|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$498.06
|
|
|
Service Code
|
NDC 50111-788-10
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$313.78 |
| Max. Negotiated Rate |
$448.25 |
| Rate for Payer: Aetna Commercial |
$423.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$323.74
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Cofinity Commercial |
$348.64
|
| Rate for Payer: Cofinity Commercial |
$428.33
|
| Rate for Payer: Healthscope Commercial |
$448.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$423.35
|
| Rate for Payer: PHP Commercial |
$423.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.64
|
| Rate for Payer: Priority Health SBD |
$313.78
|
|
|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$308.81
|
|
|
Service Code
|
NDC 60687-271-21
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.55 |
| Max. Negotiated Rate |
$277.93 |
| Rate for Payer: Aetna Commercial |
$262.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.73
|
| Rate for Payer: Cash Price |
$247.05
|
| Rate for Payer: Cofinity Commercial |
$216.17
|
| Rate for Payer: Cofinity Commercial |
$265.58
|
| Rate for Payer: Healthscope Commercial |
$277.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$262.49
|
| Rate for Payer: PHP Commercial |
$262.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.17
|
| Rate for Payer: Priority Health SBD |
$194.55
|
|
|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$250.42
|
|
|
Service Code
|
NDC 50268-099-13
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.76 |
| Max. Negotiated Rate |
$225.38 |
| Rate for Payer: Aetna Commercial |
$212.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.77
|
| Rate for Payer: Cash Price |
$200.34
|
| Rate for Payer: Cofinity Commercial |
$175.29
|
| Rate for Payer: Cofinity Commercial |
$215.36
|
| Rate for Payer: Healthscope Commercial |
$225.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.86
|
| Rate for Payer: PHP Commercial |
$212.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.29
|
| Rate for Payer: Priority Health SBD |
$157.76
|
|
|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$219.32
|
|
|
Service Code
|
NDC 0904-6909-04
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.17 |
| Max. Negotiated Rate |
$197.39 |
| Rate for Payer: Aetna Commercial |
$186.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.56
|
| Rate for Payer: Cash Price |
$175.46
|
| Rate for Payer: Cofinity Commercial |
$153.52
|
| Rate for Payer: Cofinity Commercial |
$188.62
|
| Rate for Payer: Healthscope Commercial |
$197.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.42
|
| Rate for Payer: PHP Commercial |
$186.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.52
|
| Rate for Payer: Priority Health SBD |
$138.17
|
|
|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$10.30
|
|
|
Service Code
|
NDC 60687-271-11
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$9.27 |
| Rate for Payer: Aetna Commercial |
$8.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.70
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cofinity Commercial |
$7.21
|
| Rate for Payer: Cofinity Commercial |
$8.86
|
| Rate for Payer: Healthscope Commercial |
$9.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.76
|
| Rate for Payer: PHP Commercial |
$8.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.21
|
| Rate for Payer: Priority Health SBD |
$6.49
|
|
|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$498.06
|
|
|
Service Code
|
NDC 68180-161-06
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$313.78 |
| Max. Negotiated Rate |
$448.25 |
| Rate for Payer: Aetna Commercial |
$423.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$323.74
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Cofinity Commercial |
$348.64
|
| Rate for Payer: Cofinity Commercial |
$428.33
|
| Rate for Payer: Healthscope Commercial |
$448.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$423.35
|
| Rate for Payer: PHP Commercial |
$423.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.64
|
| Rate for Payer: Priority Health SBD |
$313.78
|
|
|
AZITHROMYCIN 500 MG TABLET
|
Facility
IP
|
$8.35
|
|
|
Service Code
|
NDC 50268-099-11
|
| Hospital Charge Code |
17482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$7.52 |
| Rate for Payer: Aetna Commercial |
$7.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.43
