|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 00904732573
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna Medicare |
$6.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.34
|
| Rate for Payer: BCBS Complete |
$5.13
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Advantage |
$8.98
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.62
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health SBD |
$8.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.34
|
| Rate for Payer: UHC Core |
$6.68
|
| Rate for Payer: UHC Exchange |
$5.04
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 00904732562
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna Medicare |
$6.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.34
|
| Rate for Payer: BCBS Complete |
$5.13
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Advantage |
$8.98
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.62
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health SBD |
$8.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.34
|
| Rate for Payer: UHC Core |
$6.68
|
| Rate for Payer: UHC Exchange |
$5.04
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
NDC 57237031603
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$15.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.85
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Advantage |
$12.76
|
| Rate for Payer: Cofinity Commercial |
$15.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: PHP Commercial |
$15.50
|
| Rate for Payer: Priority Health SBD |
$11.48
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$15.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.85
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Advantage |
$12.76
|
| Rate for Payer: Cofinity Commercial |
$15.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: PHP Commercial |
$15.50
|
| Rate for Payer: Priority Health SBD |
$11.48
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$18.23
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$15.50
|
| Rate for Payer: Aetna Medicare |
$9.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.85
|
| Rate for Payer: BCBS Complete |
$7.29
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Advantage |
$12.76
|
| Rate for Payer: Cofinity Commercial |
$15.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$16.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: PHP Commercial |
$15.50
|
| Rate for Payer: Priority Health SBD |
$11.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.85
|
| Rate for Payer: UHC Core |
$9.50
|
| Rate for Payer: UHC Exchange |
$7.16
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 00904732573
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.34
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Advantage |
$8.98
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.62
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health SBD |
$8.08
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$14.38
|
|
|
Service Code
|
NDC 00536131783
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Aetna Medicare |
$7.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.35
|
| Rate for Payer: BCBS Complete |
$5.75
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cofinity Advantage |
$10.07
|
| Rate for Payer: Cofinity Commercial |
$12.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.50
|
| Rate for Payer: Healthscope Commercial |
$12.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.79
|
| Rate for Payer: PHP Commercial |
$12.22
|
| Rate for Payer: Priority Health SBD |
$9.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.35
|
| Rate for Payer: UHC Core |
$7.49
|
| Rate for Payer: UHC Exchange |
$5.65
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 57896062912
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.39
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Advantage |
$11.19
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.78
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.98
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: Priority Health SBD |
$10.07
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$18.50
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$16.65 |
| Rate for Payer: Aetna Commercial |
$15.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.03
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Advantage |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$15.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$16.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.88
|
| Rate for Payer: PHP Commercial |
$15.72
|
| Rate for Payer: Priority Health SBD |
$11.65
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 00904732562
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.34
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Advantage |
$8.98
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.62
