|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$26.13
|
|
|
Service Code
|
NDC 7811273621
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.46 |
| Max. Negotiated Rate |
$23.52 |
| Rate for Payer: Aetna Commercial |
$22.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.98
|
| Rate for Payer: Cash Price |
$20.90
|
| Rate for Payer: Cofinity Commercial |
$18.29
|
| Rate for Payer: Cofinity Commercial |
$22.47
|
| Rate for Payer: Healthscope Commercial |
$23.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.21
|
| Rate for Payer: PHP Commercial |
$22.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.29
|
| Rate for Payer: Priority Health SBD |
$16.46
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$425.35
|
|
|
Service Code
|
NDC 63739-107-10
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.97 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Aetna Commercial |
$361.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.48
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Commercial |
$297.74
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Healthscope Commercial |
$382.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.55
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.74
|
| Rate for Payer: Priority Health SBD |
$267.97
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 0904-7257-61
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.59 |
| Max. Negotiated Rate |
$315.14 |
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.60
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Healthscope Commercial |
$315.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$297.63
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.10
|
| Rate for Payer: Priority Health SBD |
$220.59
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$2.03
|
|
|
Service Code
|
NDC 68084-093-11
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.32
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cofinity Commercial |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Healthscope Commercial |
$1.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.73
|
| Rate for Payer: PHP Commercial |
$1.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.42
|
| Rate for Payer: Priority Health SBD |
$1.28
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 60687-661-11
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.70
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cofinity Commercial |
$2.91
|
| Rate for Payer: Cofinity Commercial |
$3.58
|
| Rate for Payer: Healthscope Commercial |
$3.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.54
|
| Rate for Payer: PHP Commercial |
$3.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.91
|
| Rate for Payer: Priority Health SBD |
$2.62
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$260.30
|
|
|
Service Code
|
NDC 51862-079-01
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.99 |
| Max. Negotiated Rate |
$234.27 |
| Rate for Payer: Aetna Commercial |
$221.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.20
|
| Rate for Payer: Cash Price |
$208.24
|
| Rate for Payer: Cofinity Commercial |
$223.86
|
| Rate for Payer: Cofinity Commercial |
$182.21
|
| Rate for Payer: Healthscope Commercial |
$234.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.26
|
| Rate for Payer: PHP Commercial |
$221.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health SBD |
$163.99
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 0228-2539-10
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.92 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.24
|
| Rate for Payer: Priority Health SBD |
$119.92
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$415.95
|
|
|
Service Code
|
NDC 60687-661-01
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.05 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.37
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Commercial |
$291.16
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$353.56
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.16
|
| Rate for Payer: Priority Health SBD |
$262.05
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$198.55
|
|
|
Service Code
|
NDC 63739-108-10
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.09 |
| Max. Negotiated Rate |
$178.70 |
| Rate for Payer: Aetna Commercial |
$168.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.06
|
| Rate for Payer: Cash Price |
$158.84
|
| Rate for Payer: Cofinity Commercial |
$138.98
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| Rate for Payer: Healthscope Commercial |
$178.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.77
|
| Rate for Payer: PHP Commercial |
$168.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.98
|
| Rate for Payer: Priority Health SBD |
$125.09
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$202.35
|
|
|
Service Code
|
NDC 68084-093-01
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.48 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: Aetna Commercial |
$172.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.53
|
| Rate for Payer: Cash Price |
