|
ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$428.58
|
|
|
Service Code
|
NDC 60687018821
|
| Hospital Charge Code |
26547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.01 |
| Max. Negotiated Rate |
$385.72 |
| Rate for Payer: Aetna Commercial |
$364.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.58
|
| Rate for Payer: Cash Price |
$342.86
|
| Rate for Payer: Cofinity Advantage |
$300.01
|
| Rate for Payer: Cofinity Commercial |
$368.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.86
|
| Rate for Payer: Healthscope Commercial |
$385.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$321.44
|
| Rate for Payer: PHP Commercial |
$364.29
|
| Rate for Payer: Priority Health SBD |
$270.01
|
|
|
EPCORITAMAB-BYSP 0.16 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$2,371.17
|
|
|
Service Code
|
HCPCS J9321
|
| Hospital Charge Code |
301958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$2,134.05 |
| Rate for Payer: Aetna Commercial |
$2,015.49
|
| Rate for Payer: Aetna Medicare |
$59.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,541.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$71.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$71.15
|
| Rate for Payer: BCBS Complete |
$31.26
|
| Rate for Payer: BCBS MAPPO |
$56.92
|
| Rate for Payer: BCBS Trust/PPO |
$142.50
|
| Rate for Payer: BCN Commercial |
$142.50
|
| Rate for Payer: BCN Medicare Advantage |
$56.92
|
| Rate for Payer: Cash Price |
$1,896.94
|
| Rate for Payer: Cash Price |
$1,896.94
|
| Rate for Payer: Cofinity Advantage |
$1,659.82
|
| Rate for Payer: Cofinity Commercial |
$2,039.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,896.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$2,134.05
|
| Rate for Payer: Mclaren Medicaid |
$29.77
|
| Rate for Payer: Mclaren Medicare |
$56.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$59.77
|
| Rate for Payer: Meridian Medicaid |
$59.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$62.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,015.49
|
| Rate for Payer: Nomi Health Commercial |
$170.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,778.38
|
| Rate for Payer: PACE Medicare |
$54.07
|
| Rate for Payer: PACE SWMI |
$56.92
|
| Rate for Payer: PHP Commercial |
$2,015.49
|
| Rate for Payer: PHP Medicare Advantage |
$56.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$176.13
|
| Rate for Payer: Priority Health Medicare |
$56.92
|
| Rate for Payer: Priority Health SBD |
$1,493.84
|
| Rate for Payer: Priority Health Tiered Network |
$140.90
|
| Rate for Payer: Railroad Medicare Medicare |
$56.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.74
|
| Rate for Payer: UHC Core |
$93.74
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$56.92
|
| Rate for Payer: UHC Exchange |
$93.74
|
| Rate for Payer: UHC Medicaid |
$29.77
|
| Rate for Payer: UHCCP Medicaid |
$29.77
|
| Rate for Payer: VA VA |
$56.92
|
|
|
EPCORITAMAB-BYSP 0.8 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$5,927.03
|
|
|
Service Code
|
HCPCS J9321
|
| Hospital Charge Code |
301960
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$5,334.33 |
| Rate for Payer: Aetna Commercial |
$5,037.98
|
| Rate for Payer: Aetna Medicare |
$59.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,852.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$71.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$71.15
|
| Rate for Payer: BCBS Complete |
$31.26
|
| Rate for Payer: BCBS MAPPO |
$56.92
|
| Rate for Payer: BCBS Trust/PPO |
$142.50
|
| Rate for Payer: BCN Commercial |
$142.50
|
| Rate for Payer: BCN Medicare Advantage |
$56.92
|
| Rate for Payer: Cash Price |
$4,741.62
|
| Rate for Payer: Cash Price |
$4,741.62
|
| Rate for Payer: Cofinity Advantage |
$4,148.92
|
| Rate for Payer: Cofinity Commercial |
$5,097.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,741.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$5,334.33
|
| Rate for Payer: Mclaren Medicaid |
$29.77
|
| Rate for Payer: Mclaren Medicare |
$56.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$59.77
|
| Rate for Payer: Meridian Medicaid |
$59.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$62.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,037.98
|
| Rate for Payer: Nomi Health Commercial |
$170.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,445.27
|
| Rate for Payer: PACE Medicare |
$54.07
|
| Rate for Payer: PACE SWMI |
$56.92
|
| Rate for Payer: PHP Commercial |
$5,037.98
|
| Rate for Payer: PHP Medicare Advantage |
$56.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$176.13
|
| Rate for Payer: Priority Health Medicare |
$56.92
|
| Rate for Payer: Priority Health SBD |
$3,734.03
|
| Rate for Payer: Priority Health Tiered Network |
$140.90
|
| Rate for Payer: Railroad Medicare Medicare |
$56.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.74
|
| Rate for Payer: UHC Core |
$93.74
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$56.92
|
| Rate for Payer: UHC Exchange |
$93.74
|
| Rate for Payer: UHC Medicaid |
$29.77
|
| Rate for Payer: UHCCP Medicaid |
