|
VIVONEX RTF CYCLIC FEED
|
Facility
|
IP
|
$44.40
|
|
|
Service Code
|
NDC 00212362814
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$39.96 |
| Rate for Payer: Aetna Commercial |
$37.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.86
|
| Rate for Payer: Cash Price |
$35.52
|
| Rate for Payer: Cofinity Commercial |
$31.08
|
| Rate for Payer: Cofinity Commercial |
$38.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.52
|
| Rate for Payer: Healthscope Commercial |
$39.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.74
|
| Rate for Payer: PHP Commercial |
$37.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.86
|
| Rate for Payer: Priority Health SBD |
$27.97
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
|
IP
|
$59.20
|
|
|
Service Code
|
NDC 43900036280
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.48
|
| Rate for Payer: Cash Price |
$47.36
|
| Rate for Payer: Cofinity Commercial |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$50.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.36
|
| Rate for Payer: Healthscope Commercial |
$53.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.32
|
| Rate for Payer: PHP Commercial |
$50.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.48
|
| Rate for Payer: Priority Health SBD |
$37.30
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
|
OP
|
$59.20
|
|
|
Service Code
|
NDC 43900036280
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Aetna Medicare |
$29.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.48
|
| Rate for Payer: BCBS Complete |
$23.68
|
| Rate for Payer: Cash Price |
$47.36
|
| Rate for Payer: Cofinity Commercial |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$50.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.36
|
| Rate for Payer: Healthscope Commercial |
$53.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.32
|
| Rate for Payer: PHP Commercial |
$50.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.48
|
| Rate for Payer: Priority Health SBD |
$37.30
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
OP
|
$44.40
|
|
|
Service Code
|
NDC 00212362814
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$39.96 |
| Rate for Payer: Aetna Commercial |
$37.74
|
| Rate for Payer: Aetna Medicare |
$22.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.86
|
| Rate for Payer: BCBS Complete |
$17.76
|
| Rate for Payer: Cash Price |
$35.52
|
| Rate for Payer: Cofinity Commercial |
$31.08
|
| Rate for Payer: Cofinity Commercial |
$38.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.52
|
| Rate for Payer: Healthscope Commercial |
$39.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.74
|
| Rate for Payer: PHP Commercial |
$37.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.86
|
| Rate for Payer: Priority Health SBD |
$27.97
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
IP
|
$59.20
|
|
|
Service Code
|
NDC 43900036280
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.48
|
| Rate for Payer: Cash Price |
$47.36
|
| Rate for Payer: Cofinity Commercial |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$50.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.36
|
| Rate for Payer: Healthscope Commercial |
$53.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.32
|
| Rate for Payer: PHP Commercial |
$50.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.48
|
| Rate for Payer: Priority Health SBD |
$37.30
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
IP
|
$44.40
|
|
|
Service Code
|
NDC 00212362814
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$39.96 |
| Rate for Payer: Aetna Commercial |
$37.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.86
|
| Rate for Payer: Cash Price |
$35.52
|
| Rate for Payer: Cofinity Commercial |
$31.08
|
| Rate for Payer: Cofinity Commercial |
$38.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.52
|
| Rate for Payer: Healthscope Commercial |
$39.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.74
|
| Rate for Payer: PHP Commercial |
$37.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.86
|
| Rate for Payer: Priority Health SBD |
$27.97
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
OP
|
$59.20
|
|
|
Service Code
|
NDC 43900036280
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.68 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Aetna Medicare |
$29.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.48
|
| Rate for Payer: BCBS Complete |
$23.68
|
| Rate for Payer: Cash Price |
$47.36
|
| Rate for Payer: Cofinity Commercial |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$50.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.36
|
| Rate for Payer: Healthscope Commercial |
$53.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.32
|
| Rate for Payer: PHP Commercial |
$50.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.48
|
| Rate for Payer: Priority Health SBD |
$37.30