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: Cofinity Commercial |
$5.84
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Healthscope Commercial |
$7.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.10
|
| Rate for Payer: PHP Commercial |
$7.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.84
|
| Rate for Payer: Priority Health SBD |
$5.26
|
|
|
AZTREONAM 1 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$99.29
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
9185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.55 |
| Max. Negotiated Rate |
$89.36 |
| Rate for Payer: Aetna Commercial |
$84.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.54
|
| Rate for Payer: Cash Price |
$79.43
|
| Rate for Payer: Cofinity Commercial |
$85.39
|
| Rate for Payer: Cofinity Commercial |
$69.50
|
| Rate for Payer: Healthscope Commercial |
$89.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$84.40
|
| Rate for Payer: PHP Commercial |
$84.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.50
|
| Rate for Payer: Priority Health SBD |
$62.55
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$196.28
|
|
|
Service Code
|
HCPCS J0457
|
| Hospital Charge Code |
9186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.66 |
| Max. Negotiated Rate |
$176.65 |
| Rate for Payer: Aetna Commercial |
$166.84
|
| Rate for Payer: Aetna Commercial |
$172.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$127.58
|
| Rate for Payer: Cash Price |
$162.20
|
| Rate for Payer: Cash Price |
$157.02
|
| Rate for Payer: Cofinity Commercial |
$168.80
|
| Rate for Payer: Cofinity Commercial |
$141.92
|
| Rate for Payer: Cofinity Commercial |
$174.36
|
| Rate for Payer: Cofinity Commercial |
$137.40
|
| Rate for Payer: Healthscope Commercial |
$182.48
|
| Rate for Payer: Healthscope Commercial |
$176.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$166.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.34
|
| Rate for Payer: PHP Commercial |
$166.84
|
| Rate for Payer: PHP Commercial |
$172.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.40
|
| Rate for Payer: Priority Health SBD |
$123.66
|
| Rate for Payer: Priority Health SBD |
$127.73
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT
|
Facility
IP
|
$10.92
|
|
|
Service Code
|
NDC 70000-0547-1
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.10
|
| Rate for Payer: Cash Price |
$8.74
|
| Rate for Payer: Cofinity Commercial |
$7.64
|
| Rate for Payer: Cofinity Commercial |
$9.39
|
| Rate for Payer: Healthscope Commercial |
$9.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.28
|
| Rate for Payer: PHP Commercial |
$9.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.64
|
| Rate for Payer: Priority Health SBD |
$6.88
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT
|
Facility
IP
|
$10.23
|
|
|
Service Code
|
NDC 1678411731
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$9.21 |
| Rate for Payer: Aetna Commercial |
$8.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.65
|
| Rate for Payer: Cash Price |
$8.18
|
| Rate for Payer: Cofinity Commercial |
$7.16
|
| Rate for Payer: Cofinity Commercial |
$8.80
|
| Rate for Payer: Healthscope Commercial |
$9.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.70
|
| Rate for Payer: PHP Commercial |
$8.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.16
|
| Rate for Payer: Priority Health SBD |
$6.44
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT
|
Facility
IP
|
$10.08
|
|
|
Service Code
|
NDC 61269-105-56
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$8.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.55
|
| Rate for Payer: Cash Price |
$8.06
|
| Rate for Payer: Cofinity Commercial |
$7.06
|
| Rate for Payer: Cofinity Commercial |
$8.67
|
| Rate for Payer: Healthscope Commercial |
$9.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.57
|
| Rate for Payer: PHP Commercial |
$8.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.06
|
| Rate for Payer: Priority Health SBD |
$6.35
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT
|
Facility
IP
|
$10.46
|
|
|
Service Code
|
NDC 0536-1263-28
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$9.41 |
| Rate for Payer: Aetna Commercial |
$8.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.80
|
| Rate for Payer: Cash Price |
$8.37
|
| Rate for Payer: Cofinity Commercial |
$7.32
|