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health SBD |
$8.08
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
IP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919002010
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12,716.07 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,119.76
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Advantage |
$14,128.97
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,156.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,138.18
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health SBD |
$12,716.07
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
OP
|
$14,976.68
|
|
|
Service Code
|
NDC 00591231215
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,885.84 |
| Max. Negotiated Rate |
$13,479.01 |
| Rate for Payer: Aetna Commercial |
$12,730.18
|
| Rate for Payer: Aetna Medicare |
$7,488.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,734.84
|
| Rate for Payer: BCBS Complete |
$5,990.67
|
| Rate for Payer: Cash Price |
$11,981.34
|
| Rate for Payer: Cofinity Advantage |
$10,483.68
|
| Rate for Payer: Cofinity Commercial |
$12,879.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,981.34
|
| Rate for Payer: Healthscope Commercial |
$13,479.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,981.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,730.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11,232.51
|
| Rate for Payer: PHP Commercial |
$12,730.18
|
| Rate for Payer: Priority Health SBD |
$9,435.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,734.84
|
| Rate for Payer: UHC Core |
$7,802.85
|
| Rate for Payer: UHC Exchange |
$5,885.84
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
IP
|
$14,976.68
|
|
|
Service Code
|
NDC 00591231215
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9,435.31 |
| Max. Negotiated Rate |
$13,479.01 |
| Rate for Payer: Aetna Commercial |
$12,730.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,734.84
|
| Rate for Payer: Cash Price |
$11,981.34
|
| Rate for Payer: Cofinity Advantage |
$10,483.68
|
| Rate for Payer: Cofinity Commercial |
$12,879.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,981.34
|
| Rate for Payer: Healthscope Commercial |
$13,479.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,730.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11,232.51
|
| Rate for Payer: PHP Commercial |
$12,730.18
|
| Rate for Payer: Priority Health SBD |
$9,435.31
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
OP
|
$499.23
|
|
|
Service Code
|
NDC 00591231245
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.20 |
| Max. Negotiated Rate |
$449.31 |
| Rate for Payer: Aetna Commercial |
$424.35
|
| Rate for Payer: Aetna Medicare |
$249.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$324.50
|
| Rate for Payer: BCBS Complete |
$199.69
|
| Rate for Payer: Cash Price |
$399.38
|
| Rate for Payer: Cofinity Advantage |
$349.46
|
| Rate for Payer: Cofinity Commercial |
$429.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$399.38
|
| Rate for Payer: Healthscope Commercial |
$449.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$424.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$374.42
|
| Rate for Payer: PHP Commercial |
$424.35
|
| Rate for Payer: Priority Health SBD |
$314.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$324.50
|
| Rate for Payer: UHC Core |
$260.10
|
| Rate for Payer: UHC Exchange |
$196.20
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
OP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919002010
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,932.41 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna Medicare |
$10,092.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,119.76
|
| Rate for Payer: BCBS Complete |
$8,073.70
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Advantage |
$14,128.97
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,147.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,156.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,138.18
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health SBD |
$12,716.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,119.76
|
| Rate for Payer: UHC Core |
$10,515.99
|
| Rate for Payer: UHC Exchange |
$7,932.41
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
IP
|
$499.23
|
|
|
Service Code
|
NDC 00591231245
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$314.51 |
| Max. Negotiated Rate |
$449.31 |
| Rate for Payer: Aetna Commercial |
$424.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$324.50
|
| Rate for Payer: Cash Price |
$399.38
|
| Rate for Payer: Cofinity Advantage |
$349.46
|
| Rate for Payer: Cofinity Commercial |
$429.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$399.38
|
| Rate for Payer: Healthscope Commercial |
