|
CALCIUM CARBONATE 500 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET
|
Facility
IP
|
$172.00
|
|
|
Service Code
|
NDC 1000670038
|
| Hospital Charge Code |
19483
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.36 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna Commercial |
$146.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.80
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cofinity Commercial |
$120.40
|
| Rate for Payer: Cofinity Commercial |
$147.92
|
| Rate for Payer: Healthscope Commercial |
$154.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$146.20
|
| Rate for Payer: PHP Commercial |
$146.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.40
|
| Rate for Payer: Priority Health SBD |
$108.36
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$33.65
|
|
|
Service Code
|
NDC 0517-6710-10
|
| Hospital Charge Code |
108968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$30.28 |
| Rate for Payer: Aetna Commercial |
$28.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.87
|
| Rate for Payer: Cash Price |
$26.92
|
| Rate for Payer: Cofinity Commercial |
$23.56
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Healthscope Commercial |
$30.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.60
|
| Rate for Payer: PHP Commercial |
$28.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.56
|
| Rate for Payer: Priority Health SBD |
$21.20
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$33.65
|
|
|
Service Code
|
NDC 0517-6710-01
|
| Hospital Charge Code |
108968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$30.28 |
| Rate for Payer: Aetna Commercial |
$28.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.87
|
| Rate for Payer: Cash Price |
$26.92
|
| Rate for Payer: Cofinity Commercial |
$23.56
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Healthscope Commercial |
$30.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.60
|
| Rate for Payer: PHP Commercial |
$28.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.56
|
| Rate for Payer: Priority Health SBD |
$21.20
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE
|
Facility
IP
|
$39.39
|
|
|
Service Code
|
NDC 76329-3304-1
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$35.45 |
| Rate for Payer: Aetna Commercial |
$33.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.60
|
| Rate for Payer: Cash Price |
$31.51
|
| Rate for Payer: Cofinity Commercial |
$27.57
|
| Rate for Payer: Cofinity Commercial |
$33.88
|
| Rate for Payer: Healthscope Commercial |
$35.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.48
|
| Rate for Payer: PHP Commercial |
$33.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.57
|
| Rate for Payer: Priority Health SBD |
$24.82
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE
|
Facility
OP
|
$39.39
|
|
|
Service Code
|
NDC 76329-3304-1
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.76 |
| Max. Negotiated Rate |
$35.45 |
| Rate for Payer: Aetna Commercial |
$33.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.60
|
| Rate for Payer: BCBS Complete |
$15.76
|
| Rate for Payer: Cash Price |
$31.51
|
| Rate for Payer: Cofinity Commercial |
$27.57
|
| Rate for Payer: Cofinity Commercial |
$33.88
|
| Rate for Payer: Healthscope Commercial |
$35.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.48
|
| Rate for Payer: PHP Commercial |
$33.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.57
|
| Rate for Payer: Priority Health SBD |
$24.82
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE
|
Facility
IP
|
$33.11
|
|
|
Service Code
|
NDC 64253-900-30
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$29.80 |
| Rate for Payer: Aetna Commercial |
$28.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.52
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cofinity Commercial |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$28.47
|
| Rate for Payer: Healthscope Commercial |
$29.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.14
|
| Rate for Payer: PHP Commercial |
$28.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.18
|
| Rate for Payer: Priority Health SBD |
$20.86
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE
|
Facility
IP
|
$60.08
|
|
|
Service Code
|
NDC 0409-4928-34
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.85 |
| Max. Negotiated Rate |
$54.07 |
| Rate for Payer: Aetna Commercial |
$51.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.05
|
| Rate for Payer: Cash Price |
$48.06
|
| Rate for Payer: Cofinity Commercial |
