|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$54.51
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.80 |
| Max. Negotiated Rate |
$49.06 |
| Rate for Payer: Aetna Commercial |
$46.33
|
| Rate for Payer: Aetna Commercial |
$33.03
|
| Rate for Payer: Aetna Medicare |
$19.43
|
| Rate for Payer: Aetna Medicare |
$27.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.26
|
| Rate for Payer: BCBS Complete |
$21.80
|
| Rate for Payer: BCBS Complete |
$15.54
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: Cash Price |
$31.09
|
| Rate for Payer: Cofinity Commercial |
$46.88
|
| Rate for Payer: Cofinity Commercial |
$27.20
|
| Rate for Payer: Cofinity Commercial |
$33.42
|
| Rate for Payer: Cofinity Commercial |
$38.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$38.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.61
|
| Rate for Payer: Healthscope Commercial |
$49.06
|
| Rate for Payer: Healthscope Commercial |
$34.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.03
|
| Rate for Payer: PHP Commercial |
$46.33
|
| Rate for Payer: PHP Commercial |
$33.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.43
|
| Rate for Payer: Priority Health SBD |
$24.48
|
| Rate for Payer: Priority Health SBD |
$34.34
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$54.51
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.34 |
| Max. Negotiated Rate |
$49.06 |
| Rate for Payer: Aetna Commercial |
$46.33
|
| Rate for Payer: Aetna Commercial |
$33.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.43
|
| Rate for Payer: Cash Price |
$31.09
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: Cofinity Commercial |
$46.88
|
| Rate for Payer: Cofinity Commercial |
$38.16
|
| Rate for Payer: Cofinity Commercial |
$27.20
|
| Rate for Payer: Cofinity Commercial |
$33.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$38.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.61
|
| Rate for Payer: Healthscope Commercial |
$49.06
|
| Rate for Payer: Healthscope Commercial |
$34.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.33
|
| Rate for Payer: PHP Commercial |
$46.33
|
| Rate for Payer: PHP Commercial |
$33.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.43
|
| Rate for Payer: Priority Health SBD |
$24.48
|
| Rate for Payer: Priority Health SBD |
$34.34
|
|
|
DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC
|
Facility
|
OP
|
$4,734.21
|
|
|
Service Code
|
CPT 42975
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$901.47 |
| Max. Negotiated Rate |
$4,734.21 |
| Rate for Payer: Aetna Medicare |
$1,749.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,102.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,102.30
|
| Rate for Payer: BCBS Complete |
$946.54
|
| Rate for Payer: BCBS MAPPO |
$1,681.84
|
| Rate for Payer: BCN Medicare Advantage |
$1,681.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,681.84
|
| Rate for Payer: Mclaren Medicaid |
$901.47
|
| Rate for Payer: Mclaren Medicare |
$1,681.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,765.93
|
| Rate for Payer: Meridian Medicaid |
$946.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,934.12
|
| Rate for Payer: PACE Medicare |
$1,597.75
|
| Rate for Payer: PACE SWMI |
$1,681.84
|
| Rate for Payer: PHP Medicare Advantage |
$1,681.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$901.47
|
| Rate for Payer: Priority Health Medicare |
$1,681.84
|
| Rate for Payer: Railroad Medicare Medicare |
$1,681.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,734.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,681.84
|
| Rate for Payer: UHC Medicare Advantage |
$1,681.84
|
| Rate for Payer: UHCCP Medicaid |
$946.88
|
| Rate for Payer: VA VA |
$1,681.84
|
|
|
DRUG TEST PRESUMPTIVE READ BY INSTR ASSISTED DIRECT OPTICAL OBS
|
Professional
|
Both
|
$16.00
|
|
|
Service Code
|
HCPCS G0478
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna Medicare |
$8.00
|
| Rate for Payer: BCBS Complete |
$6.40
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.40
|
|
|
DRUG TEST PRESUMPTIVE USING IMMUNOASSAY
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS G0479
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$53.30 |
| Rate for Payer: Aetna Medicare |
$41.00
|
| Rate for Payer: BCBS Complete |
$32.80
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.30
|
|
|
DRUG TEST(S), PRESUMPTIVE READ BY DIRECT OPTICAL OBSERVATION
|
Professional
|
Both
|
$12.00
|
|
|
Service Code
|
HCPCS G0477
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Medicare |
$6.00
|
| Rate for Payer: BCBS Complete |
$4.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.80
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$127.01
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.02 |
| Max. Negotiated Rate |
$114.31 |
| Rate for Payer: Aetna Commercial |
$107.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.56
|
| Rate for Payer: Cash Price |
$101.61
|
| Rate for Payer: Cofinity Commercial |
$109.23
|
| Rate for Payer: Cofinity Commercial |
$88.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$88.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.61
|
| Rate for Payer: Healthscope Commercial |
$114.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.96
|
| Rate for Payer: PHP Commercial |
$107.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.56
|
| Rate for Payer: Priority Health SBD |
$80.02
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$115.35
|
|
|
Service Code
|
NDC 00904704304
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.14 |
| Max. Negotiated Rate |
$103.81 |
| Rate for Payer: Aetna Commercial |
$98.05
|
| Rate for Payer: Aetna Medicare |
$57.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.98
|
| Rate for Payer: BCBS Complete |
$46.14
|
| Rate for Payer: Cash Price |
$92.28
|
| Rate for Payer: Cofinity Commercial |
$80.75
|
| Rate for Payer: Cofinity Commercial |
$99.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.28