$29.77
|
| Rate for Payer: VA VA |
$56.92
|
|
|
EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$75,476.73
|
|
|
Service Code
|
HCPCS J9321
|
| Hospital Charge Code |
204020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$67,929.06 |
| Rate for Payer: Aetna Commercial |
$64,155.22
|
| Rate for Payer: Aetna Medicare |
$59.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49,059.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$71.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$71.15
|
| Rate for Payer: BCBS Complete |
$31.26
|
| Rate for Payer: BCBS MAPPO |
$56.92
|
| Rate for Payer: BCBS Trust/PPO |
$142.50
|
| Rate for Payer: BCN Commercial |
$142.50
|
| Rate for Payer: BCN Medicare Advantage |
$56.92
|
| Rate for Payer: Cash Price |
$60,381.38
|
| Rate for Payer: Cash Price |
$60,381.38
|
| Rate for Payer: Cofinity Advantage |
$52,833.71
|
| Rate for Payer: Cofinity Commercial |
$64,909.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60,381.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$67,929.06
|
| Rate for Payer: Mclaren Medicaid |
$29.77
|
| Rate for Payer: Mclaren Medicare |
$56.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$59.77
|
| Rate for Payer: Meridian Medicaid |
$59.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$62.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$64,155.22
|
| Rate for Payer: Nomi Health Commercial |
$170.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56,607.55
|
| Rate for Payer: PACE Medicare |
$54.07
|
| Rate for Payer: PACE SWMI |
$56.92
|
| Rate for Payer: PHP Commercial |
$64,155.22
|
| Rate for Payer: PHP Medicare Advantage |
$56.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$176.13
|
| Rate for Payer: Priority Health Medicare |
$56.92
|
| Rate for Payer: Priority Health SBD |
$47,550.34
|
| Rate for Payer: Priority Health Tiered Network |
$140.90
|
| Rate for Payer: Railroad Medicare Medicare |
$56.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.74
|
| Rate for Payer: UHC Core |
$93.74
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$56.92
|
| Rate for Payer: UHC Exchange |
$93.74
|
| Rate for Payer: UHC Medicaid |
$29.77
|
| Rate for Payer: UHCCP Medicaid |
$29.77
|
| Rate for Payer: VA VA |
$56.92
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$39.74
|
|
|
Service Code
|
NDC 51754425003
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.62 |
| Max. Negotiated Rate |
$35.77 |
| Rate for Payer: Aetna Commercial |
$33.78
|
| Rate for Payer: Aetna Medicare |
$19.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.83
|
| Rate for Payer: BCBS Complete |
$15.90
|
| Rate for Payer: Cash Price |
$31.79
|
| Rate for Payer: Cofinity Advantage |
$27.82
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.79
|
| Rate for Payer: Healthscope Commercial |
$35.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.80
|
| Rate for Payer: PHP Commercial |
$33.78
|
| Rate for Payer: Priority Health SBD |
$25.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.83
|
| Rate for Payer: UHC Core |
$20.70
|
| Rate for Payer: UHC Exchange |
$15.62
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$39.74
|
|
|
Service Code
|
NDC 51754425001
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.62 |
| Max. Negotiated Rate |
$35.77 |
| Rate for Payer: Aetna Commercial |
$33.78
|
| Rate for Payer: Aetna Medicare |
$19.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.83
|
| Rate for Payer: BCBS Complete |
$15.90
|
| Rate for Payer: Cash Price |
$31.79
|
| Rate for Payer: Cofinity Advantage |
$27.82
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.79
|
| Rate for Payer: Healthscope Commercial |
$35.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.80
|
| Rate for Payer: PHP Commercial |
$33.78
|
| Rate for Payer: Priority Health SBD |
$25.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.83
|
| Rate for Payer: UHC Core |
$20.70
|
| Rate for Payer: UHC Exchange |
$15.62
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$39.74
|
|
|
Service Code
|
NDC 51754425001
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$35.77 |
| Rate for Payer: Aetna Commercial |
$33.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.83
|
| Rate for Payer: Cash Price |
$31.79
|
| Rate for Payer: Cofinity Advantage |
$27.82
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.79
|
| Rate for Payer: Healthscope Commercial |
$35.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.80
|
| Rate for Payer: PHP Commercial |
$33.78
|
| Rate for Payer: Priority Health SBD |
$25.04
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$39.74
|
|
|
Service Code
|
NDC 51754425003
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$35.77 |
| Rate for Payer: Aetna Commercial |
$33.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.83
|
| Rate for Payer: Cash Price |
$31.79
|
| Rate for Payer: Cofinity Advantage |
$27.82
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.79
|
| Rate for Payer: Healthscope Commercial |
$35.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.80
|
| Rate for Payer: PHP Commercial |
