|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
NDC 65162036110
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.20 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.20
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health SBD |
$118.44
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.60 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna Commercial |
$190.40
|
| Rate for Payer: Aetna Medicare |
$112.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.60
|
| Rate for Payer: BCBS Complete |
$89.60
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cofinity Commercial |
$156.80
|
| Rate for Payer: Cofinity Commercial |
$192.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.20
|
| Rate for Payer: Healthscope Commercial |
$201.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.40
|
| Rate for Payer: PHP Commercial |
$190.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.60
|
| Rate for Payer: Priority Health SBD |
$141.12
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 62584089711
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.98
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cofinity Commercial |
$1.05
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.20
|
| Rate for Payer: Healthscope Commercial |
$1.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.28
|
| Rate for Payer: PHP Commercial |
$1.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.98
|
| Rate for Payer: Priority Health SBD |
$0.95
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$161.70
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.87 |
| Max. Negotiated Rate |
$145.53 |
| Rate for Payer: Aetna Commercial |
$137.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.10
|
| Rate for Payer: Cash Price |
$129.36
|
| Rate for Payer: Cofinity Commercial |
$113.19
|
| Rate for Payer: Cofinity Commercial |
$139.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.36
|
| Rate for Payer: Healthscope Commercial |
$145.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.44
|
| Rate for Payer: PHP Commercial |
$137.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.10
|
| Rate for Payer: Priority Health SBD |
$101.87
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$147.40
|
|
|
Service Code
|
NDC 00904722461
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.96 |
| Max. Negotiated Rate |
$132.66 |
| Rate for Payer: Aetna Commercial |
$125.29
|
| Rate for Payer: Aetna Medicare |
$73.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.81
|
| Rate for Payer: BCBS Complete |
$58.96
|
| Rate for Payer: Cash Price |
$117.92
|
| Rate for Payer: Cofinity Commercial |
$103.18
|
| Rate for Payer: Cofinity Commercial |
$126.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.92
|
| Rate for Payer: Healthscope Commercial |
$132.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.29
|
| Rate for Payer: PHP Commercial |
$125.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.81
|
| Rate for Payer: Priority Health SBD |
$92.86
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.12 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna Commercial |
$190.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.60
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cofinity Commercial |
$156.80
|
| Rate for Payer: Cofinity Commercial |
$192.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.20
|
| Rate for Payer: Healthscope Commercial |
$201.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.40
|
| Rate for Payer: PHP Commercial |
$190.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.60
|
| Rate for Payer: Priority Health SBD |
$141.12
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
NDC 60687068111
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.38
|
| Rate for Payer: Aetna Medicare |
$0.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.05
|
| Rate for Payer: BCBS Complete |
$0.65
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cofinity Commercial |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.30
|
| Rate for Payer: Healthscope Commercial |
$1.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.38
|
| Rate for Payer: PHP Commercial |
$1.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.05
|
| Rate for Payer: Priority Health SBD |
$1.02
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 62584089711
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.98
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cofinity Commercial |
$1.05
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.20
|
| Rate for Payer: Healthscope Commercial |
$1.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.28
|
| Rate for Payer: PHP Commercial |
$1.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.98
|
| Rate for Payer: Priority Health SBD |
$0.95
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
NDC 69315012701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.32 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna Commercial |
$139.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cofinity Commercial |
$114.80
|
| Rate for Payer: Cofinity Commercial |
$141.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$114.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.20
|
| Rate for Payer: Healthscope Commercial |
$147.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.40
|
| Rate for Payer: PHP Commercial |
$139.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.60
|
| Rate for Payer: Priority Health SBD |
$103.32
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
NDC 60687068111
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.05