$161.88
|
| Rate for Payer: Cofinity Commercial |
$141.64
|
| Rate for Payer: Cofinity Commercial |
$174.02
|
| Rate for Payer: Healthscope Commercial |
$182.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.00
|
| Rate for Payer: PHP Commercial |
$172.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.64
|
| Rate for Payer: Priority Health SBD |
$127.48
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
NDC 0904-6237-61
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.27 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.30
|
| Rate for Payer: Priority Health SBD |
$207.27
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$200.45
|
|
|
Service Code
|
NDC 0904-6238-61
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.29
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$140.32
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.32
|
| Rate for Payer: Priority Health SBD |
$126.28
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$305.28
|
|
|
Service Code
|
NDC 68084-282-11
|
| Hospital Charge Code |
9409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.33 |
| Max. Negotiated Rate |
$274.75 |
| Rate for Payer: Aetna Commercial |
$259.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.43
|
| Rate for Payer: Cash Price |
$244.22
|
| Rate for Payer: Cofinity Commercial |
$213.70
|
| Rate for Payer: Cofinity Commercial |
$262.54
|
| Rate for Payer: Healthscope Commercial |
$274.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.49
|
| Rate for Payer: PHP Commercial |
$259.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.70
|
| Rate for Payer: Priority Health SBD |
$192.33
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$627.36
|
|
|
Service Code
|
NDC 0378-0094-01
|
| Hospital Charge Code |
9409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$395.24 |
| Max. Negotiated Rate |
$564.62 |
| Rate for Payer: Aetna Commercial |
$533.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$407.78
|
| Rate for Payer: Cash Price |
$501.89
|
| Rate for Payer: Cofinity Commercial |
$439.15
|
| Rate for Payer: Cofinity Commercial |
$539.53
|
| Rate for Payer: Healthscope Commercial |
$564.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$533.26
|
| Rate for Payer: PHP Commercial |
$533.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$439.15
|
| Rate for Payer: Priority Health SBD |
$395.24
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$305.28
|
|
|
Service Code
|
NDC 68084-282-01
|
| Hospital Charge Code |
9409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.33 |
| Max. Negotiated Rate |
$274.75 |
| Rate for Payer: Aetna Commercial |
$259.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.43
|
| Rate for Payer: Cash Price |
$244.22
|
| Rate for Payer: Cofinity Commercial |
$213.70
|
| Rate for Payer: Cofinity Commercial |
$262.54
|
| Rate for Payer: Healthscope Commercial |
$274.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.49
|
| Rate for Payer: PHP Commercial |
$259.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.70
|
| Rate for Payer: Priority Health SBD |
$192.33
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$181.12
|
|
|
Service Code
|
HCPCS J9045
|
| Hospital Charge Code |
39265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.11 |
| Max. Negotiated Rate |
$163.01 |
| Rate for Payer: Aetna Commercial |
$153.95
|
| Rate for Payer: Aetna Commercial |
$186.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.73
|
| Rate for Payer: Cash Price |
$175.06
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cofinity Commercial |
$188.19
|
| Rate for Payer: Cofinity Commercial |
$126.78
|
| Rate for Payer: Cofinity Commercial |
$155.76
|
| Rate for Payer: Cofinity Commercial |
$153.17
|
| Rate for Payer: Healthscope Commercial |
$163.01
|
| Rate for Payer: Healthscope Commercial |
$196.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.95
|
| Rate for Payer: PHP Commercial |
$186.00
|
| Rate for Payer: PHP Commercial |
$153.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$137.86
|
| Rate for Payer: Priority Health SBD |
$114.11
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$419.43
|
|
|
Service Code
|
HCPCS J9045
|
| Hospital Charge Code |
39265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$377.49 |
| Rate for Payer: Aetna Commercial |
$356.52
|
| Rate for Payer: Aetna Commercial |
$201.30
|
| Rate for Payer: Aetna Commercial |
$314.44
|
| Rate for Payer: Aetna Commercial |
$280.72
|
| Rate for Payer: Aetna Commercial |
$242.89
|
| Rate for Payer: Aetna Commercial |
$408.27
|
| Rate for Payer: Aetna Commercial |
$228.96
|
| Rate for Payer: Aetna Commercial |
$239.56
|
| Rate for Payer: Aetna Commercial |
$153.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$272.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.09
|
| Rate for Payer: BCBS Complete |
$94.73
|
| Rate for Payer: BCBS Complete |
$147.97
|
| Rate for Payer: BCBS Complete |
$192.13
|
| Rate for Payer: BCBS Complete |
$132.10
|
| Rate for Payer: BCBS Complete |
$114.30
|
| Rate for Payer: BCBS Complete |
$72.45
|
| Rate for Payer: BCBS Complete |