$33.78
|
| Rate for Payer: Priority Health SBD |
$25.04
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.97
|
|
|
Service Code
|
NDC 65219025700
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Advantage |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.73
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$16.83
|
|
|
Service Code
|
NDC 55150037301
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna Medicare |
$8.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.94
|
| Rate for Payer: BCBS Complete |
$6.73
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cofinity Advantage |
$11.78
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Healthscope Commercial |
$15.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: PHP Commercial |
$14.31
|
| Rate for Payer: Priority Health SBD |
$10.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.94
|
| Rate for Payer: UHC Core |
$8.77
|
| Rate for Payer: UHC Exchange |
$6.61
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$27.53
|
|
|
Service Code
|
NDC 00641623801
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cofinity Advantage |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$23.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Healthscope Commercial |
$24.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.65
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: Priority Health SBD |
$17.34
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$16.83
|
|
|
Service Code
|
NDC 55150037301
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.94
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cofinity Advantage |
$11.78
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Healthscope Commercial |
$15.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: PHP Commercial |
$14.31
|
| Rate for Payer: Priority Health SBD |
$10.60
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.97
|
|
|
Service Code
|
NDC 65219025701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Advantage |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.73
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$31.11
|
|
|
Service Code
|
NDC 70121163701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$26.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.22
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Cofinity Advantage |
$21.78
|
| Rate for Payer: Cofinity Commercial |
$26.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.89
|
| Rate for Payer: Healthscope Commercial |
$28.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.33
|
| Rate for Payer: PHP Commercial |
$26.44
|
| Rate for Payer: Priority Health SBD |
$19.60
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$16.83
|
|
|
Service Code
|
NDC 55150037325
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.94
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cofinity Advantage |
$11.78
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Healthscope Commercial |
$15.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: PHP Commercial |
$14.31
|
| Rate for Payer: Priority Health SBD |
$10.60
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$16.83
|
|
|
Service Code
|
NDC 55150037325
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$15.15 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna Medicare |
$8.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.94
|
| Rate for Payer: BCBS Complete |
$6.73
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cofinity Advantage |
$11.78
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Healthscope Commercial |
$15.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: PHP Commercial |
$14.31
|
| Rate for Payer: Priority Health SBD |
$10.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.94
|
| Rate for Payer: UHC Core |
$8.77
|
| Rate for Payer: UHC Exchange |
$6.61
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$27.53
|
|
|
Service Code
|
NDC 00641623825
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Medicare |
$13.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: BCBS Complete |
$11.01
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cofinity Advantage |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$23.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Healthscope Commercial |
$24.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.65
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.89
|
| Rate for Payer: UHC Core |
$14.34
|
| Rate for Payer: UHC Exchange |
$10.82
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$28.97
|
|
|
Service Code
|
NDC 65219025701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.39 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Medicare |
$14.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: BCBS Complete |
$11.59
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Advantage |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.73
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health SBD |
$18.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.83
|
| Rate for Payer: UHC Core |
$15.09
|