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cofinity Commercial |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.30
|
| Rate for Payer: Healthscope Commercial |
$1.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.38
|
| Rate for Payer: PHP Commercial |
$1.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.05
|
| Rate for Payer: Priority Health SBD |
$1.02
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$161.70
|
|
|
Service Code
|
NDC 60687068101
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$145.53 |
| Rate for Payer: Aetna Commercial |
$137.44
|
| Rate for Payer: Aetna Medicare |
$80.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.10
|
| Rate for Payer: BCBS Complete |
$64.68
|
| Rate for Payer: Cash Price |
$129.36
|
| Rate for Payer: Cofinity Commercial |
$113.19
|
| Rate for Payer: Cofinity Commercial |
$139.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.36
|
| Rate for Payer: Healthscope Commercial |
$145.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.44
|
| Rate for Payer: PHP Commercial |
$137.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.10
|
| Rate for Payer: Priority Health SBD |
$101.87
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$147.40
|
|
|
Service Code
|
NDC 00904722461
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.86 |
| Max. Negotiated Rate |
$132.66 |
| Rate for Payer: Aetna Commercial |
$125.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.81
|
| Rate for Payer: Cash Price |
$117.92
|
| Rate for Payer: Cofinity Commercial |
$103.18
|
| Rate for Payer: Cofinity Commercial |
$126.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.92
|
| Rate for Payer: Healthscope Commercial |
$132.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.29
|
| Rate for Payer: PHP Commercial |
$125.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.81
|
| Rate for Payer: Priority Health SBD |
$92.86
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$149.60
|
|
|
Service Code
|
NDC 62584089701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.25 |
| Max. Negotiated Rate |
$134.64 |
| Rate for Payer: Aetna Commercial |
$127.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.24
|
| Rate for Payer: Cash Price |
$119.68
|
| Rate for Payer: Cofinity Commercial |
$104.72
|
| Rate for Payer: Cofinity Commercial |
$128.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.68
|
| Rate for Payer: Healthscope Commercial |
$134.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.16
|
| Rate for Payer: PHP Commercial |
$127.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.24
|
| Rate for Payer: Priority Health SBD |
$94.25
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
NDC 65162036110
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.44 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.20
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health SBD |
$118.44
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$158.59
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.91 |
| Max. Negotiated Rate |
$142.73 |
| Rate for Payer: Aetna Commercial |
$134.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.08
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$111.01
|
| Rate for Payer: Cofinity Commercial |
$136.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.87
|
| Rate for Payer: Healthscope Commercial |
$142.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.80
|
| Rate for Payer: PHP Commercial |
$134.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: Priority Health SBD |
$99.91
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$158.59
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.44 |
| Max. Negotiated Rate |
$142.73 |
| Rate for Payer: Aetna Commercial |
$134.80
|
| Rate for Payer: Aetna Medicare |
$79.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.08
|
| Rate for Payer: BCBS Complete |
$63.44
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$111.01
|
| Rate for Payer: Cofinity Commercial |
$136.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.87
|
| Rate for Payer: Healthscope Commercial |
$142.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.80
|
| Rate for Payer: PHP Commercial |
$134.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: Priority Health SBD |
$99.91
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,517.76
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$1,365.98 |
| Rate for Payer: Aetna Commercial |
$1,290.10
|
| Rate for Payer: Aetna Commercial |
$2,494.16
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,907.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$986.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.70
|
| Rate for Payer: BCBS Complete |
$3.47
|
| Rate for Payer: BCBS Complete |
$3.47
|
| Rate for Payer: BCBS MAPPO |
$6.16
|
| Rate for Payer: BCBS MAPPO |
$6.16
|
| Rate for Payer: BCBS Trust/PPO |
$28.22
|
| Rate for Payer: BCBS Trust/PPO |
$28.22
|
| Rate for Payer: BCN Commercial |
$28.22
|
| Rate for Payer: BCN Commercial |
$28.22
|
| Rate for Payer: BCN Medicare Advantage |
$6.16
|
| Rate for Payer: BCN Medicare Advantage |
$6.16
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cash Price |
$1,214.21
|
| Rate for Payer: Cash Price |
$1,214.21
|
| Rate for Payer: Cofinity Commercial |
$1,062.43
|
| Rate for Payer: Cofinity Commercial |
$2,523.51
|
| Rate for Payer: Cofinity Commercial |
$2,054.02
|
| Rate for Payer: Cofinity Commercial |
$1,305.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,062.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,054.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,214.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,347.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.16