|
| Rate for Payer: Healthscope Commercial |
$103.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.05
|
| Rate for Payer: PHP Commercial |
$98.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.98
|
| Rate for Payer: Priority Health SBD |
$72.67
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$127.01
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.80 |
| Max. Negotiated Rate |
$114.31 |
| Rate for Payer: Aetna Commercial |
$107.96
|
| Rate for Payer: Aetna Medicare |
$63.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.56
|
| Rate for Payer: BCBS Complete |
$50.80
|
| Rate for Payer: Cash Price |
$101.61
|
| Rate for Payer: Cofinity Commercial |
$109.23
|
| Rate for Payer: Cofinity Commercial |
$88.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$88.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.61
|
| Rate for Payer: Healthscope Commercial |
$114.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.96
|
| Rate for Payer: PHP Commercial |
$107.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.56
|
| Rate for Payer: Priority Health SBD |
$80.02
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 60687072311
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.76
|
| Rate for Payer: BCBS Complete |
$1.70
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Cofinity Commercial |
$3.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.39
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.76
|
| Rate for Payer: Priority Health SBD |
$2.67
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$115.35
|
|
|
Service Code
|
NDC 00904704304
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.67 |
| Max. Negotiated Rate |
$103.81 |
| Rate for Payer: Aetna Commercial |
$98.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.98
|
| Rate for Payer: Cash Price |
$92.28
|
| Rate for Payer: Cofinity Commercial |
$80.75
|
| Rate for Payer: Cofinity Commercial |
$99.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.28
|
| Rate for Payer: Healthscope Commercial |
$103.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.05
|
| Rate for Payer: PHP Commercial |
$98.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.98
|
| Rate for Payer: Priority Health SBD |
$72.67
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$1,721.84
|
|
|
Service Code
|
NDC 00002323560
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,084.76 |
| Max. Negotiated Rate |
$1,549.66 |
| Rate for Payer: Aetna Commercial |
$1,463.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,119.20
|
| Rate for Payer: Cash Price |
$1,377.47
|
| Rate for Payer: Cofinity Commercial |
$1,205.29
|
| Rate for Payer: Cofinity Commercial |
$1,480.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,205.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,377.47
|
| Rate for Payer: Healthscope Commercial |
$1,549.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,463.56
|
| Rate for Payer: PHP Commercial |
$1,463.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,119.20
|
| Rate for Payer: Priority Health SBD |
$1,084.76
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 60687072311
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.76
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Cofinity Commercial |
$3.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.39
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.76
|
| Rate for Payer: Priority Health SBD |
$2.67
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$1,721.84
|
|
|
Service Code
|
NDC 00002323560
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$688.74 |
| Max. Negotiated Rate |
$1,549.66 |
| Rate for Payer: Aetna Commercial |
$1,463.56
|
| Rate for Payer: Aetna Medicare |
$860.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,119.20
|
| Rate for Payer: BCBS Complete |
$688.74
|
| Rate for Payer: Cash Price |
$1,377.47
|
| Rate for Payer: Cofinity Commercial |
$1,205.29
|
| Rate for Payer: Cofinity Commercial |
$1,480.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,205.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,377.47
|
| Rate for Payer: Healthscope Commercial |
$1,549.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,463.56
|
| Rate for Payer: PHP Commercial |
$1,463.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,119.20
|
| Rate for Payer: Priority Health SBD |
$1,084.76
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$7.15
|
|
|
Service Code
|
NDC 68084068311
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.65
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.72
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.08
|
| Rate for Payer: PHP Commercial |
$6.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.65
|
| Rate for Payer: Priority Health SBD |
$4.50
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$304.56
|
|
|
Service Code
|
NDC 57237001890
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.87 |
| Max. Negotiated Rate |
$274.10 |
| Rate for Payer: Aetna Commercial |
$258.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.96
|
| Rate for Payer: Cash Price |
$243.65
|
| Rate for Payer: Cofinity Commercial |
$213.19
|
| Rate for Payer: Cofinity Commercial |
$261.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.65
|
| Rate for Payer: Healthscope Commercial |
$274.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.88
|
| Rate for Payer: PHP Commercial |
$258.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.96
|
| Rate for Payer: Priority Health SBD |
$191.87
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$304.56
|
|
|
Service Code
|
NDC 57237001890
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.82 |
| Max. Negotiated Rate |
$274.10 |
| Rate for Payer: Aetna Commercial |
$258.88
|
| Rate for Payer: Aetna Medicare |
$152.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.96
|
| Rate for Payer: BCBS Complete |
$121.82
|
| Rate for Payer: Cash Price |
$243.65
|
| Rate for Payer: Cofinity Commercial |