| Rate for Payer: UHC Exchange |
$11.39
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$27.53
|
|
|
Service Code
|
NDC 00641623801
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Medicare |
$13.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: BCBS Complete |
$11.01
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cofinity Advantage |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$23.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Healthscope Commercial |
$24.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.65
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.89
|
| Rate for Payer: UHC Core |
$14.34
|
| Rate for Payer: UHC Exchange |
$10.82
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$34.71
|
|
|
Service Code
|
NDC 70121163705
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.87 |
| Max. Negotiated Rate |
$31.24 |
| Rate for Payer: Aetna Commercial |
$29.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.56
|
| Rate for Payer: Cash Price |
$27.77
|
| Rate for Payer: Cofinity Advantage |
$24.30
|
| Rate for Payer: Cofinity Commercial |
$29.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.77
|
| Rate for Payer: Healthscope Commercial |
$31.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.03
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: Priority Health SBD |
$21.87
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$27.53
|
|
|
Service Code
|
NDC 00641623825
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cofinity Advantage |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$23.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Healthscope Commercial |
$24.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.65
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: Priority Health SBD |
$17.34
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$31.11
|
|
|
Service Code
|
NDC 70121163701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.23 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$26.44
|
| Rate for Payer: Aetna Medicare |
$15.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.22
|
| Rate for Payer: BCBS Complete |
$12.44
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Cofinity Advantage |
$21.78
|
| Rate for Payer: Cofinity Commercial |
$26.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.89
|
| Rate for Payer: Healthscope Commercial |
$28.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.33
|
| Rate for Payer: PHP Commercial |
$26.44
|
| Rate for Payer: Priority Health SBD |
$19.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.22
|
| Rate for Payer: UHC Core |
$16.21
|
| Rate for Payer: UHC Exchange |
$12.23
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$28.97
|
|
|
Service Code
|
NDC 65219025700
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.39 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Medicare |
$14.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: BCBS Complete |
$11.59
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Advantage |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.73
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health SBD |
$18.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.83
|
| Rate for Payer: UHC Core |
$15.09
|
| Rate for Payer: UHC Exchange |
$11.39
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$34.71
|
|
|
Service Code
|
NDC 70121163705
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.64 |
| Max. Negotiated Rate |
$31.24 |
| Rate for Payer: Aetna Commercial |
$29.50
|
| Rate for Payer: Aetna Medicare |
$17.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.56
|
| Rate for Payer: BCBS Complete |
$13.88
|
| Rate for Payer: Cash Price |
$27.77
|
| Rate for Payer: Cofinity Advantage |
$24.30
|
| Rate for Payer: Cofinity Commercial |
$29.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.77
|
| Rate for Payer: Healthscope Commercial |
$31.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.03
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: Priority Health SBD |
$21.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.56
|
| Rate for Payer: UHC Core |
$18.08
|
| Rate for Payer: UHC Exchange |
$13.64
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$27.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
179024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.94
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cofinity Advantage |
$19.27
|
| Rate for Payer: Cofinity Advantage |
$11.78
|
| Rate for Payer: Cofinity Advantage |
$20.28
|
| Rate for Payer: Cofinity Advantage |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Commercial |
$23.68
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Healthscope Commercial |
$24.78
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Healthscope Commercial |
$15.15
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: PHP Commercial |
$14.31
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health SBD |
$12.34
|
| Rate for Payer: Priority Health SBD |
$18.25
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: Priority Health SBD |
$10.60
|
|
