|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$65.80
|
|
|
Service Code
|
NDC 16729-200-01
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.45 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.06
|
| Rate for Payer: Priority Health SBD |
$41.45
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$105.75
|
|
|
Service Code
|
NDC 64380-741-06
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.62 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$112.80
|
|
|
Service Code
|
NDC 24689-781-01
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.06 |
| Max. Negotiated Rate |
$101.52 |
| Rate for Payer: Aetna Commercial |
$95.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.32
|
| Rate for Payer: Cash Price |
$90.24
|
| Rate for Payer: Cofinity Commercial |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$97.01
|
| Rate for Payer: Healthscope Commercial |
$101.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$95.88
|
| Rate for Payer: PHP Commercial |
$95.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.96
|
| Rate for Payer: Priority Health SBD |
$71.06
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$564.00
|
|
|
Service Code
|
NDC 0093-0053-05
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$355.32 |
| Max. Negotiated Rate |
$507.60 |
| Rate for Payer: Aetna Commercial |
$479.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.60
|
| Rate for Payer: Cash Price |
$451.20
|
| Rate for Payer: Cofinity Commercial |
$394.80
|
| Rate for Payer: Cofinity Commercial |
$485.04
|
| Rate for Payer: Healthscope Commercial |
$507.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$479.40
|
| Rate for Payer: PHP Commercial |
$479.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$394.80
|
| Rate for Payer: Priority Health SBD |
$355.32
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$105.75
|
|
|
Service Code
|
NDC 68382-180-01
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.62 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$220.90
|
|
|
Service Code
|
NDC 51079-985-20
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.17 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.58
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Commercial |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Healthscope Commercial |
$198.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.76
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.63
|
| Rate for Payer: Priority Health SBD |
$139.17
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$220.90
|
|
|
Service Code
|
NDC 0904-7122-61
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.17 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.58
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Commercial |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Healthscope Commercial |
$198.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.76
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.63
|
| Rate for Payer: Priority Health SBD |
$139.17
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$2.21
|
|
|
Service Code
|
NDC 51079-985-01
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$1.55
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
| Rate for Payer: PHP Commercial |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health SBD |
$1.39
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$365.40
|
|
|
Service Code
|
NDC 0904-6938-06
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.20 |
| Max. Negotiated Rate |
$328.86 |
| Rate for Payer: Aetna Commercial |
$310.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.51
|
| Rate for Payer: Cash Price |
$292.32
|
| Rate for Payer: Cofinity Commercial |
$255.78
|
| Rate for Payer: Cofinity Commercial |
$314.24
|
| Rate for Payer: Healthscope Commercial |
$328.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$310.59
|
| Rate for Payer: PHP Commercial |
$310.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.78
|
| Rate for Payer: Priority Health SBD |
$230.20
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$735.70
|
|
|
Service Code
|
NDC 0603-2544-21
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$463.49 |
| Max. Negotiated Rate |
$662.13 |
| Rate for Payer: Aetna Commercial |
$625.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$478.20
|
| Rate for Payer: Cash Price |
$588.56
|
| Rate for Payer: Cofinity Commercial |
$514.99
|
| Rate for Payer: Cofinity Commercial |
$632.70
|
| Rate for Payer: Healthscope Commercial |
$662.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$625.34
|
| Rate for Payer: PHP Commercial |
$625.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$514.99
|
| Rate for Payer: Priority Health SBD |
$463.49
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$10.65
|
|
|
Service Code
|
NDC 68084-396-11
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.92
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cofinity Commercial |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$9.16
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.05
|
| Rate for Payer: PHP Commercial |
$9.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.46
|
| Rate for Payer: Priority Health SBD |
$6.71
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$532.35
