|
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$272.98
|
|
|
Service Code
|
CPT 20936
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$272.98 |
| Max. Negotiated Rate |
$272.98 |
| Rate for Payer: BCBS Trust/PPO |
$272.98
|
| Rate for Payer: BCN Commercial |
$272.98
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$36,621.26
|
|
|
Service Code
|
APR-DRG 0083
|
| Min. Negotiated Rate |
$34,877.39 |
| Max. Negotiated Rate |
$36,621.26 |
| Rate for Payer: BCBS Complete |
$36,621.26
|
| Rate for Payer: Mclaren Medicaid |
$34,877.39
|
| Rate for Payer: Meridian Medicaid |
$36,621.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$34,877.39
|
| Rate for Payer: UHC Medicaid |
$34,877.39
|
| Rate for Payer: UHCCP Medicaid |
$34,877.39
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$24,741.33
|
|
|
Service Code
|
APR-DRG 0082
|
| Min. Negotiated Rate |
$23,563.18 |
| Max. Negotiated Rate |
$24,741.33 |
| Rate for Payer: BCBS Complete |
$24,741.33
|
| Rate for Payer: Mclaren Medicaid |
$23,563.18
|
| Rate for Payer: Meridian Medicaid |
$24,741.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$23,563.18
|
| Rate for Payer: UHC Medicaid |
$23,563.18
|
| Rate for Payer: UHCCP Medicaid |
$23,563.18
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$20,476.56
|
|
|
Service Code
|
APR-DRG 0081
|
| Min. Negotiated Rate |
$19,501.48 |
| Max. Negotiated Rate |
$20,476.56 |
| Rate for Payer: BCBS Complete |
$20,476.56
|
| Rate for Payer: Mclaren Medicaid |
$19,501.48
|
| Rate for Payer: Meridian Medicaid |
$20,476.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$19,501.48
|
| Rate for Payer: UHC Medicaid |
$19,501.48
|
| Rate for Payer: UHCCP Medicaid |
$19,501.48
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$60,462.51
|
|
|
Service Code
|
APR-DRG 0084
|
| Min. Negotiated Rate |
$57,583.34 |
| Max. Negotiated Rate |
$60,462.51 |
| Rate for Payer: BCBS Complete |
$60,462.51
|
| Rate for Payer: Mclaren Medicaid |
$57,583.34
|
| Rate for Payer: Meridian Medicaid |
$60,462.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$57,583.34
|
| Rate for Payer: UHC Medicaid |
$57,583.34
|
| Rate for Payer: UHCCP Medicaid |
$57,583.34
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
|
IP
|
$208,284.38
|
|
|
Service Code
|
MSDRG 016
|
| Min. Negotiated Rate |
$44,084.82 |
| Max. Negotiated Rate |
$208,284.38 |
| Rate for Payer: Aetna Medicare |
$48,261.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$58,006.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$58,006.34
|
| Rate for Payer: BCBS MAPPO |
$46,405.07
|
| Rate for Payer: BCBS Trust/PPO |
$208,284.38
|
| Rate for Payer: BCN Commercial |
$208,284.38
|
| Rate for Payer: BCN Medicare Advantage |
$46,405.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$46,405.07
|
| Rate for Payer: Mclaren Medicare |
$46,405.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$48,725.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$53,365.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$51,045.58
|
| Rate for Payer: Nomi Health Commercial |
$76,493.13
|
| Rate for Payer: PACE Medicare |
$44,084.82
|
| Rate for Payer: PACE SWMI |
$46,405.07
|
| Rate for Payer: PHP Medicare Advantage |
$46,405.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$95,599.45
|
| Rate for Payer: Priority Health Medicare |
$46,405.07
|
| Rate for Payer: Priority Health Tiered Network |
$76,479.55
|
| Rate for Payer: Railroad Medicare Medicare |
$46,405.07
|
| Rate for Payer: VA VA |
$46,405.07
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$106,562.58
|
|
|
Service Code
|
MSDRG 017
|
| Min. Negotiated Rate |
$40,432.99 |
| Max. Negotiated Rate |
$106,562.58 |
| Rate for Payer: Aetna Medicare |
$44,263.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$53,201.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$53,201.30
|
| Rate for Payer: BCBS MAPPO |
$42,561.04
|
| Rate for Payer: BCBS Trust/PPO |
$106,562.58
|
| Rate for Payer: BCN Commercial |
$106,562.58
|
| Rate for Payer: BCN Medicare Advantage |
$42,561.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$42,561.04
|
| Rate for Payer: Mclaren Medicare |
$42,561.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44,689.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48,945.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$46,817.14
|
| Rate for Payer: Nomi Health Commercial |
$62,414.07
|
| Rate for Payer: PACE Medicare |
$40,432.99
|
| Rate for Payer: PACE SWMI |
$42,561.04
|
| Rate for Payer: PHP Medicare Advantage |
$42,561.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$87,580.30
|
| Rate for Payer: Priority Health Medicare |
$42,561.04
|
| Rate for Payer: Priority Health Tiered Network |
$70,064.23
|
| Rate for Payer: Railroad Medicare Medicare |
$42,561.04
|
| Rate for Payer: VA VA |
$42,561.04
|
|
|
AZACITIDINE 100 MG/10 ML SOLN
|
Facility
|
IP
|
$242.50
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