$42.06
|
| Rate for Payer: Cofinity Commercial |
$51.67
|
| Rate for Payer: Healthscope Commercial |
$54.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.07
|
| Rate for Payer: PHP Commercial |
$51.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.06
|
| Rate for Payer: Priority Health SBD |
$37.85
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE
|
Facility
IP
|
$36.23
|
|
|
Service Code
|
NDC 64253-900-91
|
| Hospital Charge Code |
1306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.82 |
| Max. Negotiated Rate |
$32.61 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.55
|
| Rate for Payer: Cash Price |
$28.98
|
| Rate for Payer: Cofinity Commercial |
$25.36
|
| Rate for Payer: Cofinity Commercial |
$31.16
|
| Rate for Payer: Healthscope Commercial |
$32.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.80
|
| Rate for Payer: PHP Commercial |
$30.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.36
|
| Rate for Payer: Priority Health SBD |
$22.82
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) IV SYRINGE (CODE)
|
Facility
IP
|
$60.08
|
|
|
Service Code
|
NDC 0409-4928-34
|
| Hospital Charge Code |
163711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.85 |
| Max. Negotiated Rate |
$54.07 |
| Rate for Payer: Aetna Commercial |
$51.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.05
|
| Rate for Payer: Cash Price |
$48.06
|
| Rate for Payer: Cofinity Commercial |
$42.06
|
| Rate for Payer: Cofinity Commercial |
$51.67
|
| Rate for Payer: Healthscope Commercial |
$54.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.07
|
| Rate for Payer: PHP Commercial |
$51.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.06
|
| Rate for Payer: Priority Health SBD |
$37.85
|
|
|
CALCIUM CHLORIDE 100 MG/ML (10 %) IV SYRINGE (CODE)
|
Facility
IP
|
$39.39
|
|
|
Service Code
|
NDC 76329-3304-1
|
| Hospital Charge Code |
163711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$35.45 |
| Rate for Payer: Aetna Commercial |
$33.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.60
|
| Rate for Payer: Cash Price |
$31.51
|
| Rate for Payer: Cofinity Commercial |
$33.88
|
| Rate for Payer: Cofinity Commercial |
$27.57
|
| Rate for Payer: Healthscope Commercial |
$35.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.48
|
| Rate for Payer: PHP Commercial |
$33.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.57
|
| Rate for Payer: Priority Health SBD |
$24.82
|
|
|
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$39.34
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
1312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.78 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Aetna Commercial |
$33.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.57
|
| Rate for Payer: Cash Price |
$31.47
|
| Rate for Payer: Cofinity Commercial |
$27.54
|
| Rate for Payer: Cofinity Commercial |
$33.83
|
| Rate for Payer: Healthscope Commercial |
$35.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.44
|
| Rate for Payer: PHP Commercial |
$33.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.54
|
| Rate for Payer: Priority Health SBD |
$24.78
|
|
|
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION
|
Facility
OP
|
$39.34
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
1312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Aetna Commercial |
$33.44
|
| Rate for Payer: Aetna Medicare |
$0.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.06
|
| Rate for Payer: BCBS Complete |
$0.03
|
| Rate for Payer: BCBS MAPPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.15
|
| Rate for Payer: BCN Medicare Advantage |
$0.05
|
| Rate for Payer: Cash Price |
$31.47
|
| Rate for Payer: Cash Price |
$31.47
|
| Rate for Payer: Cofinity Commercial |
$33.83
|
| Rate for Payer: Cofinity Commercial |
$27.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.05
|
| Rate for Payer: Healthscope Commercial |
$35.41
|
| Rate for Payer: Mclaren Medicaid |
$0.03
|
| Rate for Payer: Mclaren Medicare |
$0.05
|
| Rate for Payer: Meridian Medicaid |
$0.03
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$0.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.44
|
| Rate for Payer: PACE Medicare |
$0.05
|
| Rate for Payer: PACE SWMI |
$0.05
|
| Rate for Payer: PHP Commercial |
$33.44
|
| Rate for Payer: PHP Medicare Advantage |
$0.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.54
|
| Rate for Payer: Priority Health Medicare |
$0.05
|
| Rate for Payer: Priority Health SBD |
$24.78
|