| Rate for Payer: Cofinity Commercial |
$9.00
|
| Rate for Payer: Healthscope Commercial |
$9.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.89
|
| Rate for Payer: PHP Commercial |
$8.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.32
|
| Rate for Payer: Priority Health SBD |
$6.59
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT
|
Facility
IP
|
$10.26
|
|
|
Service Code
|
NDC 1442800944
|
| Hospital Charge Code |
13818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET
|
Facility
IP
|
$1.27
|
|
|
Service Code
|
NDC 53329-089-87
|
| Hospital Charge Code |
113171
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna Commercial |
$1.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.83
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cofinity Commercial |
$0.89
|
| Rate for Payer: Cofinity Commercial |
$1.09
|
| Rate for Payer: Healthscope Commercial |
$1.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.08
|
| Rate for Payer: PHP Commercial |
$1.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.89
|
| Rate for Payer: Priority Health SBD |
$0.80
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT IN PACKET
|
Facility
IP
|
$1.27
|
|
|
Service Code
|
NDC 53329-089-86
|
| Hospital Charge Code |
113171
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna Commercial |
$1.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.83
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cofinity Commercial |
$0.89
|
| Rate for Payer: Cofinity Commercial |
$1.09
|
| Rate for Payer: Healthscope Commercial |
$1.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.08
|
| Rate for Payer: PHP Commercial |
$1.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.89
|
| Rate for Payer: Priority Health SBD |
$0.80
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC
|
Facility
IP
|
$36,091.81
|
|
|
Service Code
|
MS-DRG 519
|
| Min. Negotiated Rate |
$13,936.66 |
| Max. Negotiated Rate |
$36,091.81 |
| Rate for Payer: Aetna Medicare |
$15,256.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,337.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,337.71
|
| Rate for Payer: BCBS MAPPO |
$14,670.17
|
| Rate for Payer: BCBS Trust/PPO |
$36,091.81
|
| Rate for Payer: BCN Medicare Advantage |
$14,670.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,670.17
|
| Rate for Payer: Mclaren Medicare |
$14,670.17
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15,403.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,870.70
|
| Rate for Payer: PACE Medicare |
$13,936.66
|
| Rate for Payer: PACE SWMI |
$14,670.17
|
| Rate for Payer: PHP Medicare Advantage |
$14,670.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28,249.25
|
| Rate for Payer: Priority Health Medicare |
$14,670.17
|
| Rate for Payer: Priority Health Narrow Network |
$22,599.40
|
| Rate for Payer: Railroad Medicare Medicare |
$14,670.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30,029.02
|
| Rate for Payer: UHC Core |
$18,426.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$14,670.17
|
| Rate for Payer: UHC Exchange |
$19,735.22
|
| Rate for Payer: UHC Medicare Advantage |
$15,110.28
|
| Rate for Payer: VA VA |
$14,670.17
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR
|
Facility
IP
|
$55,704.56
|
|
|
Service Code
|
MS-DRG 518
|
| Min. Negotiated Rate |
$25,452.61 |
| Max. Negotiated Rate |
$55,704.56 |
| Rate for Payer: Aetna Medicare |
$27,863.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33,490.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33,490.28
|
| Rate for Payer: BCBS MAPPO |
$26,792.22
|
| Rate for Payer: BCBS Trust/PPO |
$52,157.02
|
| Rate for Payer: BCN Medicare Advantage |
$26,792.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26,792.22
|
| Rate for Payer: Mclaren Medicare |
$26,792.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$28,131.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30,811.05
|
| Rate for Payer: PACE Medicare |
$25,452.61
|
| Rate for Payer: PACE SWMI |
$26,792.22
|
| Rate for Payer: PHP Medicare Advantage |
$26,792.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52,403.04
|
| Rate for Payer: Priority Health Medicare |
$26,792.22
|
| Rate for Payer: Priority Health Narrow Network |
$41,922.43
|
| Rate for Payer: Railroad Medicare Medicare |
$26,792.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55,704.56
|
| Rate for Payer: UHC Core |