$107.75
|
| Rate for Payer: BCBS Complete |
$112.73
|
| Rate for Payer: BCBS Complete |
$167.77
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: Cash Price |
$225.46
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$189.46
|
| Rate for Payer: Cash Price |
$189.46
|
| Rate for Payer: Cash Price |
$215.50
|
| Rate for Payer: Cash Price |
$215.50
|
| Rate for Payer: Cash Price |
$225.46
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$264.21
|
| Rate for Payer: Cash Price |
$264.21
|
| Rate for Payer: Cash Price |
$295.94
|
| Rate for Payer: Cash Price |
$295.94
|
| Rate for Payer: Cash Price |
$335.54
|
| Rate for Payer: Cash Price |
$335.54
|
| Rate for Payer: Cash Price |
$384.26
|
| Rate for Payer: Cash Price |
$384.26
|
| Rate for Payer: Cofinity Commercial |
$284.02
|
| Rate for Payer: Cofinity Commercial |
$165.77
|
| Rate for Payer: Cofinity Commercial |
$258.95
|
| Rate for Payer: Cofinity Commercial |
$242.37
|
| Rate for Payer: Cofinity Commercial |
$197.28
|
| Rate for Payer: Cofinity Commercial |
$203.67
|
| Rate for Payer: Cofinity Commercial |
$200.02
|
| Rate for Payer: Cofinity Commercial |
$245.74
|
| Rate for Payer: Cofinity Commercial |
$318.14
|
| Rate for Payer: Cofinity Commercial |
$360.71
|
| Rate for Payer: Cofinity Commercial |
$413.08
|
| Rate for Payer: Cofinity Commercial |
$231.66
|
| Rate for Payer: Cofinity Commercial |
$336.22
|
| Rate for Payer: Cofinity Commercial |
$188.56
|
| Rate for Payer: Cofinity Commercial |
$126.78
|
| Rate for Payer: Cofinity Commercial |
$155.76
|
| Rate for Payer: Cofinity Commercial |
$293.60
|
| Rate for Payer: Cofinity Commercial |
$231.18
|
| Rate for Payer: Healthscope Commercial |
$377.49
|
| Rate for Payer: Healthscope Commercial |
$253.65
|
| Rate for Payer: Healthscope Commercial |
$257.18
|
| Rate for Payer: Healthscope Commercial |
$432.29
|
| Rate for Payer: Healthscope Commercial |
$163.01
|
| Rate for Payer: Healthscope Commercial |
$297.23
|
| Rate for Payer: Healthscope Commercial |
$242.43
|
| Rate for Payer: Healthscope Commercial |
$213.14
|
| Rate for Payer: Healthscope Commercial |
$332.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$242.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$280.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$228.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$356.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$408.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.30
|
| Rate for Payer: PHP Commercial |
$228.96
|
| Rate for Payer: PHP Commercial |
$242.89
|
| Rate for Payer: PHP Commercial |
$280.72
|
| Rate for Payer: PHP Commercial |
$201.30
|
| Rate for Payer: PHP Commercial |
$239.56
|
| Rate for Payer: PHP Commercial |
$314.44
|
| Rate for Payer: PHP Commercial |
$153.95
|
| Rate for Payer: PHP Commercial |
$356.52
|
| Rate for Payer: PHP Commercial |
$408.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.77
|
| Rate for Payer: Priority Health SBD |
$114.11
|
| Rate for Payer: Priority Health SBD |
$264.24
|
| Rate for Payer: Priority Health SBD |
$208.06
|
| Rate for Payer: Priority Health SBD |
$149.20
|
| Rate for Payer: Priority Health SBD |
$169.70
|
| Rate for Payer: Priority Health SBD |
$177.55
|
| Rate for Payer: Priority Health SBD |
$180.02
|
| Rate for Payer: Priority Health SBD |
$302.60
|
| Rate for Payer: Priority Health SBD |
$233.06
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$294.63
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.62 |
| Max. Negotiated Rate |
$265.17 |
| Rate for Payer: Aetna Commercial |
$250.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.51
|
| Rate for Payer: Cash Price |
$235.70
|
| Rate for Payer: Cofinity Commercial |
$206.24
|
| Rate for Payer: Cofinity Commercial |
$253.38
|
| Rate for Payer: Healthscope Commercial |
$265.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$250.44
|
| Rate for Payer: PHP Commercial |
$250.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.24
|
| Rate for Payer: Priority Health SBD |
$185.62
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$868.97
|
|
|
Service Code
|
NDC 69784-240-10
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$547.45 |
| Max. Negotiated Rate |
$782.07 |
| Rate for Payer: Aetna Commercial |
$738.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$564.83
|
| Rate for Payer: Cash Price |
$695.18
|
| Rate for Payer: Cofinity Commercial |
$608.28
|
| Rate for Payer: Cofinity Commercial |
$747.31
|
| Rate for Payer: Healthscope Commercial |
$782.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$738.62
|
| Rate for Payer: PHP Commercial |
$738.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.28
|
| Rate for Payer: Priority Health SBD |
$547.45
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$256.53
|
|
|
Service Code
|
NDC 0009-0856-05
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$161.61 |
| Max. Negotiated Rate |
$230.88 |
| Rate for Payer: Aetna Commercial |
$218.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.74
|
| Rate for Payer: Cash Price |
$205.22
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Commercial |