| Rate for Payer: Railroad Medicare Medicare |
$0.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.05
|
| Rate for Payer: UHC Medicare Advantage |
$0.05
|
| Rate for Payer: VA VA |
$0.05
|
|
|
CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS (TPN COMPONENT)
|
Facility
IP
|
$167.77
|
|
|
Service Code
|
HCPCS J0612
|
| Hospital Charge Code |
180903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$150.99 |
| Rate for Payer: Aetna Commercial |
$142.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.05
|
| Rate for Payer: Cash Price |
$134.22
|
| Rate for Payer: Cofinity Commercial |
$117.44
|
| Rate for Payer: Cofinity Commercial |
$144.28
|
| Rate for Payer: Healthscope Commercial |
$150.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$142.60
|
| Rate for Payer: PHP Commercial |
$142.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$117.44
|
| Rate for Payer: Priority Health SBD |
$105.70
|
|
|
CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION
|
Facility
IP
|
$35.38
|
|
|
Service Code
|
HCPCS J0613
|
| Hospital Charge Code |
189461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.29 |
| Max. Negotiated Rate |
$31.84 |
| Rate for Payer: Aetna Commercial |
$30.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.00
|
| Rate for Payer: Cash Price |
$28.30
|
| Rate for Payer: Cofinity Commercial |
$24.77
|
| Rate for Payer: Cofinity Commercial |
$30.43
|
| Rate for Payer: Healthscope Commercial |
$31.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.07
|
| Rate for Payer: PHP Commercial |
$30.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.77
|
| Rate for Payer: Priority Health SBD |
$22.29
|
|
|
CALCIUM GLUCONATE 2 GRAM/100 ML IN SODIUM CHLORIDE,ISO-OSM IV SOLUTION
|
Facility
IP
|
$74.32
|
|
|
Service Code
|
HCPCS J0613
|
| Hospital Charge Code |
190608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.82 |
| Max. Negotiated Rate |
$66.89 |
| Rate for Payer: Aetna Commercial |
$63.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.31
|
| Rate for Payer: Cash Price |
$59.46
|
| Rate for Payer: Cofinity Commercial |
$52.02
|
| Rate for Payer: Cofinity Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$66.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.17
|
| Rate for Payer: PHP Commercial |
$63.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.02
|
| Rate for Payer: Priority Health SBD |
$46.82
|
|
|
CALCIUM GLUCONATE (BULK) POWDER
|
Facility
IP
|
$366.00
|
|
|
Service Code
|
NDC 3877918268
|
| Hospital Charge Code |
1316
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.58 |
| Max. Negotiated Rate |
$329.40 |
| Rate for Payer: Aetna Commercial |
$311.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.90
|
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Cofinity Commercial |
$256.20
|
| Rate for Payer: Cofinity Commercial |
$314.76
|
| Rate for Payer: Healthscope Commercial |
$329.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$311.10
|
| Rate for Payer: PHP Commercial |
$311.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.20
|
| Rate for Payer: Priority Health SBD |
$230.58
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM
|
Facility
IP
|
$14.85
|
|
|
Service Code
|
NDC 0536-2525-25
|
| Hospital Charge Code |
1350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$13.36 |
| Rate for Payer: Aetna Commercial |
$12.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.65
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cofinity Commercial |
$10.40
|
| Rate for Payer: Cofinity Commercial |
$12.77
|
| Rate for Payer: Healthscope Commercial |
$13.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.62
|
| Rate for Payer: PHP Commercial |
$12.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.40
|
| Rate for Payer: Priority Health SBD |
$9.36
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM
|
Facility
IP
|
$18.47
|
|
|
Service Code
|
NDC 0536-1118-25
|
| Hospital Charge Code |
9399
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.64 |
| Max. Negotiated Rate |
$16.62 |
| Rate for Payer: Aetna Commercial |
$15.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.01
|
| Rate for Payer: Cash Price |
$14.78
|
| Rate for Payer: Cofinity Commercial |
$12.93
|
| Rate for Payer: Cofinity Commercial |
$15.88
|
| Rate for Payer: Healthscope Commercial |
$16.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.70
|
| Rate for Payer: PHP Commercial |
$15.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.93
|
| Rate for Payer: Priority Health SBD |
$11.64
|
|
|
CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)
|
Facility
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 28270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$331.70 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$1,058.03
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$364.87
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$331.70
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
IP
|
$579.84
|
|
|
Service Code
|
NDC 51079-863-20
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$365.30 |
| Max. Negotiated Rate |
$521.86 |
| Rate for Payer: Aetna Commercial |
$492.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.90
|
| Rate for Payer: Cash Price |
$463.87
|
| Rate for Payer: Cofinity Commercial |
$405.89
|
| Rate for Payer: Cofinity Commercial |
$498.66
|
| Rate for Payer: Healthscope Commercial |
$521.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$492.86
|
| Rate for Payer: PHP Commercial |
$492.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$405.89
|
| Rate for Payer: Priority Health SBD |
$365.30
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
IP
|
$523.68
|
|
|
Service Code
|
NDC 0904-7105-61
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$329.92 |
| Max. Negotiated Rate |
$471.31 |
| Rate for Payer: Aetna Commercial |
$445.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.39
|
| Rate for Payer: Cash Price |
$418.94
|
| Rate for Payer: Cofinity Commercial |
$366.58
|
| Rate for Payer: Cofinity Commercial |
$450.36
|
| Rate for Payer: Healthscope Commercial |
$471.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$445.13
|
| Rate for Payer: PHP Commercial |
$445.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$366.58
|
| Rate for Payer: Priority Health SBD |
$329.92
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
IP
|
$5.80
|
|
|
Service Code
|
NDC 51079-863-01
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna Commercial |
$4.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.77
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cofinity Commercial |
$4.06
|
| Rate for Payer: Cofinity Commercial |
$4.99
|
| Rate for Payer: Healthscope Commercial |
$5.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.93
|
| Rate for Payer: PHP Commercial |
$4.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.06
|
| Rate for Payer: Priority Health SBD |
$3.65
|
|
|
CARBAMAZEPINE 100 MG/5 ML (5 ML) ORAL SUSPENSION
|
Facility
IP
|
$13.59
|
|
|
Service Code
|
NDC 68094-007-59
|
| Hospital Charge Code |
119222
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$12.23 |
| Rate for Payer: Aetna Commercial |
$11.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.83
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: Cofinity Commercial |
$11.69
|
| Rate for Payer: Cofinity Commercial |
$9.51
|
| Rate for Payer: Healthscope Commercial |
$12.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.55
|
| Rate for Payer: PHP Commercial |
$11.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.51
|
| Rate for Payer: Priority Health SBD |
$8.56
|
|
|
CARBAMAZEPINE 100 MG/5 ML (5 ML) ORAL SUSPENSION
|
Facility
IP
|
$13.59
|
|
|
Service Code
|
NDC 68094-007-62
|
| Hospital Charge Code |
119222
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$12.23 |
| Rate for Payer: Aetna Commercial |
$11.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.83
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: Cofinity Commercial |
$11.69
|
| Rate for Payer: Cofinity Commercial |
$9.51
|
| Rate for Payer: Healthscope Commercial |
$12.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.55
|
| Rate for Payer: PHP Commercial |
$11.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.51
|
| Rate for Payer: Priority Health SBD |
$8.56
|
|
|
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$1,662.98
|
|
|
Service Code
|
NDC 0078-0508-83
|
| Hospital Charge Code |
109663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,047.68 |
| Max. Negotiated Rate |
$1,496.68 |
| Rate for Payer: Aetna Commercial |
$1,413.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,080.94
|
| Rate for Payer: Cash Price |
$1,330.38
|
| Rate for Payer: Cofinity Commercial |
$1,164.09
|
| Rate for Payer: Cofinity Commercial |
$1,430.16
|
| Rate for Payer: Healthscope Commercial |
$1,496.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,413.53
|
| Rate for Payer: PHP Commercial |
$1,413.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,164.09
|
| Rate for Payer: Priority Health SBD |
$1,047.68
|
|
