|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$8.17
|
|
|
Service Code
|
NDC 60687067211
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$7.35 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.31
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Cofinity Advantage |
$5.72
|
| Rate for Payer: Cofinity Commercial |
$7.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.54
|
| Rate for Payer: Healthscope Commercial |
$7.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.13
|
| Rate for Payer: PHP Commercial |
$6.94
|
| Rate for Payer: Priority Health SBD |
$5.15
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$373.45
|
|
|
Service Code
|
NDC 00904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.77 |
| Max. Negotiated Rate |
$336.11 |
| Rate for Payer: Aetna Commercial |
$317.43
|
| Rate for Payer: Aetna Medicare |
$186.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.74
|
| Rate for Payer: BCBS Complete |
$149.38
|
| Rate for Payer: Cash Price |
$298.76
|
| Rate for Payer: Cofinity Advantage |
$261.42
|
| Rate for Payer: Cofinity Commercial |
$321.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.76
|
| Rate for Payer: Healthscope Commercial |
$336.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$298.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.09
|
| Rate for Payer: PHP Commercial |
$317.43
|
| Rate for Payer: Priority Health SBD |
$235.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$242.74
|
| Rate for Payer: UHC Core |
$194.57
|
| Rate for Payer: UHC Exchange |
$146.77
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$408.45
|
|
|
Service Code
|
NDC 60687067265
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.32 |
| Max. Negotiated Rate |
$367.61 |
| Rate for Payer: Aetna Commercial |
$347.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.49
|
| Rate for Payer: Cash Price |
$326.76
|
| Rate for Payer: Cofinity Advantage |
$285.92
|
| Rate for Payer: Cofinity Commercial |
$351.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$326.76
|
| Rate for Payer: Healthscope Commercial |
$367.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$347.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$306.34
|
| Rate for Payer: PHP Commercial |
$347.18
|
| Rate for Payer: Priority Health SBD |
$257.32
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$735.70
|
|
|
Service Code
|
NDC 00603254421
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$463.49 |
| Max. Negotiated Rate |
$662.13 |
| Rate for Payer: Aetna Commercial |
$625.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$478.20
|
| Rate for Payer: Cash Price |
$588.56
|
| Rate for Payer: Cofinity Advantage |
$514.99
|
| Rate for Payer: Cofinity Commercial |
$632.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$588.56
|
| Rate for Payer: Healthscope Commercial |
$662.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$625.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$551.77
|
| Rate for Payer: PHP Commercial |
$625.35
|
| Rate for Payer: Priority Health SBD |
$463.49
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$302.75
|
|
|
Service Code
|
NDC 00527169501
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.73 |
| Max. Negotiated Rate |
$272.48 |
| Rate for Payer: Aetna Commercial |
$257.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.79
|
| Rate for Payer: Cash Price |
$242.20
|
| Rate for Payer: Cofinity Advantage |
$211.93
|
| Rate for Payer: Cofinity Commercial |
$260.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.20
|
| Rate for Payer: Healthscope Commercial |
$272.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$227.06
|
| Rate for Payer: PHP Commercial |
$257.34
|
| Rate for Payer: Priority Health SBD |
$190.73
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$408.45
|
|
|
Service Code
|
NDC 60687067265
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.52 |
| Max. Negotiated Rate |
$367.61 |
| Rate for Payer: Aetna Commercial |
$347.18
|
| Rate for Payer: Aetna Medicare |
$204.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.49
|
| Rate for Payer: BCBS Complete |
$163.38
|
| Rate for Payer: Cash Price |
$326.76
|
| Rate for Payer: Cofinity Advantage |
$285.92
|
| Rate for Payer: Cofinity Commercial |
$351.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$326.76
|
| Rate for Payer: Healthscope Commercial |
$367.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$326.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$347.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$306.34
|
| Rate for Payer: PHP Commercial |
$347.18
|
| Rate for Payer: Priority Health SBD |
$257.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.49
|
| Rate for Payer: UHC Core |
$212.80
|
| Rate for Payer: UHC Exchange |