|
|
|
Service Code
|
NDC 68084-396-65
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$335.38 |
| Max. Negotiated Rate |
$479.12 |
| Rate for Payer: Aetna Commercial |
$452.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.03
|
| Rate for Payer: Cash Price |
$425.88
|
| Rate for Payer: Cofinity Commercial |
$372.64
|
| Rate for Payer: Cofinity Commercial |
$457.82
|
| Rate for Payer: Healthscope Commercial |
$479.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$452.50
|
| Rate for Payer: PHP Commercial |
$452.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$372.64
|
| Rate for Payer: Priority Health SBD |
$335.38
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$8.57
|
|
|
Service Code
|
NDC 60687-672-11
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.57
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: Cofinity Commercial |
$6.00
|
| Rate for Payer: Cofinity Commercial |
$7.37
|
| Rate for Payer: Healthscope Commercial |
$7.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.28
|
| Rate for Payer: PHP Commercial |
$7.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.00
|
| Rate for Payer: Priority Health SBD |
$5.40
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$428.05
|
|
|
Service Code
|
NDC 60687-672-65
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$269.67 |
| Max. Negotiated Rate |
$385.24 |
| Rate for Payer: Aetna Commercial |
$363.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.23
|
| Rate for Payer: Cash Price |
$342.44
|
| Rate for Payer: Cofinity Commercial |
$299.64
|
| Rate for Payer: Cofinity Commercial |
$368.12
|
| Rate for Payer: Healthscope Commercial |
$385.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$363.84
|
| Rate for Payer: PHP Commercial |
$363.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.64
|
| Rate for Payer: Priority Health SBD |
$269.67
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION
|
Facility
IP
|
$35.90
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
9334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$32.31 |
| Rate for Payer: Aetna Commercial |
$30.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.34
|
| Rate for Payer: Cash Price |
$28.72
|
| Rate for Payer: Cofinity Commercial |
$25.13
|
| Rate for Payer: Cofinity Commercial |
$30.87
|
| Rate for Payer: Healthscope Commercial |
$32.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.52
|
| Rate for Payer: PHP Commercial |
$30.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.13
|
| Rate for Payer: Priority Health SBD |
$22.62
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION
|
Facility
IP
|
$62,272.49
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
105644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39,231.67 |
| Max. Negotiated Rate |
$56,045.24 |
| Rate for Payer: Aetna Commercial |
$52,931.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40,477.12
|
| Rate for Payer: Cash Price |
$49,817.99
|
| Rate for Payer: Cofinity Commercial |
$43,590.74
|
| Rate for Payer: Cofinity Commercial |
$53,554.34
|
| Rate for Payer: Healthscope Commercial |
$56,045.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52,931.62
|
| Rate for Payer: PHP Commercial |
$52,931.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43,590.74
|
| Rate for Payer: Priority Health SBD |
$39,231.67
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION
|
Facility
OP
|
$62,272.49
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
105644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.12 |
| Max. Negotiated Rate |
$56,045.24 |
| Rate for Payer: Aetna Commercial |
$52,931.62
|
| Rate for Payer: Aetna Medicare |
$218.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40,477.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$263.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$263.07
|
| Rate for Payer: BCBS Complete |
$120.88
|
| Rate for Payer: BCBS MAPPO |
$210.45
|
| Rate for Payer: BCBS Trust/PPO |
$623.04
|
| Rate for Payer: BCN Medicare Advantage |
$210.45
|
| Rate for Payer: Cash Price |
$49,817.99
|
| Rate for Payer: Cash Price |
$49,817.99
|
| Rate for Payer: Cofinity Commercial |
$53,554.34
|
| Rate for Payer: Cofinity Commercial |
$43,590.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$210.45
|
| Rate for Payer: Healthscope Commercial |
$56,045.24
|
| Rate for Payer: Mclaren Medicaid |
$115.12
|
| Rate for Payer: Mclaren Medicare |
$210.45
|
| Rate for Payer: Meridian Medicaid |
$120.88
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$220.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$242.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52,931.62
|
| Rate for Payer: PACE Medicare |
$199.93
|
| Rate for Payer: PACE SWMI |
$210.45
|
| Rate for Payer: PHP Commercial |
$52,931.62
|
| Rate for Payer: PHP Medicare Advantage |
$210.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$115.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43,590.74
|
| Rate for Payer: Priority Health Medicare |
$210.45
|
| Rate for Payer: Priority Health SBD |
$39,231.67
|
| Rate for Payer: Railroad Medicare Medicare |
$210.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$210.45
|
| Rate for Payer: UHC Medicare Advantage |
$216.77
|