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$70.45
|
|
|
Service Code
|
HCPCS J3465
|
| Hospital Charge Code |
33010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$63.40 |
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: Aetna Commercial |
$140.71
|
| Rate for Payer: Aetna Commercial |
$54.62
|
| Rate for Payer: Aetna Commercial |
$49.82
|
| Rate for Payer: Aetna Medicare |
$32.13
|
| Rate for Payer: Aetna Medicare |
$82.77
|
| Rate for Payer: Aetna Medicare |
$35.22
|
| Rate for Payer: Aetna Medicare |
$29.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.10
|
| Rate for Payer: BCBS Complete |
$25.70
|
| Rate for Payer: BCBS Complete |
$28.18
|
| Rate for Payer: BCBS Complete |
$23.44
|
| Rate for Payer: BCBS Complete |
$66.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$46.89
|
| Rate for Payer: Cash Price |
$132.43
|
| Rate for Payer: Cash Price |
$51.41
|
| Rate for Payer: Cash Price |
$46.89
|
| Rate for Payer: Cash Price |
$51.41
|
| Rate for Payer: Cash Price |
$56.36
|
| Rate for Payer: Cash Price |
$56.36
|
| Rate for Payer: Cash Price |
$132.43
|
| Rate for Payer: Cofinity Commercial |
$41.03
|
| Rate for Payer: Cofinity Commercial |
$115.88
|
| Rate for Payer: Cofinity Commercial |
$142.36
|
| Rate for Payer: Cofinity Commercial |
$50.40
|
| Rate for Payer: Cofinity Commercial |
$44.98
|
| Rate for Payer: Cofinity Commercial |
$55.26
|
| Rate for Payer: Cofinity Commercial |
$49.32
|
| Rate for Payer: Cofinity Commercial |
$60.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.89
|
| Rate for Payer: Healthscope Commercial |
$52.75
|
| Rate for Payer: Healthscope Commercial |
$63.40
|
| Rate for Payer: Healthscope Commercial |
$57.83
|
| Rate for Payer: Healthscope Commercial |
$148.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.88
|
| Rate for Payer: PHP Commercial |
$59.88
|
| Rate for Payer: PHP Commercial |
$49.82
|
| Rate for Payer: PHP Commercial |
$54.62
|
| Rate for Payer: PHP Commercial |
$140.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.10
|
| Rate for Payer: Priority Health SBD |
$44.38
|
| Rate for Payer: Priority Health SBD |
$36.92
|
| Rate for Payer: Priority Health SBD |
$104.29
|
| Rate for Payer: Priority Health SBD |
$40.48
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$64.26
|
|
|
Service Code
|
HCPCS J3465
|
| Hospital Charge Code |
33010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$57.83 |
| Rate for Payer: Aetna Commercial |
$54.62
|
| Rate for Payer: Aetna Commercial |
$49.82
|
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: Aetna Commercial |
$140.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.79
|
| Rate for Payer: Cash Price |
$51.41
|
| Rate for Payer: Cash Price |
$46.89
|
| Rate for Payer: Cash Price |
$132.43
|
| Rate for Payer: Cash Price |
$56.36
|
| Rate for Payer: Cofinity Commercial |
$115.88
|
| Rate for Payer: Cofinity Commercial |
$60.59
|
| Rate for Payer: Cofinity Commercial |
$49.32
|
| Rate for Payer: Cofinity Commercial |
$41.03
|
| Rate for Payer: Cofinity Commercial |
$50.40
|
| Rate for Payer: Cofinity Commercial |
$55.26
|
| Rate for Payer: Cofinity Commercial |
$44.98
|
| Rate for Payer: Cofinity Commercial |
$142.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.36
|
| Rate for Payer: Healthscope Commercial |
$52.75
|
| Rate for Payer: Healthscope Commercial |
$148.99
|
| Rate for Payer: Healthscope Commercial |
$63.40
|
| Rate for Payer: Healthscope Commercial |
$57.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.71
|
| Rate for Payer: PHP Commercial |
$140.71
|
| Rate for Payer: PHP Commercial |
$54.62
|
| Rate for Payer: PHP Commercial |
$49.82
|
| Rate for Payer: PHP Commercial |
$59.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.79
|
| Rate for Payer: Priority Health SBD |
$104.29
|
| Rate for Payer: Priority Health SBD |
$40.48
|
| Rate for Payer: Priority Health SBD |
$36.92
|
| Rate for Payer: Priority Health SBD |
$44.38
|
|
|
VORICONAZOLE 200 MG TABLET
|
Facility
|
OP
|
$212.69
|
|
|
Service Code
|
NDC 27241006303
|
| Hospital Charge Code |
33009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.08 |
| Max. Negotiated Rate |
$191.42 |
| Rate for Payer: Aetna Commercial |
$180.79
|
| Rate for Payer: Aetna Medicare |
$106.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.25
|
| Rate for Payer: BCBS Complete |
$85.08
|
| Rate for Payer: Cash Price |
$170.15
|
| Rate for Payer: Cofinity Commercial |
$148.88
|
| Rate for Payer: Cofinity Commercial |
$182.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.15
|
| Rate for Payer: Healthscope Commercial |
$191.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.79
|
| Rate for Payer: PHP Commercial |
$180.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.25
|
| Rate for Payer: Priority Health SBD |
$133.99
|
|
|
VORICONAZOLE 200 MG TABLET
|
Facility
|
OP
|
$385.40
|
|
|
Service Code
|
NDC 00049318030
|
| Hospital Charge Code |
