|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$91.39
|
|
|
Service Code
|
NDC 00409166022
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.92 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Aetna Medicare |
$45.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.40
|
| Rate for Payer: BCBS Complete |
$36.56
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Advantage |
$63.97
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: Priority Health SBD |
$57.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.40
|
| Rate for Payer: UHC Core |
$47.61
|
| Rate for Payer: UHC Exchange |
$35.92
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$91.39
|
|
|
Service Code
|
NDC 00409166022
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.58 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.40
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Advantage |
$63.97
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: Priority Health SBD |
$57.58
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$91.39
|
|
|
Service Code
|
NDC 00409166020
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.92 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Aetna Medicare |
$45.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.40
|
| Rate for Payer: BCBS Complete |
$36.56
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Advantage |
$63.97
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: Priority Health SBD |
$57.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.40
|
| Rate for Payer: UHC Core |
$47.61
|
| Rate for Payer: UHC Exchange |
$35.92
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$75.62
|
|
|
Service Code
|
NDC 00781349380
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.64 |
| Max. Negotiated Rate |
$68.06 |
| Rate for Payer: Aetna Commercial |
$64.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.15
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cofinity Advantage |
$52.93
|
| Rate for Payer: Cofinity Commercial |
$65.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.50
|
| Rate for Payer: Healthscope Commercial |
$68.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$64.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.72
|
| Rate for Payer: PHP Commercial |
$64.28
|
| Rate for Payer: Priority Health SBD |
$47.64
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$231.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$196.44
|
| Rate for Payer: Aetna Medicare |
$51.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.17
|
| Rate for Payer: BCBS Complete |
$27.32
|
| Rate for Payer: BCBS MAPPO |
$49.74
|
| Rate for Payer: BCBS Trust/PPO |
$145.53
|
| Rate for Payer: BCN Commercial |
$145.53
|
| Rate for Payer: BCN Medicare Advantage |
$49.74
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cofinity Advantage |
$161.78
|
| Rate for Payer: Cofinity Commercial |
$198.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.74
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Mclaren Medicaid |
$26.01
|
| Rate for Payer: Mclaren Medicare |
$49.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.23
|
| Rate for Payer: Meridian Medicaid |
$52.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$54.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.44
|
| Rate for Payer: Nomi Health Commercial |
$149.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.33
|
| Rate for Payer: PACE Medicare |
$47.25
|
| Rate for Payer: PACE SWMI |
$49.74
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: PHP Medicare Advantage |
$49.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$198.88
|
| Rate for Payer: Priority Health Medicare |
$49.74
|
| Rate for Payer: Priority Health SBD |
$145.60
|
| Rate for Payer: Priority Health Tiered Network |
$159.10
|
| Rate for Payer: Railroad Medicare Medicare |
$49.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.72
|
| Rate for Payer: UHC Core |
$95.72
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$49.74
|
| Rate for Payer: UHC Exchange |
$95.72
|
| Rate for Payer: UHC Medicaid |
$26.01
|
| Rate for Payer: UHCCP Medicaid |
$26.01
|
| Rate for Payer: VA VA |
$49.74
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$231.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna Commercial |
$196.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.22
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cofinity Advantage |
$161.78
|
| Rate for Payer: Cofinity Commercial |
$198.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.89
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.33
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: Priority Health SBD |
$145.60
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$983.57
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$885.21 |
| Rate for Payer: Aetna Commercial |
$836.03
|
| Rate for Payer: Aetna Medicare |
$51.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.17
|
| Rate for Payer: BCBS Complete |
$27.32
|
| Rate for Payer: BCBS MAPPO |
$49.74
|
| Rate for Payer: BCBS Trust/PPO |
$145.53
|
| Rate for Payer: BCN Commercial |
$145.53
|
| Rate for Payer: BCN Medicare Advantage |
$49.74
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cofinity Advantage |
$688.50
|
| Rate for Payer: Cofinity Commercial |
$845.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.74
|
| Rate for Payer: Healthscope Commercial |
$885.21
|
| Rate for Payer: Mclaren Medicaid |
$26.01
|
| Rate for Payer: Mclaren Medicare |
$49.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.23
|
| Rate for Payer: Meridian Medicaid |
$52.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$54.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$836.03
|
| Rate for Payer: Nomi Health Commercial |
$149.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$737.68
|
| Rate for Payer: PACE Medicare |
$47.25
|
| Rate for Payer: PACE SWMI |
$49.74
|
| Rate for Payer: PHP Commercial |
$836.03
|
| Rate for Payer: PHP Medicare Advantage |
$49.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$198.88
|
| Rate for Payer: Priority Health Medicare |
$49.74
|
| Rate for Payer: Priority Health SBD |
$619.65
|
| Rate for Payer: Priority Health Tiered Network |
$159.10
|
| Rate for Payer: Railroad Medicare Medicare |
$49.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.72
|
| Rate for Payer: UHC Core |