$449.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$424.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$374.42
|
| Rate for Payer: PHP Commercial |
$424.35
|
| Rate for Payer: Priority Health SBD |
$314.51
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
|
OP
|
$621.12
|
|
|
Service Code
|
NDC 00904704261
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$244.10 |
| Max. Negotiated Rate |
$559.01 |
| Rate for Payer: Aetna Commercial |
$527.95
|
| Rate for Payer: Aetna Medicare |
$310.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$403.73
|
| Rate for Payer: BCBS Complete |
$248.45
|
| Rate for Payer: Cash Price |
$496.90
|
| Rate for Payer: Cofinity Advantage |
$434.78
|
| Rate for Payer: Cofinity Commercial |
$534.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$496.90
|
| Rate for Payer: Healthscope Commercial |
$559.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$496.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$527.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$465.84
|
| Rate for Payer: PHP Commercial |
$527.95
|
| Rate for Payer: Priority Health SBD |
$391.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$403.73
|
| Rate for Payer: UHC Core |
$323.60
|
| Rate for Payer: UHC Exchange |
$244.10
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
|
IP
|
$621.12
|
|
|
Service Code
|
NDC 00904704261
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$391.31 |
| Max. Negotiated Rate |
$559.01 |
| Rate for Payer: Aetna Commercial |
$527.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$403.73
|
| Rate for Payer: Cash Price |
$496.90
|
| Rate for Payer: Cofinity Advantage |
$434.78
|
| Rate for Payer: Cofinity Commercial |
$534.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$496.90
|
| Rate for Payer: Healthscope Commercial |
$559.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$527.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$465.84
|
| Rate for Payer: PHP Commercial |
$527.95
|
| Rate for Payer: Priority Health SBD |
$391.31
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$18.26
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
119785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$16.43 |
| Rate for Payer: Aetna Commercial |
$15.52
|
| Rate for Payer: Aetna Commercial |
$16.38
|
| Rate for Payer: Aetna Commercial |
$43.12
|
| Rate for Payer: Aetna Medicare |
$9.13
|
| Rate for Payer: Aetna Medicare |
$9.63
|
| Rate for Payer: Aetna Medicare |
$25.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.97
|
| Rate for Payer: BCBS Complete |
$20.29
|
| Rate for Payer: BCBS Complete |
$7.30
|
| Rate for Payer: BCBS Complete |
$7.71
|
| Rate for Payer: BCBS Trust/PPO |
$1.55
|
| Rate for Payer: BCBS Trust/PPO |
$1.55
|
| Rate for Payer: BCBS Trust/PPO |
$1.55
|
| Rate for Payer: BCN Commercial |
$1.55
|
| Rate for Payer: BCN Commercial |
$1.55
|
| Rate for Payer: BCN Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cash Price |
$14.61
|
| Rate for Payer: Cash Price |
$14.61
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cofinity Advantage |
$13.49
|
| Rate for Payer: Cofinity Advantage |
$12.78
|
| Rate for Payer: Cofinity Advantage |
$35.51
|
| Rate for Payer: Cofinity Commercial |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$16.57
|
| Rate for Payer: Cofinity Commercial |
$43.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.61
|
| Rate for Payer: Healthscope Commercial |
$45.66
|
| Rate for Payer: Healthscope Commercial |
$17.34
|
| Rate for Payer: Healthscope Commercial |
$16.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.05
|
| Rate for Payer: PHP Commercial |
$15.52
|
| Rate for Payer: PHP Commercial |
$16.38
|
| Rate for Payer: PHP Commercial |
$43.12
|
| Rate for Payer: Priority Health SBD |
$11.50
|
| Rate for Payer: Priority Health SBD |
$31.96
|
| Rate for Payer: Priority Health SBD |
$12.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.02
|
| Rate for Payer: UHC Core |
$1.02
|
| Rate for Payer: UHC Core |
$1.02
|
| Rate for Payer: UHC Core |
$1.02
|
| Rate for Payer: UHC Exchange |
$1.02
|
| Rate for Payer: UHC Exchange |
$1.02
|
| Rate for Payer: UHC Exchange |
$1.02
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$18.26
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
119785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$16.43 |
| Rate for Payer: Aetna Commercial |
$15.52
|
| Rate for Payer: Aetna Commercial |
$16.38
|
| Rate for Payer: Aetna Commercial |
$43.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.97
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cash Price |
$14.61
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cofinity Advantage |
$13.49
|
| Rate for Payer: Cofinity Advantage |
$12.78
|
| Rate for Payer: Cofinity Advantage |
$35.51
|
| Rate for Payer: Cofinity Commercial |
$16.57
|
| Rate for Payer: Cofinity Commercial |
$43.63
|
| Rate for Payer: Cofinity Commercial |