168892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.78 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: Aetna Commercial |
$206.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.62
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cofinity Advantage |
$169.75
|
| Rate for Payer: Cofinity Commercial |
$208.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.00
|
| Rate for Payer: Healthscope Commercial |
$218.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.88
|
| Rate for Payer: PHP Commercial |
$206.12
|
| Rate for Payer: Priority Health SBD |
$152.78
|
|
|
AZACITIDINE 100 MG/10 ML SOLN
|
Facility
|
OP
|
$242.50
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
168892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: Aetna Commercial |
$206.12
|
| Rate for Payer: Aetna Commercial |
$2,233.57
|
| Rate for Payer: Aetna Commercial |
$389.10
|
| Rate for Payer: Aetna Commercial |
$595.27
|
| Rate for Payer: Aetna Commercial |
$187.21
|
| Rate for Payer: Aetna Commercial |
$264.51
|
| Rate for Payer: Aetna Medicare |
$350.16
|
| Rate for Payer: Aetna Medicare |
$155.59
|
| Rate for Payer: Aetna Medicare |
$110.12
|
| Rate for Payer: Aetna Medicare |
$1,313.87
|
| Rate for Payer: Aetna Medicare |
$228.88
|
| Rate for Payer: Aetna Medicare |
$121.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,708.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$455.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.62
|
| Rate for Payer: BCBS Complete |
$1,051.09
|
| Rate for Payer: BCBS Complete |
$280.13
|
| Rate for Payer: BCBS Complete |
$97.00
|
| Rate for Payer: BCBS Complete |
$88.10
|
| Rate for Payer: BCBS Complete |
$183.11
|
| Rate for Payer: BCBS Complete |
$124.48
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cofinity Advantage |
$217.83
|
| Rate for Payer: Cofinity Advantage |
$154.18
|
| Rate for Payer: Cofinity Advantage |
$169.75
|
| Rate for Payer: Cofinity Advantage |
$490.22
|
| Rate for Payer: Cofinity Advantage |
$320.44
|
| Rate for Payer: Cofinity Advantage |
$1,839.41
|
| Rate for Payer: Cofinity Commercial |
$2,259.85
|
| Rate for Payer: Cofinity Commercial |
$602.28
|
| Rate for Payer: Cofinity Commercial |
$208.55
|
| Rate for Payer: Cofinity Commercial |
$393.68
|
| Rate for Payer: Cofinity Commercial |
$189.41
|
| Rate for Payer: Cofinity Commercial |
$267.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,102.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$560.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.00
|
| Rate for Payer: Healthscope Commercial |
$630.29
|
| Rate for Payer: Healthscope Commercial |
$411.99
|
| Rate for Payer: Healthscope Commercial |
$218.25
|
| Rate for Payer: Healthscope Commercial |
$2,364.96
|
| Rate for Payer: Healthscope Commercial |
$198.22
|
| Rate for Payer: Healthscope Commercial |
$280.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$248.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$176.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$194.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,102.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$366.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$560.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$595.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,233.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$525.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$343.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,970.80
|
| Rate for Payer: PHP Commercial |
$264.51
|
| Rate for Payer: PHP Commercial |
$2,233.57
|
| Rate for Payer: PHP Commercial |
$206.12
|
| Rate for Payer: PHP Commercial |
$595.27
|
| Rate for Payer: PHP Commercial |
$389.10
|
| Rate for Payer: PHP Commercial |
$187.21
|
| Rate for Payer: Priority Health SBD |
$152.78
|
| Rate for Payer: Priority Health SBD |
$138.76
|
| Rate for Payer: Priority Health SBD |
$1,655.47
|
| Rate for Payer: Priority Health SBD |
$441.20
|
| Rate for Payer: Priority Health SBD |
$196.05
|
| Rate for Payer: Priority Health SBD |
$288.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$2,627.73
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
78420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,655.47 |
| Max. Negotiated Rate |
$2,364.96 |
| Rate for Payer: Aetna Commercial |
$2,233.57
|
| Rate for Payer: Aetna Commercial |
$187.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,708.02
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cofinity Advantage |
$1,839.41
|
| Rate for Payer: Cofinity Advantage |
$154.18
|
| Rate for Payer: Cofinity Commercial |
$189.41
|
| Rate for Payer: Cofinity Commercial |
$2,259.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,102.18
|
| Rate for Payer: Healthscope Commercial |
$198.22
|
| Rate for Payer: Healthscope Commercial |
$2,364.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,233.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,970.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.19
|
| Rate for Payer: PHP Commercial |
$187.21
|