33009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.16 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna Medicare |
$192.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: BCBS Complete |
$154.16
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.51
|
| Rate for Payer: Priority Health SBD |
$242.80
|
|
|
VORICONAZOLE 200 MG TABLET
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 00049318030
|
| Hospital Charge Code |
33009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.80 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.51
|
| Rate for Payer: Priority Health SBD |
$242.80
|
|
|
VORICONAZOLE 200 MG TABLET
|
Facility
|
IP
|
$212.69
|
|
|
Service Code
|
NDC 27241006303
|
| Hospital Charge Code |
33009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.99 |
| Max. Negotiated Rate |
$191.42 |
| Rate for Payer: Aetna Commercial |
$180.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.25
|
| Rate for Payer: Cash Price |
$170.15
|
| Rate for Payer: Cofinity Commercial |
$148.88
|
| Rate for Payer: Cofinity Commercial |
$182.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.15
|
| Rate for Payer: Healthscope Commercial |
$191.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.79
|
| Rate for Payer: PHP Commercial |
$180.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.25
|
| Rate for Payer: Priority Health SBD |
$133.99
|
|
|
VORTIOXETINE 10 MG TABLET
|
Facility
|
IP
|
$1,769.23
|
|
|
Service Code
|
NDC 64764073030
|
| Hospital Charge Code |
168416
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,114.61 |
| Max. Negotiated Rate |
$1,592.31 |
| Rate for Payer: Aetna Commercial |
$1,503.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,415.38
|
| Rate for Payer: Cofinity Commercial |
$1,238.46
|
| Rate for Payer: Cofinity Commercial |
$1,521.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,238.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,415.38
|
| Rate for Payer: Healthscope Commercial |
$1,592.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,503.85
|
| Rate for Payer: PHP Commercial |
$1,503.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,150.00
|
| Rate for Payer: Priority Health SBD |
$1,114.61
|
|
|
VORTIOXETINE 10 MG TABLET
|
Facility
|
OP
|
$1,769.23
|
|
|
Service Code
|
NDC 64764073030
|
| Hospital Charge Code |
168416
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$707.69 |
| Max. Negotiated Rate |
$1,592.31 |
| Rate for Payer: Aetna Commercial |
$1,503.85
|
| Rate for Payer: Aetna Medicare |
$884.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,150.00
|
| Rate for Payer: BCBS Complete |
$707.69
|
| Rate for Payer: Cash Price |
$1,415.38
|
| Rate for Payer: Cofinity Commercial |
$1,238.46
|
| Rate for Payer: Cofinity Commercial |
$1,521.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,238.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,415.38
|
| Rate for Payer: Healthscope Commercial |
$1,592.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,503.85
|
| Rate for Payer: PHP Commercial |
$1,503.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,150.00
|
| Rate for Payer: Priority Health SBD |
$1,114.61
|
|
|
VORTIOXETINE 5 MG TABLET
|
Facility
|
OP
|
$1,769.23
|
|
|
Service Code
|
NDC 64764072030
|
| Hospital Charge Code |
168415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$707.69 |
| Max. Negotiated Rate |
$1,592.31 |
| Rate for Payer: Aetna Commercial |
$1,503.85
|
| Rate for Payer: Aetna Medicare |
$884.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,150.00
|
| Rate for Payer: BCBS Complete |
$707.69
|
| Rate for Payer: Cash Price |
$1,415.38
|
| Rate for Payer: Cofinity Commercial |
$1,238.46
|
| Rate for Payer: Cofinity Commercial |
$1,521.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,238.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,415.38
|
| Rate for Payer: Healthscope Commercial |
$1,592.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,503.85
|
| Rate for Payer: PHP Commercial |
$1,503.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,150.00
|
| Rate for Payer: Priority Health SBD |
$1,114.61
|
|
|
VORTIOXETINE 5 MG TABLET
|
Facility
|
IP
|
$1,769.23
|
|
|
Service Code
|
NDC 64764072030
|
| Hospital Charge Code |
168415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,114.61 |
| Max. Negotiated Rate |
$1,592.31 |
| Rate for Payer: Aetna Commercial |
$1,503.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,415.38
|
| Rate for Payer: Cofinity Commercial |
$1,238.46
|
| Rate for Payer: Cofinity Commercial |
$1,521.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,238.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,415.38
|
| Rate for Payer: Healthscope Commercial |
$1,592.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,503.85
|
| Rate for Payer: PHP Commercial |
$1,503.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,150.00
|
| Rate for Payer: Priority Health SBD |
$1,114.61
|