$160.52
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$8.17
|
|
|
Service Code
|
NDC 60687067211
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$7.35 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Aetna Medicare |
$4.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.31
|
| Rate for Payer: BCBS Complete |
$3.27
|
| Rate for Payer: Cash Price |
$6.54
|
| Rate for Payer: Cofinity Advantage |
$5.72
|
| Rate for Payer: Cofinity Commercial |
$7.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.54
|
| Rate for Payer: Healthscope Commercial |
$7.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.13
|
| Rate for Payer: PHP Commercial |
$6.94
|
| Rate for Payer: Priority Health SBD |
$5.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.31
|
| Rate for Payer: UHC Core |
$4.26
|
| Rate for Payer: UHC Exchange |
$3.21
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$91.32
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
9334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.53 |
| Max. Negotiated Rate |
$82.19 |
| Rate for Payer: Aetna Commercial |
$77.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.36
|
| Rate for Payer: Cash Price |
$73.06
|
| Rate for Payer: Cofinity Advantage |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$78.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.06
|
| Rate for Payer: Healthscope Commercial |
$82.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.49
|
| Rate for Payer: PHP Commercial |
$77.62
|
| Rate for Payer: Priority Health SBD |
$57.53
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$91.32
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
9334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$82.19 |
| Rate for Payer: Aetna Commercial |
$77.62
|
| Rate for Payer: Aetna Medicare |
$45.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.36
|
| Rate for Payer: BCBS Complete |
$36.53
|
| Rate for Payer: BCBS Trust/PPO |
$13.89
|
| Rate for Payer: BCN Commercial |
$13.89
|
| Rate for Payer: Cash Price |
$73.06
|
| Rate for Payer: Cash Price |
$73.06
|
| Rate for Payer: Cofinity Advantage |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$78.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.06
|
| Rate for Payer: Healthscope Commercial |
$82.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.49
|
| Rate for Payer: PHP Commercial |
$77.62
|
| Rate for Payer: Priority Health SBD |
$57.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.14
|
| Rate for Payer: UHC Core |
$9.14
|
| Rate for Payer: UHC Exchange |
$9.14
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$66,092.12
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
105644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.84 |
| Max. Negotiated Rate |
$59,482.91 |
| Rate for Payer: Aetna Commercial |
$56,178.30
|
| Rate for Payer: Aetna Medicare |
$240.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42,959.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$288.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$288.81
|
| Rate for Payer: BCBS Complete |
$126.89
|
| Rate for Payer: BCBS MAPPO |
$231.05
|
| Rate for Payer: BCBS Trust/PPO |
$579.03
|
| Rate for Payer: BCN Commercial |
$579.03
|
| Rate for Payer: BCN Medicare Advantage |
$231.05
|
| Rate for Payer: Cash Price |
$52,873.70
|
| Rate for Payer: Cash Price |
$52,873.70
|
| Rate for Payer: Cofinity Advantage |
$46,264.48
|
| Rate for Payer: Cofinity Commercial |
$56,839.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52,873.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$231.05
|
| Rate for Payer: Healthscope Commercial |
$59,482.91
|
| Rate for Payer: Mclaren Medicaid |
$120.84
|
| Rate for Payer: Mclaren Medicare |
$231.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$242.60
|
| Rate for Payer: Meridian Medicaid |
$242.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$265.71
|
| Rate for Payer: Molina Medicare/Medicaid |
$254.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56,178.30
|
| Rate for Payer: Nomi Health Commercial |
$693.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$49,569.09
|
| Rate for Payer: PACE Medicare |
$219.50
|
| Rate for Payer: PACE SWMI |
$231.05
|
| Rate for Payer: PHP Commercial |
$56,178.30
|
| Rate for Payer: PHP Medicare Advantage |
$231.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$120.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$716.82
|
| Rate for Payer: Priority Health Medicare |
$231.05
|
| Rate for Payer: Priority Health SBD |
$41,638.04
|
| Rate for Payer: Priority Health Tiered Network |
$573.46
|
| Rate for Payer: Railroad Medicare Medicare |
$231.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$380.82
|
| Rate for Payer: UHC Core |