| Rate for Payer: VA VA |
$210.45
|
|
|
CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER
|
Facility
IP
|
$11,311.36
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,126.16 |
| Max. Negotiated Rate |
$10,180.22 |
| Rate for Payer: Aetna Commercial |
$9,614.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,352.38
|
| Rate for Payer: Cash Price |
$9,049.09
|
| Rate for Payer: Cofinity Commercial |
$7,917.95
|
| Rate for Payer: Cofinity Commercial |
$9,727.77
|
| Rate for Payer: Healthscope Commercial |
$10,180.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,614.66
|
| Rate for Payer: PHP Commercial |
$9,614.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,917.95
|
| Rate for Payer: Priority Health SBD |
$7,126.16
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER
|
Facility
IP
|
$16,967.03
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,689.23 |
| Max. Negotiated Rate |
$15,270.33 |
| Rate for Payer: Aetna Commercial |
$14,421.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,028.57
|
| Rate for Payer: Cash Price |
$13,573.62
|
| Rate for Payer: Cofinity Commercial |
$11,876.92
|
| Rate for Payer: Cofinity Commercial |
$14,591.65
|
| Rate for Payer: Healthscope Commercial |
$15,270.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14,421.98
|
| Rate for Payer: PHP Commercial |
$14,421.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,876.92
|
| Rate for Payer: Priority Health SBD |
$10,689.23
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE INTRAVENOUS SOLUTION
|
Facility
IP
|
$48.07
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$43.26 |
| Rate for Payer: Aetna Commercial |
$40.86
|
| Rate for Payer: Aetna Commercial |
$38.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.25
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cash Price |
$38.46
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Cofinity Commercial |
$31.35
|
| Rate for Payer: Cofinity Commercial |
$41.34
|
| Rate for Payer: Cofinity Commercial |
$33.65
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Healthscope Commercial |
$43.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.06
|
| Rate for Payer: PHP Commercial |
$40.86
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.35
|
| Rate for Payer: Priority Health SBD |
$30.28
|
| Rate for Payer: Priority Health SBD |
$28.21
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE ORAL SOLUTION
|
Facility
IP
|
$37.76
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.79 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna Commercial |
$32.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.54
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cofinity Commercial |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.10
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.43
|
| Rate for Payer: Priority Health SBD |
$23.79
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
IP
|
$108.02
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.05 |
| Max. Negotiated Rate |
$97.22 |
| Rate for Payer: Aetna Commercial |
$91.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.21
|
| Rate for Payer: Cash Price |
$86.42
|
| Rate for Payer: Cofinity Commercial |
$75.61
|
| Rate for Payer: Cofinity Commercial |
$92.90
|
| Rate for Payer: Healthscope Commercial |
$97.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.82
|
| Rate for Payer: PHP Commercial |
$91.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.61
|
| Rate for Payer: Priority Health SBD |
$68.05
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
IP
|
$108.02
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.05 |
| Max. Negotiated Rate |
$97.22 |
| Rate for Payer: Aetna Commercial |
$91.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.21
|
| Rate for Payer: Cash Price |
$86.42
|
| Rate for Payer: Cofinity Commercial |
$75.61
|
| Rate for Payer: Cofinity Commercial |
$92.90
|
| Rate for Payer: Healthscope Commercial |
$97.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.82
|
| Rate for Payer: PHP Commercial |
$91.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.61
|
| Rate for Payer: Priority Health SBD |
$68.05
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
IP
|
$14.34
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$12.91 |
| Rate for Payer: Aetna Commercial |
$12.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.32
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cofinity Commercial |
$10.04
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Healthscope Commercial |
$12.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.19
|
| Rate for Payer: PHP Commercial |
$12.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.04
|
| Rate for Payer: Priority Health SBD |
$9.03
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
IP
|
$8.50
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.52
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cofinity Commercial |
$5.95
|
| Rate for Payer: Cofinity Commercial |
$7.31
|
| Rate for Payer: Healthscope Commercial |
$7.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.22
|
| Rate for Payer: PHP Commercial |
$7.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.95
|
| Rate for Payer: Priority Health SBD |
$5.36
|
|