$220.62
|
| Rate for Payer: Healthscope Commercial |
$230.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$218.05
|
| Rate for Payer: PHP Commercial |
$218.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.57
|
| Rate for Payer: Priority Health SBD |
$161.61
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$868.97
|
|
|
Service Code
|
NDC 69784-240-01
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$547.45 |
| Max. Negotiated Rate |
$782.07 |
| Rate for Payer: Aetna Commercial |
$738.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$564.83
|
| Rate for Payer: Cash Price |
$695.18
|
| Rate for Payer: Cofinity Commercial |
$608.28
|
| Rate for Payer: Cofinity Commercial |
$747.31
|
| Rate for Payer: Healthscope Commercial |
$782.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$738.62
|
| Rate for Payer: PHP Commercial |
$738.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.28
|
| Rate for Payer: Priority Health SBD |
$547.45
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$285.03
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.57 |
| Max. Negotiated Rate |
$256.53 |
| Rate for Payer: Aetna Commercial |
$242.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.27
|
| Rate for Payer: Cash Price |
$228.02
|
| Rate for Payer: Cofinity Commercial |
$199.52
|
| Rate for Payer: Cofinity Commercial |
$245.13
|
| Rate for Payer: Healthscope Commercial |
$256.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$242.28
|
| Rate for Payer: PHP Commercial |
$242.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.52
|
| Rate for Payer: Priority Health SBD |
$179.57
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$256.53
|
|
|
Service Code
|
NDC 0009-0856-08
|
| Hospital Charge Code |
9413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$161.61 |
| Max. Negotiated Rate |
$230.88 |
| Rate for Payer: Aetna Commercial |
$218.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.74
|
| Rate for Payer: Cash Price |
$205.22
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Commercial |
$220.62
|
| Rate for Payer: Healthscope Commercial |
$230.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$218.05
|
| Rate for Payer: PHP Commercial |
$218.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.57
|
| Rate for Payer: Priority Health SBD |
$161.61
|
|
|
CARDIAC ARREST, UNEXPLAINED WITH CC
|
Facility
|
IP
|
$11,114.06
|
|
|
Service Code
|
MS-DRG 297
|
| Min. Negotiated Rate |
$5,452.96 |
| Max. Negotiated Rate |
$11,114.06 |
| Rate for Payer: Aetna Medicare |
$5,969.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,174.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,174.95
|
| Rate for Payer: BCBS MAPPO |
$5,739.96
|
| Rate for Payer: BCBS Trust/PPO |
$10,404.17
|
| Rate for Payer: BCN Medicare Advantage |
$5,739.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,739.96
|
| Rate for Payer: Mclaren Medicare |
$5,739.96
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,026.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,600.95
|
| Rate for Payer: PACE Medicare |
$5,452.96
|
| Rate for Payer: PACE SWMI |
$5,739.96
|
| Rate for Payer: PHP Medicare Advantage |
$5,739.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,455.35
|
| Rate for Payer: Priority Health Medicare |
$5,739.96
|
| Rate for Payer: Priority Health Narrow Network |
$8,364.28
|
| Rate for Payer: Railroad Medicare Medicare |
$5,739.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,114.06
|
| Rate for Payer: UHC Core |
$6,819.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,739.96
|
| Rate for Payer: UHC Exchange |
$7,304.22
|
| Rate for Payer: UHC Medicare Advantage |
$5,912.16
|
| Rate for Payer: VA VA |
$5,739.96
|
|
|
CARDIAC ARREST, UNEXPLAINED WITH MCC
|
Facility
|
IP
|
$30,823.85
|
|
|
Service Code
|
MS-DRG 296
|
| Min. Negotiated Rate |
$11,436.71 |
| Max. Negotiated Rate |
$30,823.85 |
| Rate for Payer: Aetna Medicare |
$12,520.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,048.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,048.30
|
| Rate for Payer: BCBS MAPPO |
$12,038.64
|
| Rate for Payer: BCBS Trust/PPO |
$30,823.85
|
| Rate for Payer: BCN Medicare Advantage |
$12,038.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,038.64
|
| Rate for Payer: Mclaren Medicare |
$12,038.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,640.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,844.44
|
| Rate for Payer: PACE Medicare |
$11,436.71
|
| Rate for Payer: PACE SWMI |
$12,038.64
|
| Rate for Payer: PHP Medicare Advantage |
$12,038.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23,005.79
|
| Rate for Payer: Priority Health Medicare |
$12,038.64
|
| Rate for Payer: Priority Health Narrow Network |
$18,404.63
|
| Rate for Payer: Railroad Medicare Medicare |
$12,038.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,455.21
|
| Rate for Payer: UHC Core |
$15,005.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,038.64
|
| Rate for Payer: UHC Exchange |
$16,072.08
|
| Rate for Payer: UHC Medicare Advantage |
$12,399.80
|
| Rate for Payer: VA VA |
$12,038.64
|
|