|
|
VULVECTOMY SIMPLE; PARTIAL
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 56620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$620.52 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,874.85
|
| Rate for Payer: BCN Commercial |
$1,874.85
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$620.52
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,753.88
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
WARFARIN 10 MG TABLET
|
Facility
|
IP
|
$207.10
|
|
|
Service Code
|
NDC 00832121901
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.47 |
| Max. Negotiated Rate |
$186.39 |
| Rate for Payer: Aetna Commercial |
$176.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.62
|
| Rate for Payer: Cash Price |
$165.68
|
| Rate for Payer: Cofinity Commercial |
$144.97
|
| Rate for Payer: Cofinity Commercial |
$178.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.68
|
| Rate for Payer: Healthscope Commercial |
$186.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.04
|
| Rate for Payer: PHP Commercial |
$176.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.62
|
| Rate for Payer: Priority Health SBD |
$130.47
|
|
|
WARFARIN 10 MG TABLET
|
Facility
|
OP
|
$2.08
|
|
|
Service Code
|
NDC 00832121989
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Commercial |
$1.77
|
| Rate for Payer: Aetna Medicare |
$1.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.35
|
| Rate for Payer: BCBS Complete |
$0.83
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.46
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.66
|
| Rate for Payer: Healthscope Commercial |
$1.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.77
|
| Rate for Payer: PHP Commercial |
$1.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.35
|
| Rate for Payer: Priority Health SBD |
$1.31
|
|
|
WARFARIN 10 MG TABLET
|
Facility
|
OP
|
$260.85
|
|
|
Service Code
|
NDC 00093172001
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.34 |
| Max. Negotiated Rate |
$234.76 |
| Rate for Payer: Aetna Commercial |
$221.72
|
| Rate for Payer: Aetna Medicare |
$130.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.55
|
| Rate for Payer: BCBS Complete |
$104.34
|
| Rate for Payer: Cash Price |
$208.68
|
| Rate for Payer: Cofinity Commercial |
$182.60
|
| Rate for Payer: Cofinity Commercial |
$224.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.68
|
| Rate for Payer: Healthscope Commercial |
$234.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.72
|
| Rate for Payer: PHP Commercial |
$221.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.55
|
| Rate for Payer: Priority Health SBD |
$164.34
|
|
|
WARFARIN 10 MG TABLET
|
Facility
|
IP
|
$260.85
|
|
|
Service Code
|
NDC 00093172001
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.34 |
| Max. Negotiated Rate |
$234.76 |
| Rate for Payer: Aetna Commercial |
$221.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.55
|
| Rate for Payer: Cash Price |
$208.68
|
| Rate for Payer: Cofinity Commercial |
$182.60
|
| Rate for Payer: Cofinity Commercial |
$224.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.68
|
| Rate for Payer: Healthscope Commercial |
$234.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.72
|
| Rate for Payer: PHP Commercial |
$221.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.55
|
| Rate for Payer: Priority Health SBD |
$164.34
|
|
|
WARFARIN 10 MG TABLET
|
Facility
|
IP
|
$2.08
|
|
|
Service Code
|
NDC 00832121989
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Commercial |
$1.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.35
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.46
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.66
|
| Rate for Payer: Healthscope Commercial |
$1.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.77
|
| Rate for Payer: PHP Commercial |
$1.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.35
|
| Rate for Payer: Priority Health SBD |
$1.31
|
|
|
WARFARIN 10 MG TABLET
|
Facility
|
OP
|
$207.10
|
|
|
Service Code
|
NDC 00832121901
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.84 |
| Max. Negotiated Rate |
$186.39 |
| Rate for Payer: Aetna Commercial |
$176.04
|
| Rate for Payer: Aetna Medicare |
$103.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.62
|
| Rate for Payer: BCBS Complete |
$82.84
|
| Rate for Payer: Cash Price |
$165.68
|
| Rate for Payer: Cofinity Commercial |
$144.97
|
| Rate for Payer: Cofinity Commercial |
$178.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.68
|
| Rate for Payer: Healthscope Commercial |
$186.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.04
|
| Rate for Payer: PHP Commercial |
$176.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.62
|
| Rate for Payer: Priority Health SBD |
$130.47
|
|
|
WARFARIN 1 MG TABLET
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 51672402701
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
|