$15.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.61
|
| Rate for Payer: Healthscope Commercial |
$17.34
|
| Rate for Payer: Healthscope Commercial |
$16.43
|
| Rate for Payer: Healthscope Commercial |
$45.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.70
|
| Rate for Payer: PHP Commercial |
$15.52
|
| Rate for Payer: PHP Commercial |
$16.38
|
| Rate for Payer: PHP Commercial |
$43.12
|
| Rate for Payer: Priority Health SBD |
$12.14
|
| Rate for Payer: Priority Health SBD |
$11.50
|
| Rate for Payer: Priority Health SBD |
$31.96
|
|
|
AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION
|
Facility
|
IP
|
$134.56
|
|
|
Service Code
|
NDC 00338114403
|
| Hospital Charge Code |
200244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$121.10 |
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.46
|
| Rate for Payer: Cash Price |
$107.65
|
| Rate for Payer: Cofinity Advantage |
$94.19
|
| Rate for Payer: Cofinity Commercial |
$115.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.65
|
| Rate for Payer: Healthscope Commercial |
$121.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.92
|
| Rate for Payer: PHP Commercial |
$114.38
|
| Rate for Payer: Priority Health SBD |
$84.77
|
|
|
AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION
|
Facility
|
OP
|
$134.56
|
|
|
Service Code
|
NDC 00338114403
|
| Hospital Charge Code |
200244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.88 |
| Max. Negotiated Rate |
$121.10 |
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Aetna Medicare |
$67.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.46
|
| Rate for Payer: BCBS Complete |
$53.82
|
| Rate for Payer: Cash Price |
$107.65
|
| Rate for Payer: Cofinity Advantage |
$94.19
|
| Rate for Payer: Cofinity Commercial |
$115.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.65
|
| Rate for Payer: Healthscope Commercial |
$121.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$107.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.92
|
| Rate for Payer: PHP Commercial |
$114.38
|
| Rate for Payer: Priority Health SBD |
$84.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.46
|
| Rate for Payer: UHC Core |
$70.11
|
| Rate for Payer: UHC Exchange |
$52.88
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION
|
Facility
|
IP
|
$153.12
|
|
|
Service Code
|
NDC 00338703006
|
| Hospital Charge Code |
27963
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.47 |
| Max. Negotiated Rate |
$137.81 |
| Rate for Payer: Aetna Commercial |
$130.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.53
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cofinity Advantage |
$107.18
|
| Rate for Payer: Cofinity Commercial |
$131.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.50
|
| Rate for Payer: Healthscope Commercial |
$137.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$114.84
|
| Rate for Payer: PHP Commercial |
$130.15
|
| Rate for Payer: Priority Health SBD |
$96.47
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION
|
Facility
|
OP
|
$153.12
|
|
|
Service Code
|
NDC 00338703001
|
| Hospital Charge Code |
27963
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.18 |
| Max. Negotiated Rate |
$137.81 |
| Rate for Payer: Aetna Commercial |
$130.15
|
| Rate for Payer: Aetna Medicare |
$76.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.53
|
| Rate for Payer: BCBS Complete |
$61.25
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cofinity Advantage |
$107.18
|
| Rate for Payer: Cofinity Commercial |
$131.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.50
|
| Rate for Payer: Healthscope Commercial |
$137.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$114.84
|
| Rate for Payer: PHP Commercial |
$130.15
|
| Rate for Payer: Priority Health SBD |
$96.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.53
|
| Rate for Payer: UHC Core |
$79.78
|
| Rate for Payer: UHC Exchange |
$60.18
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION
|
Facility
|
OP
|
$153.12
|
|
|
Service Code
|
NDC 00338703006
|
| Hospital Charge Code |
27963
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.18 |
| Max. Negotiated Rate |
$137.81 |
| Rate for Payer: Aetna Commercial |
$130.15
|
| Rate for Payer: Aetna Medicare |
$76.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.53
|
| Rate for Payer: BCBS Complete |
$61.25
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cofinity Advantage |
$107.18
|
| Rate for Payer: Cofinity Commercial |
$131.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.50
|
| Rate for Payer: Healthscope Commercial |
$137.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$114.84
|
| Rate for Payer: PHP Commercial |
$130.15
|
| Rate for Payer: Priority Health SBD |
$96.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.53
|
| Rate for Payer: UHC Core |
$79.78
|
| Rate for Payer: UHC Exchange |
$60.18
|
|