$380.82
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$231.05
|
| Rate for Payer: UHC Exchange |
$380.82
|
| Rate for Payer: UHC Medicaid |
$120.84
|
| Rate for Payer: UHCCP Medicaid |
$120.84
|
| Rate for Payer: VA VA |
$231.05
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$66,092.12
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
105644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41,638.04 |
| Max. Negotiated Rate |
$59,482.91 |
| Rate for Payer: Aetna Commercial |
$56,178.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42,959.88
|
| Rate for Payer: Cash Price |
$52,873.70
|
| Rate for Payer: Cofinity Advantage |
$46,264.48
|
| Rate for Payer: Cofinity Commercial |
$56,839.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52,873.70
|
| Rate for Payer: Healthscope Commercial |
$59,482.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56,178.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$49,569.09
|
| Rate for Payer: PHP Commercial |
$56,178.30
|
| Rate for Payer: Priority Health SBD |
$41,638.04
|
|
|
CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER
|
Facility
|
IP
|
$20,048.54
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,630.58 |
| Max. Negotiated Rate |
$18,043.69 |
| Rate for Payer: Aetna Commercial |
$17,041.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,031.55
|
| Rate for Payer: Cash Price |
$16,038.83
|
| Rate for Payer: Cofinity Advantage |
$14,033.98
|
| Rate for Payer: Cofinity Commercial |
$17,241.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,038.83
|
| Rate for Payer: Healthscope Commercial |
$18,043.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,041.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,036.41
|
| Rate for Payer: PHP Commercial |
$17,041.26
|
| Rate for Payer: Priority Health SBD |
$12,630.58
|
|
|
CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER
|
Facility
|
OP
|
$20,048.54
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$18,043.69 |
| Rate for Payer: Aetna Commercial |
$17,041.26
|
| Rate for Payer: Aetna Medicare |
$25.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,031.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30.23
|
| Rate for Payer: BCBS Complete |
$13.28
|
| Rate for Payer: BCBS MAPPO |
$24.18
|
| Rate for Payer: BCBS Trust/PPO |
$60.60
|
| Rate for Payer: BCN Commercial |
$60.60
|
| Rate for Payer: BCN Medicare Advantage |
$24.18
|
| Rate for Payer: Cash Price |
$16,038.83
|
| Rate for Payer: Cash Price |
$16,038.83
|
| Rate for Payer: Cofinity Advantage |
$14,033.98
|
| Rate for Payer: Cofinity Commercial |
$17,241.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,038.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.18
|
| Rate for Payer: Healthscope Commercial |
$18,043.69
|
| Rate for Payer: Mclaren Medicaid |
$12.65
|
| Rate for Payer: Mclaren Medicare |
$24.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.39
|
| Rate for Payer: Meridian Medicaid |
$25.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$26.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,041.26
|
| Rate for Payer: Nomi Health Commercial |
$72.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,036.41
|
| Rate for Payer: PACE Medicare |
$22.97
|
| Rate for Payer: PACE SWMI |
$24.18
|
| Rate for Payer: PHP Commercial |
$17,041.26
|
| Rate for Payer: PHP Medicare Advantage |
$24.18
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$74.59
|
| Rate for Payer: Priority Health Medicare |
$24.18
|
| Rate for Payer: Priority Health SBD |
$12,630.58
|
| Rate for Payer: Priority Health Tiered Network |
$59.67
|
| Rate for Payer: Railroad Medicare Medicare |
$24.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.86
|
| Rate for Payer: UHC Core |
$39.86
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$24.18
|
| Rate for Payer: UHC Exchange |
$39.86
|
| Rate for Payer: UHC Medicaid |
$12.65
|
| Rate for Payer: UHCCP Medicaid |
$12.65
|
| Rate for Payer: VA VA |
$24.18
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER
|
Facility
|
OP
|
$30,072.00
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$27,064.80 |
| Rate for Payer: Aetna Commercial |
$25,561.20
|
| Rate for Payer: Aetna Medicare |
$25.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,546.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30.23
|
| Rate for Payer: BCBS Complete |
$13.28
|
| Rate for Payer: BCBS MAPPO |
$24.18
|
| Rate for Payer: BCBS Trust/PPO |
$60.60
|
| Rate for Payer: BCN Commercial |
$60.60
|
| Rate for Payer: BCN Medicare Advantage |
$24.18
|
| Rate for Payer: Cash Price |
$24,057.60
|
| Rate for Payer: Cash Price |
$24,057.60
|
| Rate for Payer: Cofinity Advantage |
$21,050.40
|
| Rate for Payer: Cofinity Commercial |