|
| Rate for Payer: Healthscope Commercial |
$2,640.88
|
| Rate for Payer: Healthscope Commercial |
$1,365.98
|
| Rate for Payer: Mclaren Medicaid |
$3.30
|
| Rate for Payer: Mclaren Medicaid |
$3.30
|
| Rate for Payer: Mclaren Medicare |
$6.16
|
| Rate for Payer: Mclaren Medicare |
$6.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.47
|
| Rate for Payer: Meridian Medicaid |
$3.47
|
| Rate for Payer: Meridian Medicaid |
$3.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,494.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,290.10
|
| Rate for Payer: Nomi Health Commercial |
$18.48
|
| Rate for Payer: Nomi Health Commercial |
$18.48
|
| Rate for Payer: PACE Medicare |
$5.85
|
| Rate for Payer: PACE Medicare |
$5.85
|
| Rate for Payer: PACE SWMI |
$6.16
|
| Rate for Payer: PACE SWMI |
$6.16
|
| Rate for Payer: PHP Commercial |
$1,290.10
|
| Rate for Payer: PHP Commercial |
$2,494.16
|
| Rate for Payer: PHP Medicare Advantage |
$6.16
|
| Rate for Payer: PHP Medicare Advantage |
$6.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$986.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,907.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.53
|
| Rate for Payer: Priority Health Medicare |
$6.16
|
| Rate for Payer: Priority Health Medicare |
$6.16
|
| Rate for Payer: Priority Health Narrow Network |
$14.82
|
| Rate for Payer: Priority Health Narrow Network |
$14.82
|
| Rate for Payer: Priority Health SBD |
$1,848.62
|
| Rate for Payer: Priority Health SBD |
$956.19
|
| Rate for Payer: Railroad Medicare Medicare |
$6.16
|
| Rate for Payer: Railroad Medicare Medicare |
$6.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.16
|
| Rate for Payer: UHC Medicare Advantage |
$6.16
|
| Rate for Payer: UHC Medicare Advantage |
$6.16
|
| Rate for Payer: UHCCP Medicaid |
$3.47
|
| Rate for Payer: UHCCP Medicaid |
$3.47
|
| Rate for Payer: VA VA |
$6.16
|
| Rate for Payer: VA VA |
$6.16
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,517.76
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$956.19 |
| Max. Negotiated Rate |
$1,365.98 |
| Rate for Payer: Aetna Commercial |
$1,290.10
|
| Rate for Payer: Aetna Commercial |
$2,494.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$986.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,907.30
|
| Rate for Payer: Cash Price |
$1,214.21
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cofinity Commercial |
$1,062.43
|
| Rate for Payer: Cofinity Commercial |
$2,054.02
|
| Rate for Payer: Cofinity Commercial |
$2,523.51
|
| Rate for Payer: Cofinity Commercial |
$1,305.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,054.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,062.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,214.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,347.45
|
| Rate for Payer: Healthscope Commercial |
$1,365.98
|
| Rate for Payer: Healthscope Commercial |
$2,640.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,290.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,494.16
|
| Rate for Payer: PHP Commercial |
$1,290.10
|
| Rate for Payer: PHP Commercial |
$2,494.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,907.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$986.54
|
| Rate for Payer: Priority Health SBD |
$1,848.62
|
| Rate for Payer: Priority Health SBD |
$956.19
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$166.75
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$150.08 |
| Rate for Payer: Aetna Commercial |
$141.74
|
| Rate for Payer: Aetna Medicare |
$83.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.39
|
| Rate for Payer: BCBS Complete |
$66.70
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$133.40
|
| Rate for Payer: Cash Price |
$133.40
|
| Rate for Payer: Cofinity Commercial |
$116.72
|
| Rate for Payer: Cofinity Commercial |
$143.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.40
|
| Rate for Payer: Healthscope Commercial |
$150.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.74
|
| Rate for Payer: PHP Commercial |
$141.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.39
|
| Rate for Payer: Priority Health SBD |
$105.05
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$166.75
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.05 |
| Max. Negotiated Rate |
$150.08 |
| Rate for Payer: Aetna Commercial |
$141.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.39
|
| Rate for Payer: Cash Price |
$133.40
|
| Rate for Payer: Cofinity Commercial |
$116.72
|
| Rate for Payer: Cofinity Commercial |
$143.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.40
|
| Rate for Payer: Healthscope Commercial |
$150.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.74
|
| Rate for Payer: PHP Commercial |
$141.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.39
|
| Rate for Payer: Priority Health SBD |
$105.05
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$32.93
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$29.64 |
| Rate for Payer: Aetna Commercial |
$27.99
|
| Rate for Payer: Aetna Commercial |
$21.49
|
| Rate for Payer: Aetna Commercial |
$43.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.96
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$40.57
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Cofinity Commercial |
$21.74
|
| Rate for Payer: Cofinity Commercial |
$23.05
|
| Rate for Payer: Cofinity Commercial |
$28.32
|
| Rate for Payer: Cofinity Commercial |
$35.50