$213.19
|
| Rate for Payer: Cofinity Commercial |
$261.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.65
|
| Rate for Payer: Healthscope Commercial |
$274.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.88
|
| Rate for Payer: PHP Commercial |
$258.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.96
|
| Rate for Payer: Priority Health SBD |
$191.87
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$7.15
|
|
|
Service Code
|
NDC 68084068311
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Aetna Medicare |
$3.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.65
|
| Rate for Payer: BCBS Complete |
$2.86
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.72
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.08
|
| Rate for Payer: PHP Commercial |
$6.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.65
|
| Rate for Payer: Priority Health SBD |
$4.50
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$714.24
|
|
|
Service Code
|
NDC 68084068301
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$449.97 |
| Max. Negotiated Rate |
$642.82 |
| Rate for Payer: Aetna Commercial |
$607.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.26
|
| Rate for Payer: Cash Price |
$571.39
|
| Rate for Payer: Cofinity Commercial |
$499.97
|
| Rate for Payer: Cofinity Commercial |
$614.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$499.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$571.39
|
| Rate for Payer: Healthscope Commercial |
$642.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$607.10
|
| Rate for Payer: PHP Commercial |
$607.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$464.26
|
| Rate for Payer: Priority Health SBD |
$449.97
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$445.44
|
|
|
Service Code
|
NDC 00904704461
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.63 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$378.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$289.54
|
| Rate for Payer: Cash Price |
$356.35
|
| Rate for Payer: Cofinity Commercial |
$311.81
|
| Rate for Payer: Cofinity Commercial |
$383.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$356.35
|
| Rate for Payer: Healthscope Commercial |
$400.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$378.62
|
| Rate for Payer: PHP Commercial |
$378.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$289.54
|
| Rate for Payer: Priority Health SBD |
$280.63
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$714.24
|
|
|
Service Code
|
NDC 68084068301
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.70 |
| Max. Negotiated Rate |
$642.82 |
| Rate for Payer: Aetna Commercial |
$607.10
|
| Rate for Payer: Aetna Medicare |
$357.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.26
|
| Rate for Payer: BCBS Complete |
$285.70
|
| Rate for Payer: Cash Price |
$571.39
|
| Rate for Payer: Cofinity Commercial |
$499.97
|
| Rate for Payer: Cofinity Commercial |
$614.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$499.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$571.39
|
| Rate for Payer: Healthscope Commercial |
$642.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$607.10
|
| Rate for Payer: PHP Commercial |
$607.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$464.26
|
| Rate for Payer: Priority Health SBD |
$449.97
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$445.44
|
|
|
Service Code
|
NDC 00904704461
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.18 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$378.62
|
| Rate for Payer: Aetna Medicare |
$222.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$289.54
|
| Rate for Payer: BCBS Complete |
$178.18
|
| Rate for Payer: Cash Price |
$356.35
|
| Rate for Payer: Cofinity Commercial |
$311.81
|
| Rate for Payer: Cofinity Commercial |
$383.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$356.35
|
| Rate for Payer: Healthscope Commercial |
$400.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$378.62
|
| Rate for Payer: PHP Commercial |
$378.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$289.54
|
| Rate for Payer: Priority Health SBD |
$280.63
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 50268028811
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Aetna Medicare |
$1.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.22
|
| Rate for Payer: BCBS Complete |
$1.37
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.74
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.91
|
| Rate for Payer: PHP Commercial |
$2.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.22
|
| Rate for Payer: Priority Health SBD |
$2.15
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$102.53
|
|
|
Service Code
|
NDC 50268028813
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.01 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Aetna Commercial |
$87.15
|
| Rate for Payer: Aetna Medicare |
$51.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.64
|
| Rate for Payer: BCBS Complete |
$41.01
|
| Rate for Payer: Cash Price |
$82.02
|
| Rate for Payer: Cofinity Commercial |
$71.77
|
| Rate for Payer: Cofinity Commercial |
$88.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$71.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.02
|
| Rate for Payer: Healthscope Commercial |
$92.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.15
|
| Rate for Payer: PHP Commercial |
$87.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.64
|
| Rate for Payer: Priority Health SBD |
$64.59
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$7.15
|
|
|
Service Code
|
NDC 68084069211
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.65
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.72
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.08
|
| Rate for Payer: PHP Commercial |
$6.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.65
|
| Rate for Payer: Priority Health SBD |
$4.50
|
|