$25,861.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24,057.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.18
|
| Rate for Payer: Healthscope Commercial |
$27,064.80
|
| Rate for Payer: Mclaren Medicaid |
$12.65
|
| Rate for Payer: Mclaren Medicare |
$24.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.39
|
| Rate for Payer: Meridian Medicaid |
$25.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$26.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,561.20
|
| Rate for Payer: Nomi Health Commercial |
$72.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22,554.00
|
| Rate for Payer: PACE Medicare |
$22.97
|
| Rate for Payer: PACE SWMI |
$24.18
|
| Rate for Payer: PHP Commercial |
$25,561.20
|
| Rate for Payer: PHP Medicare Advantage |
$24.18
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$74.59
|
| Rate for Payer: Priority Health Medicare |
$24.18
|
| Rate for Payer: Priority Health SBD |
$18,945.36
|
| Rate for Payer: Priority Health Tiered Network |
$59.67
|
| Rate for Payer: Railroad Medicare Medicare |
$24.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.86
|
| Rate for Payer: UHC Core |
$39.86
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$24.18
|
| Rate for Payer: UHC Exchange |
$39.86
|
| Rate for Payer: UHC Medicaid |
$12.65
|
| Rate for Payer: UHCCP Medicaid |
$12.65
|
| Rate for Payer: VA VA |
$24.18
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER
|
Facility
|
IP
|
$30,072.00
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,945.36 |
| Max. Negotiated Rate |
$27,064.80 |
| Rate for Payer: Aetna Commercial |
$25,561.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,546.80
|
| Rate for Payer: Cash Price |
$24,057.60
|
| Rate for Payer: Cofinity Advantage |
$21,050.40
|
| Rate for Payer: Cofinity Commercial |
$25,861.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24,057.60
|
| Rate for Payer: Healthscope Commercial |
$27,064.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,561.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22,554.00
|
| Rate for Payer: PHP Commercial |
$25,561.20
|
| Rate for Payer: Priority Health SBD |
$18,945.36
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$48.07
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$43.26 |
| Rate for Payer: Aetna Commercial |
$40.86
|
| Rate for Payer: Aetna Commercial |
$38.06
|
| Rate for Payer: Aetna Medicare |
$22.39
|
| Rate for Payer: Aetna Medicare |
$24.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.11
|
| Rate for Payer: BCBS Complete |
$17.91
|
| Rate for Payer: BCBS Complete |
$19.23
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: Cash Price |
$38.46
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cash Price |
$38.46
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Advantage |
$33.65
|
| Rate for Payer: Cofinity Advantage |
$31.35
|
| Rate for Payer: Cofinity Commercial |
$41.34
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.46
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Healthscope Commercial |
$43.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$38.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.59
|
| Rate for Payer: PHP Commercial |
$40.86
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: Priority Health SBD |
$30.28
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.35
|
| Rate for Payer: UHC Core |
$3.35
|
| Rate for Payer: UHC Core |
$3.35
|
| Rate for Payer: UHC Exchange |
$3.35
|
| Rate for Payer: UHC Exchange |
$3.35
|
|
|
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 Advantage |
$31.35
|
| Rate for Payer: Cofinity Advantage |
$33.65
|
| Rate for Payer: Cofinity Commercial |
$41.34
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$43.26
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.05
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$40.86
|
| 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
|
OP
|
$37.76
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna Commercial |
$32.10
|
| Rate for Payer: Aetna Medicare |
$18.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.54
|
| Rate for Payer: BCBS Complete |
$15.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cofinity Advantage |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.21
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.32
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health SBD |
$23.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.35
|
| Rate for Payer: UHC Core |
$3.35
|
| Rate for Payer: UHC Exchange |
$3.35
|
|
|
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 Advantage |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.21
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.32
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health SBD |
$23.79
