Payer: Cofinity Commercial |
$47.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$38.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.88
|
| Rate for Payer: Healthscope Commercial |
$49.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.62
|
| Rate for Payer: PHP Commercial |
$46.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.65
|
| Rate for Payer: Priority Health SBD |
$34.56
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.17
|
|
|
Service Code
|
NDC 00143978510
|
| Hospital Charge Code |
20887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Aetna Medicare |
$8.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.51
|
| Rate for Payer: BCBS Complete |
$6.47
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: Cofinity Commercial |
$11.32
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.94
|
| Rate for Payer: Healthscope Commercial |
$14.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.74
|
| Rate for Payer: PHP Commercial |
$13.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.51
|
| Rate for Payer: Priority Health SBD |
$10.19
|
|
|
VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.17
|
|
|
Service Code
|
NDC 00143978510
|
| Hospital Charge Code |
20887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.51
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: Cofinity Commercial |
$11.32
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.94
|
| Rate for Payer: Healthscope Commercial |
$14.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.74
|
| Rate for Payer: PHP Commercial |
$13.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.51
|
| Rate for Payer: Priority Health SBD |
$10.19
|
|
|
VALPROIC ACID 250 MG CAPSULE
|
Facility
|
OP
|
$359.55
|
|
|
Service Code
|
NDC 69452015020
|
| Hospital Charge Code |
8429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.82 |
| Max. Negotiated Rate |
$323.60 |
| Rate for Payer: Aetna Commercial |
$305.62
|
| Rate for Payer: Aetna Medicare |
$179.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.71
|
| Rate for Payer: BCBS Complete |
$143.82
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$251.68
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.71
|
| Rate for Payer: Priority Health SBD |
$226.52
|
|
|
VALPROIC ACID 250 MG CAPSULE
|
Facility
|
IP
|
$359.55
|
|
|
Service Code
|
NDC 69452015020
|
| Hospital Charge Code |
8429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$226.52 |
| Max. Negotiated Rate |
$323.60 |
| Rate for Payer: Aetna Commercial |
$305.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.71
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$251.68
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.71
|
| Rate for Payer: Priority Health SBD |
$226.52
|
|
|
VALPROIC ACID 250 MG CAPSULE
|
Facility
|
IP
|
$293.55
|
|
|
Service Code
|
NDC 63739008610
|
| Hospital Charge Code |
8429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.94 |
| Max. Negotiated Rate |
$264.20 |
| Rate for Payer: Aetna Commercial |
$249.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.81
|
| Rate for Payer: Cash Price |
$234.84
|
| Rate for Payer: Cofinity Commercial |
$205.48
|
| Rate for Payer: Cofinity Commercial |
$252.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$205.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.84
|
| Rate for Payer: Healthscope Commercial |
$264.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.52
|
| Rate for Payer: PHP Commercial |
$249.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.81
|
| Rate for Payer: Priority Health SBD |
$184.94
|
|
|
VALPROIC ACID 250 MG CAPSULE
|
Facility
|
OP
|
$293.55
|
|
|
Service Code
|
NDC 63739008610
|
| Hospital Charge Code |
8429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.42 |
| Max. Negotiated Rate |
$264.20 |
| Rate for Payer: Aetna Commercial |
$249.52
|
| Rate for Payer: Aetna Medicare |
$146.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.81
|
| Rate for Payer: BCBS Complete |
$117.42
|
| Rate for Payer: Cash Price |
$234.84
|
| Rate for Payer: Cofinity Commercial |
$205.48
|
| Rate for Payer: Cofinity Commercial |
$252.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$205.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.84
|
| Rate for Payer: Healthscope Commercial |
$264.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.52
|
| Rate for Payer: PHP Commercial |
$249.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.81
|
| Rate for Payer: Priority Health SBD |
$184.94
|
|