$95.72
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$49.74
|
| Rate for Payer: UHC Exchange |
$95.72
|
| Rate for Payer: UHC Medicaid |
$26.01
|
| Rate for Payer: UHCCP Medicaid |
$26.01
|
| Rate for Payer: VA VA |
$49.74
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$983.57
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$619.65 |
| Max. Negotiated Rate |
$885.21 |
| Rate for Payer: Aetna Commercial |
$836.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.32
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cofinity Advantage |
$688.50
|
| Rate for Payer: Cofinity Commercial |
$845.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.86
|
| Rate for Payer: Healthscope Commercial |
$885.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$836.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$737.68
|
| Rate for Payer: PHP Commercial |
$836.03
|
| Rate for Payer: Priority Health SBD |
$619.65
|
|
|
DEXTRAN 40 10 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,342.42
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
23876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$845.72 |
| Max. Negotiated Rate |
$1,208.18 |
| Rate for Payer: Aetna Commercial |
$1,141.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$872.57
|
| Rate for Payer: Cash Price |
$1,073.94
|
| Rate for Payer: Cofinity Advantage |
$939.69
|
| Rate for Payer: Cofinity Commercial |
$1,154.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,073.94
|
| Rate for Payer: Healthscope Commercial |
$1,208.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,141.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,006.82
|
| Rate for Payer: PHP Commercial |
$1,141.06
|
| Rate for Payer: Priority Health SBD |
$845.72
|
|
|
DEXTRAN 40 10 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,342.42
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
23876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$168.72 |
| Max. Negotiated Rate |
$1,208.18 |
| Rate for Payer: Aetna Commercial |
$1,141.06
|
| Rate for Payer: Aetna Medicare |
$671.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$872.57
|
| Rate for Payer: BCBS Complete |
$536.97
|
| Rate for Payer: BCBS Trust/PPO |
$168.72
|
| Rate for Payer: BCN Commercial |
$168.72
|
| Rate for Payer: Cash Price |
$1,073.94
|
| Rate for Payer: Cash Price |
$1,073.94
|
| Rate for Payer: Cofinity Advantage |
$939.69
|
| Rate for Payer: Cofinity Commercial |
$1,154.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,073.94
|
| Rate for Payer: Healthscope Commercial |
$1,208.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,073.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,141.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,006.82
|
| Rate for Payer: PHP Commercial |
$1,141.06
|
| Rate for Payer: Priority Health SBD |
$845.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$872.57
|
| Rate for Payer: UHC Core |
$699.40
|
| Rate for Payer: UHC Exchange |
$527.57
|
|
|
DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS
|
Facility
|
IP
|
$1,216.03
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
9759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$766.10 |
| Max. Negotiated Rate |
$1,094.43 |
| Rate for Payer: Aetna Commercial |
$1,033.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$790.42
|
| Rate for Payer: Cash Price |
$972.82
|
| Rate for Payer: Cofinity Advantage |
$851.22
|
| Rate for Payer: Cofinity Commercial |
$1,045.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$972.82
|
| Rate for Payer: Healthscope Commercial |
$1,094.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,033.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$912.02
|
| Rate for Payer: PHP Commercial |
$1,033.63
|
| Rate for Payer: Priority Health SBD |
$766.10
|
|
|
DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS
|
Facility
|
OP
|
$1,216.03
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
9759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$168.72 |
| Max. Negotiated Rate |
$1,094.43 |
| Rate for Payer: Aetna Commercial |
$1,033.63
|
| Rate for Payer: Aetna Medicare |
$608.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$790.42
|
| Rate for Payer: BCBS Complete |
$486.41
|
| Rate for Payer: BCBS Trust/PPO |
$168.72
|
| Rate for Payer: BCN Commercial |
$168.72
|
| Rate for Payer: Cash Price |
$972.82
|
| Rate for Payer: Cash Price |
$972.82
|
| Rate for Payer: Cofinity Advantage |
$851.22
|
| Rate for Payer: Cofinity Commercial |
$1,045.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$972.82
|
| Rate for Payer: Healthscope Commercial |
$1,094.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$972.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,033.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$912.02
|
| Rate for Payer: PHP Commercial |
$1,033.63
|
| Rate for Payer: Priority Health SBD |
$766.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$790.42
|
| Rate for Payer: UHC Core |
$633.55
|
| Rate for Payer: UHC Exchange |
$477.90
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$3,938.55
|
|
|
Service Code
|
NDC 57844011001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,481.29 |
| Max. Negotiated Rate |
$3,544.70 |
| Rate for Payer: Aetna Commercial |
$3,347.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,560.06
|
| Rate for Payer: Cash Price |
$3,150.84
|
| Rate for Payer: Cofinity Advantage |
$2,756.99
|
| Rate for Payer: Cofinity Commercial |
$3,387.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,150.84
|
| Rate for Payer: Healthscope Commercial |
$3,544.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,347.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,953.91
|
| Rate for Payer: PHP Commercial |
$3,347.77
|
| Rate for Payer: Priority Health SBD |
$2,481.29
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
|
Service Code
|
NDC 00527150237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$518.17 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$563.50
|
|
|
Service Code
|
NDC 00555097202
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.46 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna Medicare |
$281.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.27
|
| Rate for Payer: BCBS Complete |
$225.40
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Advantage |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$422.62