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
OP
|
$139.81
|
|
|
Service Code
|
NDC 00517250201
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$125.83 |
| Rate for Payer: Aetna Commercial |
$118.84
|
| Rate for Payer: Aetna Medicare |
$69.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.88
|
| Rate for Payer: BCBS Complete |
$55.92
|
| Rate for Payer: Cash Price |
$111.85
|
| Rate for Payer: Cofinity Advantage |
$97.87
|
| Rate for Payer: Cofinity Commercial |
$120.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.85
|
| Rate for Payer: Healthscope Commercial |
$125.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.86
|
| Rate for Payer: PHP Commercial |
$118.84
|
| Rate for Payer: Priority Health SBD |
$88.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.88
|
| Rate for Payer: UHC Core |
$72.84
|
| Rate for Payer: UHC Exchange |
$54.95
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
IP
|
$139.81
|
|
|
Service Code
|
NDC 00517250201
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.08 |
| Max. Negotiated Rate |
$125.83 |
| Rate for Payer: Aetna Commercial |
$118.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.88
|
| Rate for Payer: Cash Price |
$111.85
|
| Rate for Payer: Cofinity Advantage |
$97.87
|
| Rate for Payer: Cofinity Commercial |
$120.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.85
|
| Rate for Payer: Healthscope Commercial |
$125.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.86
|
| Rate for Payer: PHP Commercial |
$118.84
|
| Rate for Payer: Priority Health SBD |
$88.08
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
IP
|
$139.81
|
|
|
Service Code
|
NDC 00517250210
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.08 |
| Max. Negotiated Rate |
$125.83 |
| Rate for Payer: Aetna Commercial |
$118.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.88
|
| Rate for Payer: Cash Price |
$111.85
|
| Rate for Payer: Cofinity Advantage |
$97.87
|
| Rate for Payer: Cofinity Commercial |
$120.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.85
|
| Rate for Payer: Healthscope Commercial |
$125.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.86
|
| Rate for Payer: PHP Commercial |
$118.84
|
| Rate for Payer: Priority Health SBD |
$88.08
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
OP
|
$139.81
|
|
|
Service Code
|
NDC 00517250210
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$125.83 |
| Rate for Payer: Aetna Commercial |
$118.84
|
| Rate for Payer: Aetna Medicare |
$69.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.88
|
| Rate for Payer: BCBS Complete |
$55.92
|
| Rate for Payer: Cash Price |
$111.85
|
| Rate for Payer: Cofinity Advantage |
$97.87
|
| Rate for Payer: Cofinity Commercial |
$120.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.85
|
| Rate for Payer: Healthscope Commercial |
$125.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.86
|
| Rate for Payer: PHP Commercial |
$118.84
|
| Rate for Payer: Priority Health SBD |
$88.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.88
|
| Rate for Payer: UHC Core |
$72.84
|
| Rate for Payer: UHC Exchange |
$54.95
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
|
OP
|
$17.53
|
|
|
Service Code
|
NDC 00395041396
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$15.78 |
| Rate for Payer: Aetna Commercial |
$14.90
|
| Rate for Payer: Aetna Medicare |
$8.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.39
|
| Rate for Payer: BCBS Complete |
$7.01
|
| Rate for Payer: Cash Price |
$14.02
|
| Rate for Payer: Cofinity Advantage |
$12.27
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.02
|
| Rate for Payer: Healthscope Commercial |
$15.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.15
|
| Rate for Payer: PHP Commercial |
$14.90
|
| Rate for Payer: Priority Health SBD |
$11.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.39
|
| Rate for Payer: UHC Core |
$9.13
|
| Rate for Payer: UHC Exchange |
$6.89
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
|
OP
|
$8.50
|
|
|
Service Code
|
NDC 00904253321
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.22
|
| Rate for Payer: Aetna Medicare |
$4.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.53
|
| Rate for Payer: BCBS Complete |
$3.40
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cofinity Advantage |
$5.95
|
| Rate for Payer: Cofinity Commercial |
$7.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.80
|
| Rate for Payer: Healthscope Commercial |
$7.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.38
|
| Rate for Payer: PHP Commercial |
$7.22
|
| Rate for Payer: Priority Health SBD |
$5.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.53
|
| Rate for Payer: UHC Core |
$4.43
|
| Rate for Payer: UHC Exchange |
$3.34
|
|