| Rate for Payer: PHP Commercial |
$2,233.57
|
| Rate for Payer: Priority Health SBD |
$138.76
|
| Rate for Payer: Priority Health SBD |
$1,655.47
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$242.50
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
78420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: Aetna Commercial |
$206.12
|
| Rate for Payer: Aetna Commercial |
$2,233.57
|
| Rate for Payer: Aetna Commercial |
$595.27
|
| Rate for Payer: Aetna Commercial |
$187.21
|
| Rate for Payer: Aetna Commercial |
$264.51
|
| Rate for Payer: Aetna Commercial |
$389.10
|
| Rate for Payer: Aetna Medicare |
$110.12
|
| Rate for Payer: Aetna Medicare |
$121.25
|
| Rate for Payer: Aetna Medicare |
$1,313.87
|
| Rate for Payer: Aetna Medicare |
$228.88
|
| Rate for Payer: Aetna Medicare |
$350.16
|
| Rate for Payer: Aetna Medicare |
$155.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$455.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,708.02
|
| Rate for Payer: BCBS Complete |
$1,051.09
|
| Rate for Payer: BCBS Complete |
$280.13
|
| Rate for Payer: BCBS Complete |
$183.11
|
| Rate for Payer: BCBS Complete |
$97.00
|
| Rate for Payer: BCBS Complete |
$88.10
|
| Rate for Payer: BCBS Complete |
$124.48
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cash Price |
$176.20
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Cash Price |
$194.00
|
| Rate for Payer: Cofinity Advantage |
$154.18
|
| Rate for Payer: Cofinity Advantage |
$320.44
|
| Rate for Payer: Cofinity Advantage |
$217.83
|
| Rate for Payer: Cofinity Advantage |
$490.22
|
| Rate for Payer: Cofinity Advantage |
$1,839.41
|
| Rate for Payer: Cofinity Advantage |
$169.75
|
| Rate for Payer: Cofinity Commercial |
$2,259.85
|
| Rate for Payer: Cofinity Commercial |
$208.55
|
| Rate for Payer: Cofinity Commercial |
$189.41
|
| Rate for Payer: Cofinity Commercial |
$602.28
|
| Rate for Payer: Cofinity Commercial |
$267.62
|
| Rate for Payer: Cofinity Commercial |
$393.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,102.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$560.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.22
|
| Rate for Payer: Healthscope Commercial |
$630.29
|
| Rate for Payer: Healthscope Commercial |
$411.99
|
| Rate for Payer: Healthscope Commercial |
$280.07
|
| Rate for Payer: Healthscope Commercial |
$2,364.96
|
| Rate for Payer: Healthscope Commercial |
$218.25
|
| Rate for Payer: Healthscope Commercial |
$198.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$176.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$560.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$248.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$366.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,102.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$194.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,233.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$595.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,970.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$343.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$525.24
|
| Rate for Payer: PHP Commercial |
$264.51
|
| Rate for Payer: PHP Commercial |
$206.12
|
| Rate for Payer: PHP Commercial |
$2,233.57
|
| Rate for Payer: PHP Commercial |
$187.21
|
| Rate for Payer: PHP Commercial |
$595.27
|
| Rate for Payer: PHP Commercial |
$389.10
|
| Rate for Payer: Priority Health SBD |
$288.40
|
| Rate for Payer: Priority Health SBD |
$152.78
|
| Rate for Payer: Priority Health SBD |
$441.20
|
| Rate for Payer: Priority Health SBD |
$196.05
|
| Rate for Payer: Priority Health SBD |
$1,655.47
|
| Rate for Payer: Priority Health SBD |
$138.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Core |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
|
|
AZATHIOPRINE 50 MG TABLET
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
9183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna Commercial |
$264.79
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Aetna Medicare |
$155.76
|
| Rate for Payer: Aetna Medicare |
$199.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: BCBS Complete |
$124.61
|
| Rate for Payer: BCBS Complete |
$1.25
|
| Rate for Payer: BCBS Complete |
$159.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.46
|
| Rate for Payer: BCN Commercial |
$2.46
|
| Rate for Payer: BCN Commercial |
$2.46
|
| Rate for Payer: BCN Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cash Price |
$249.22
|
| Rate for Payer: Cash Price |
$249.22
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Advantage |
$218.06
|
| Rate for Payer: Cofinity Advantage |
$278.63
|
| Rate for Payer: Cofinity Advantage |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Cofinity Commercial |
$267.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$358.25
|
| Rate for Payer: Healthscope Commercial |
$280.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$318.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$298.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.34