$34,180.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$26,792.22
|
| Rate for Payer: UHC Exchange |
$36,609.30
|
| Rate for Payer: UHC Medicare Advantage |
$27,595.99
|
| Rate for Payer: VA VA |
$26,792.22
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC
|
Facility
IP
|
$28,616.97
|
|
|
Service Code
|
MS-DRG 520
|
| Min. Negotiated Rate |
$10,262.00 |
| Max. Negotiated Rate |
$28,616.97 |
| Rate for Payer: Aetna Medicare |
$11,234.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,502.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,502.64
|
| Rate for Payer: BCBS MAPPO |
$10,802.11
|
| Rate for Payer: BCBS Trust/PPO |
$28,616.97
|
| Rate for Payer: BCN Medicare Advantage |
$10,802.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,802.11
|
| Rate for Payer: Mclaren Medicare |
$10,802.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,342.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,422.43
|
| Rate for Payer: PACE Medicare |
$10,262.00
|
| Rate for Payer: PACE SWMI |
$10,802.11
|
| Rate for Payer: PHP Medicare Advantage |
$10,802.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,541.91
|
| Rate for Payer: Priority Health Medicare |
$10,802.11
|
| Rate for Payer: Priority Health Narrow Network |
$16,433.53
|
| Rate for Payer: Railroad Medicare Medicare |
$10,802.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21,836.10
|
| Rate for Payer: UHC Core |
$13,398.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,802.11
|
| Rate for Payer: UHC Exchange |
$14,350.79
|
| Rate for Payer: UHC Medicare Advantage |
$11,126.17
|
| Rate for Payer: VA VA |
$10,802.11
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$799.00
|
|
|
Service Code
|
NDC 0172-4096-80
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$503.37 |
| Max. Negotiated Rate |
$719.10 |
| Rate for Payer: Aetna Commercial |
$679.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$519.35
|
| Rate for Payer: Cash Price |
$639.20
|
| Rate for Payer: Cofinity Commercial |
$559.30
|
| Rate for Payer: Cofinity Commercial |
$687.14
|
| Rate for Payer: Healthscope Commercial |
$719.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$679.15
|
| Rate for Payer: PHP Commercial |
$679.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$559.30
|
| Rate for Payer: Priority Health SBD |
$503.37
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$96.35
|
|
|
Service Code
|
NDC 72888-010-01
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.70 |
| Max. Negotiated Rate |
$86.72 |
| Rate for Payer: Aetna Commercial |
$81.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.63
|
| Rate for Payer: Cash Price |
$77.08
|
| Rate for Payer: Cofinity Commercial |
$67.44
|
| Rate for Payer: Cofinity Commercial |
$82.86
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.90
|
| Rate for Payer: PHP Commercial |
$81.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.44
|
| Rate for Payer: Priority Health SBD |
$60.70
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$254.88
|
|
|
Service Code
|
NDC 60687-503-01
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.57 |
| Max. Negotiated Rate |
$229.39 |
| Rate for Payer: Aetna Commercial |
$216.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.67
|
| Rate for Payer: Cash Price |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$178.42
|
| Rate for Payer: Cofinity Commercial |
$219.20
|
| Rate for Payer: Healthscope Commercial |
$229.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.65
|
| Rate for Payer: PHP Commercial |
$216.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.42
|
| Rate for Payer: Priority Health SBD |
$160.57
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$331.55
|
|
|
Service Code
|
NDC 0904-6475-61
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.88 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.08
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.08
|
| Rate for Payer: Priority Health SBD |
$208.88
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$2.55
|
|
|
Service Code
|
NDC 60687-503-11
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health SBD |
$1.61
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$131.60
|
|
|
Service Code
|
NDC 52817-320-10
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.91 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.12
|
| Rate for Payer: Priority Health SBD |
$82.91
|
|