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.27
|
| Rate for Payer: UHC Core |
$293.58
|
| Rate for Payer: UHC Exchange |
$221.46
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 00555097202
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$355.00 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.27
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Advantage |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$422.62
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health SBD |
$355.00
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$822.50
|
|
|
Service Code
|
NDC 00527150237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$323.24 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna Medicare |
$411.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: BCBS Complete |
$329.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$658.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$534.62
|
| Rate for Payer: UHC Core |
$428.52
|
| Rate for Payer: UHC Exchange |
$323.24
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$822.50
|
|
|
Service Code
|
NDC 00406889201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$323.24 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna Medicare |
$411.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: BCBS Complete |
$329.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$658.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$534.62
|
| Rate for Payer: UHC Core |
$428.52
|
| Rate for Payer: UHC Exchange |
$323.24
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
|
Service Code
|
NDC 00406889201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$518.17 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$610.75
|
|
|
Service Code
|
NDC 13107007001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$384.77 |
| Max. Negotiated Rate |
$549.67 |
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Advantage |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$458.06
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health SBD |
$384.77
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$610.75
|
|
|
Service Code
|
NDC 13107007001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.02 |
| Max. Negotiated Rate |
$549.67 |
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna Medicare |
$305.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: BCBS Complete |
$244.30
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Advantage |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$488.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$458.06
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health SBD |
$384.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$396.99
|
| Rate for Payer: UHC Core |
$318.20
|
| Rate for Payer: UHC Exchange |
$240.02
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$3,938.55
|
|
|
Service Code
|
NDC 57844011001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,547.85 |
| Max. Negotiated Rate |
$3,544.70 |
| Rate for Payer: Aetna Commercial |
$3,347.77
|
| Rate for Payer: Aetna Medicare |
$1,969.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,560.06
|
| Rate for Payer: BCBS Complete |
$1,575.42
|
| Rate for Payer: Cash Price |
$3,150.84
|
| Rate for Payer: Cofinity Advantage |
$2,756.99
|
| Rate for Payer: Cofinity Commercial |
$3,387.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,150.84
|
| Rate for Payer: Healthscope Commercial |
$3,544.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,150.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,347.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,953.91
|
| Rate for Payer: PHP Commercial |
$3,347.77
|
| Rate for Payer: Priority Health SBD |
$2,481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,560.06
|
| Rate for Payer: UHC Core |
$2,051.98
|
| Rate for Payer: UHC Exchange |
$1,547.85
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$985.25
|
|
|
Service Code
|
NDC 70010003001
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$387.20 |
| Max. Negotiated Rate |
$886.73 |
| Rate for Payer: Aetna Commercial |
$837.46
|
| Rate for Payer: Aetna Medicare |
$492.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$640.41
|
| Rate for Payer: BCBS Complete |
$394.10
|
| Rate for Payer: Cash Price |
$788.20
|
| Rate for Payer: Cofinity Advantage |
$689.67
|
| Rate for Payer: Cofinity Commercial |
$847.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$788.20
|
| Rate for Payer: Healthscope Commercial |
$886.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$788.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$837.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$738.94
|
| Rate for Payer: PHP Commercial |
$837.46
|
| Rate for Payer: Priority Health SBD |
$620.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$640.41
|
| Rate for Payer: UHC Core |
$513.32
|
| Rate for Payer: UHC Exchange |
$387.20
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$985.25
|
|
|
Service Code
|
NDC 70010003001
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$620.71 |
| Max. Negotiated Rate |
$886.73 |
| Rate for Payer: Aetna Commercial |
$837.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$640.41
|
| Rate for Payer: Cash Price |
$788.20
|
| Rate for Payer: Cofinity Advantage |
$689.67
|
| Rate for Payer: Cofinity Commercial |
$847.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$788.20
|
| Rate for Payer: Healthscope Commercial |
$886.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$837.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$738.94
|
| Rate for Payer: PHP Commercial |
$837.46
|
| Rate for Payer: Priority Health SBD |
$620.71
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$716.10
|
|
|
Service Code
|
NDC 66993059502
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.43 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna Medicare |
$358.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: BCBS Complete |
$286.44
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Advantage |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$572.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.08
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$465.46
|
| Rate for Payer: UHC Core |
$373.09
|
| Rate for Payer: UHC Exchange |
$281.43
|
|