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: PHP Commercial |
$264.79
|
| Rate for Payer: Priority Health SBD |
$250.77
|
| Rate for Payer: Priority Health SBD |
$196.26
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$202.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$258.73
|
| Rate for Payer: UHC Core |
$162.30
|
| Rate for Payer: UHC Core |
$207.38
|
| Rate for Payer: UHC Core |
$1.63
|
| Rate for Payer: UHC Exchange |
$156.43
|
| Rate for Payer: UHC Exchange |
$1.23
|
| Rate for Payer: UHC Exchange |
$122.43
|
|
|
AZATHIOPRINE 50 MG TABLET
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
9183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Commercial |
$264.79
|
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.49
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cash Price |
$249.22
|
| Rate for Payer: Cofinity Advantage |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$218.06
|
| Rate for Payer: Cofinity Advantage |
$278.63
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Cofinity Commercial |
$267.91
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$280.37
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$358.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$298.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.34
|
| Rate for Payer: PHP Commercial |
$264.79
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health SBD |
$250.77
|
| Rate for Payer: Priority Health SBD |
$196.26
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$89.28
|
|
|
Service Code
|
NDC 59762314001
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Advantage |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.96
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health SBD |
$56.25
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$116.79
|
|
|
Service Code
|
NDC 00093202631
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: Aetna Commercial |
$99.27
|
| Rate for Payer: Aetna Medicare |
$58.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.91
|
| Rate for Payer: BCBS Complete |
$46.72
|
| Rate for Payer: Cash Price |
$93.43
|
| Rate for Payer: Cofinity Advantage |
$81.75
|
| Rate for Payer: Cofinity Commercial |
$100.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.43
|
| Rate for Payer: Healthscope Commercial |
$105.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.59
|
| Rate for Payer: PHP Commercial |
$99.27
|
| Rate for Payer: Priority Health SBD |
$73.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.91
|
| Rate for Payer: UHC Core |
$60.85
|
| Rate for Payer: UHC Exchange |
$45.90
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$116.79
|
|
|
Service Code
|
NDC 00093202631
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.58 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: Aetna Commercial |
$99.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.91
|
| Rate for Payer: Cash Price |
$93.43
|
| Rate for Payer: Cofinity Advantage |
$81.75
|
| Rate for Payer: Cofinity Commercial |
$100.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.43
|
| Rate for Payer: Healthscope Commercial |
$105.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.59
|
| Rate for Payer: PHP Commercial |
$99.27
|
| Rate for Payer: Priority Health SBD |
$73.58
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$124.55
|
|
|
Service Code
|
NDC 70710146002
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.95 |
| Max. Negotiated Rate |
$112.09 |
| Rate for Payer: Aetna Commercial |
$105.87
|
| Rate for Payer: Aetna Medicare |
$62.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.96
|
| Rate for Payer: BCBS Complete |
$49.82
|
| Rate for Payer: Cash Price |
$99.64
|
| Rate for Payer: Cofinity Advantage |
$87.19
|
| Rate for Payer: Cofinity Commercial |
$107.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.64
|
| Rate for Payer: Healthscope Commercial |
$112.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$93.41
|
| Rate for Payer: PHP Commercial |
$105.87
|
| Rate for Payer: Priority Health SBD |
$78.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.96
|
| Rate for Payer: UHC Core |
$64.89
|
| Rate for Payer: UHC Exchange |
$48.95
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$82.37
|
|
|
Service Code
|
NDC 42806015134
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.37 |
| Max. Negotiated Rate |
$74.13 |
| Rate for Payer: Aetna Commercial |
$70.01
|
| Rate for Payer: Aetna Medicare |
$41.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.54
|
| Rate for Payer: BCBS Complete |
$32.95
|
| Rate for Payer: Cash Price |
$65.90
|
| Rate for Payer: Cofinity Advantage |
$57.66
|
| Rate for Payer: Cofinity Commercial |
$70.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.90
|
| Rate for Payer: Healthscope Commercial |
$74.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.78
|
| Rate for Payer: PHP Commercial |
$70.01
|
| Rate for Payer: Priority Health SBD |