|
| Rate for Payer: Cofinity Commercial |
$43.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.57
|
| Rate for Payer: Healthscope Commercial |
$22.75
|
| Rate for Payer: Healthscope Commercial |
$29.64
|
| Rate for Payer: Healthscope Commercial |
$45.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.10
|
| Rate for Payer: PHP Commercial |
$27.99
|
| Rate for Payer: PHP Commercial |
$43.10
|
| Rate for Payer: PHP Commercial |
$21.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.43
|
| Rate for Payer: Priority Health SBD |
$31.95
|
| Rate for Payer: Priority Health SBD |
$20.75
|
| Rate for Payer: Priority Health SBD |
$15.93
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$50.71
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$45.64 |
| Rate for Payer: Aetna Commercial |
$43.10
|
| Rate for Payer: Aetna Commercial |
$21.49
|
| Rate for Payer: Aetna Commercial |
$27.99
|
| Rate for Payer: Aetna Medicare |
$12.64
|
| Rate for Payer: Aetna Medicare |
$16.46
|
| Rate for Payer: Aetna Medicare |
$25.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.96
|
| Rate for Payer: BCBS Complete |
$13.17
|
| Rate for Payer: BCBS Complete |
$10.11
|
| Rate for Payer: BCBS Complete |
$20.28
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$40.57
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$40.57
|
| Rate for Payer: Cofinity Commercial |
$23.05
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Cofinity Commercial |
$21.74
|
| Rate for Payer: Cofinity Commercial |
$28.32
|
| Rate for Payer: Cofinity Commercial |
$35.50
|
| Rate for Payer: Cofinity Commercial |
$43.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.57
|
| Rate for Payer: Healthscope Commercial |
$29.64
|
| Rate for Payer: Healthscope Commercial |
$22.75
|
| Rate for Payer: Healthscope Commercial |
$45.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.10
|
| Rate for Payer: PHP Commercial |
$27.99
|
| Rate for Payer: PHP Commercial |
$43.10
|
| Rate for Payer: PHP Commercial |
$21.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.43
|
| Rate for Payer: Priority Health SBD |
$15.93
|
| Rate for Payer: Priority Health SBD |
$31.95
|
| Rate for Payer: Priority Health SBD |
$20.75
|
|
|
FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$82.31
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.86 |
| Max. Negotiated Rate |
$74.08 |
| Rate for Payer: Aetna Commercial |
$69.96
|
| Rate for Payer: Aetna Commercial |
$55.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.50
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Cofinity Commercial |
$70.79
|
| Rate for Payer: Cofinity Commercial |
$57.62
|
| Rate for Payer: Cofinity Commercial |
$46.07
|
| Rate for Payer: Cofinity Commercial |
$56.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.85
|
| Rate for Payer: Healthscope Commercial |
$74.08
|
| Rate for Payer: Healthscope Commercial |
$59.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.96
|
| Rate for Payer: PHP Commercial |
$69.96
|
| Rate for Payer: PHP Commercial |
$55.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.50
|
| Rate for Payer: Priority Health SBD |
$41.46
|
| Rate for Payer: Priority Health SBD |
$51.86
|
|
|
FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$65.81
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$59.23 |
| Rate for Payer: Aetna Commercial |
$55.94
|
| Rate for Payer: Aetna Commercial |
$69.96
|
| Rate for Payer: Aetna Medicare |
$41.16
|
| Rate for Payer: Aetna Medicare |
$32.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.50
|
| Rate for Payer: BCBS Complete |
$32.92
|
| Rate for Payer: BCBS Complete |
$26.32
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Cofinity Commercial |
$56.60
|
| Rate for Payer: Cofinity Commercial |
$46.07
|
| Rate for Payer: Cofinity Commercial |
$57.62
|
| Rate for Payer: Cofinity Commercial |
$70.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.85
|
| Rate for Payer: Healthscope Commercial |
$74.08
|
| Rate for Payer: Healthscope Commercial |
$59.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.94
|
| Rate for Payer: PHP Commercial |
$69.96
|
| Rate for Payer: PHP Commercial |
$55.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.78
|
| Rate for Payer: Priority Health SBD |
$51.86
|
| Rate for Payer: Priority Health SBD |
$41.46
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$127.79
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
39803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$115.01 |
| Rate for Payer: Aetna Commercial |
$108.62
|
| Rate for Payer: Aetna Commercial |
$163.89
|
| Rate for Payer: Aetna Medicare |
$96.40
|
| Rate for Payer: Aetna Medicare |
$63.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.33
|
| Rate for Payer: BCBS Complete |
$77.12
|
| Rate for Payer: BCBS Complete |
$51.12
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$154.25
|
| Rate for Payer: Cash Price |
$102.23
|
| Rate for Payer: Cash Price |
$102.23
|
| Rate for Payer: Cash Price |
$154.25
|
| Rate for Payer: Cofinity Commercial |
$89.45
|
| Rate for Payer: Cofinity Commercial |
$109.90
|
| Rate for Payer: Cofinity Commercial |
$134.97
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.25
|
| Rate for Payer: Healthscope Commercial |
$173.53
|
| Rate for Payer: Healthscope Commercial |
$115.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.62
|
| Rate for Payer: PHP Commercial |
$163.89
|
| Rate for Payer: PHP Commercial |
$108.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.06
|
| Rate for Payer: Priority Health SBD |
$121.47
|
| Rate for Payer: Priority Health SBD |
$80.51
|
|