$51.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.54
|
| Rate for Payer: UHC Core |
$42.91
|
| Rate for Payer: UHC Exchange |
$32.37
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$82.37
|
|
|
Service Code
|
NDC 42806015134
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.89 |
| Max. Negotiated Rate |
$74.13 |
| Rate for Payer: Aetna Commercial |
$70.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.54
|
| Rate for Payer: Cash Price |
$65.90
|
| Rate for Payer: Cofinity Advantage |
$57.66
|
| Rate for Payer: Cofinity Commercial |
$70.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.90
|
| Rate for Payer: Healthscope Commercial |
$74.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.78
|
| Rate for Payer: PHP Commercial |
$70.01
|
| Rate for Payer: Priority Health SBD |
$51.89
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$124.55
|
|
|
Service Code
|
NDC 70710146002
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.47 |
| Max. Negotiated Rate |
$112.09 |
| Rate for Payer: Aetna Commercial |
$105.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.96
|
| Rate for Payer: Cash Price |
$99.64
|
| Rate for Payer: Cofinity Advantage |
$87.19
|
| Rate for Payer: Cofinity Commercial |
$107.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.64
|
| Rate for Payer: Healthscope Commercial |
$112.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$93.41
|
| Rate for Payer: PHP Commercial |
$105.87
|
| Rate for Payer: Priority Health SBD |
$78.47
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$89.28
|
|
|
Service Code
|
NDC 59762314001
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna Medicare |
$44.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: BCBS Complete |
$35.71
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Advantage |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.96
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.03
|
| Rate for Payer: UHC Core |
$46.51
|
| Rate for Payer: UHC Exchange |
$35.09
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$409.92
|
|
|
Service Code
|
NDC 00904670861
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.25 |
| Max. Negotiated Rate |
$368.93 |
| Rate for Payer: Aetna Commercial |
$348.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.45
|
| Rate for Payer: Cash Price |
$327.94
|
| Rate for Payer: Cofinity Advantage |
$286.94
|
| Rate for Payer: Cofinity Commercial |
$352.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.94
|
| Rate for Payer: Healthscope Commercial |
$368.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$348.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$307.44
|
| Rate for Payer: PHP Commercial |
$348.43
|
| Rate for Payer: Priority Health SBD |
$258.25
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$419.04
|
|
|
Service Code
|
NDC 00904735061
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.68 |
| Max. Negotiated Rate |
$377.14 |
| Rate for Payer: Aetna Commercial |
$356.18
|
| Rate for Payer: Aetna Medicare |
$209.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$272.38
|
| Rate for Payer: BCBS Complete |
$167.62
|
| Rate for Payer: Cash Price |
$335.23
|
| Rate for Payer: Cofinity Advantage |
$293.33
|
| Rate for Payer: Cofinity Commercial |
$360.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$335.23
|
| Rate for Payer: Healthscope Commercial |
$377.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$335.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$356.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$314.28
|
| Rate for Payer: PHP Commercial |
$356.18
|
| Rate for Payer: Priority Health SBD |
$264.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$272.38
|
| Rate for Payer: UHC Core |
$218.32
|
| Rate for Payer: UHC Exchange |
$164.68
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$593.85
|
|
|
Service Code
|
NDC 00069406189
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$374.13 |
| Max. Negotiated Rate |
$534.47 |
| Rate for Payer: Aetna Commercial |
$504.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.00
|
| Rate for Payer: Cash Price |
$475.08
|
| Rate for Payer: Cofinity Advantage |
$415.69
|
| Rate for Payer: Cofinity Commercial |
$510.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$475.08
|
| Rate for Payer: Healthscope Commercial |
$534.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$504.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$445.39
|
| Rate for Payer: PHP Commercial |
$504.77
|
| Rate for Payer: Priority Health SBD |
$374.13
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 50268007411
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.26
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cofinity Advantage |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.78
|
| Rate for Payer: Healthscope Commercial |
$3.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.61
|
| Rate for Payer: PHP Commercial |
$2.96
|
| Rate for Payer: Priority Health SBD |
$2.19
|
|
