|
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS
|
Facility
|
OP
|
$13,047.94
|
|
|
Service Code
|
HCPCS J9205
|
| Hospital Charge Code |
176129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.38 |
| Max. Negotiated Rate |
$11,743.15 |
| Rate for Payer: Aetna Commercial |
$11,090.75
|
| Rate for Payer: Aetna Medicare |
$68.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,481.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$82.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$82.50
|
| Rate for Payer: BCBS Complete |
$37.14
|
| Rate for Payer: BCBS MAPPO |
$66.00
|
| Rate for Payer: BCN Medicare Advantage |
$66.00
|
| Rate for Payer: Cash Price |
$10,438.35
|
| Rate for Payer: Cash Price |
$10,438.35
|
| Rate for Payer: Cofinity Commercial |
$9,133.56
|
| Rate for Payer: Cofinity Commercial |
$11,221.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$9,133.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10,438.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$66.00
|
| Rate for Payer: Healthscope Commercial |
$11,743.15
|
| Rate for Payer: Mclaren Medicaid |
$35.38
|
| Rate for Payer: Mclaren Medicare |
$66.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$69.30
|
| Rate for Payer: Meridian Medicaid |
$37.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$75.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11,090.75
|
| Rate for Payer: PACE Medicare |
$62.70
|
| Rate for Payer: PACE SWMI |
$66.00
|
| Rate for Payer: PHP Commercial |
$11,090.75
|
| Rate for Payer: PHP Medicare Advantage |
$66.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$35.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,481.16
|
| Rate for Payer: Priority Health Medicare |
$66.00
|
| Rate for Payer: Priority Health SBD |
$8,220.20
|
| Rate for Payer: Railroad Medicare Medicare |
$66.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$185.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$66.00
|
| Rate for Payer: UHC Medicare Advantage |
$66.00
|
| Rate for Payer: UHCCP Medicaid |
$37.16
|
| Rate for Payer: VA VA |
$66.00
|
|
|
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$161.68
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
186569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.86 |
| Max. Negotiated Rate |
$145.51 |
| Rate for Payer: Aetna Commercial |
$137.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.09
|
| Rate for Payer: Cash Price |
$129.34
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$139.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.34
|
| Rate for Payer: Healthscope Commercial |
$145.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.43
|
| Rate for Payer: PHP Commercial |
$137.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.09
|
| Rate for Payer: Priority Health SBD |
$101.86
|
|
|
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$161.68
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
186569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$145.51 |
| Rate for Payer: Aetna Commercial |
$137.43
|
| Rate for Payer: Aetna Medicare |
$18.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.64
|
| Rate for Payer: BCBS Complete |
$10.19
|
| Rate for Payer: BCBS MAPPO |
$18.11
|
| Rate for Payer: BCN Medicare Advantage |
$18.11
|
| Rate for Payer: Cash Price |
$129.34
|
| Rate for Payer: Cash Price |
$129.34
|
| Rate for Payer: Cofinity Commercial |
$139.04
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.11
|
| Rate for Payer: Healthscope Commercial |
$145.51
|
| Rate for Payer: Mclaren Medicaid |
$9.71
|
| Rate for Payer: Mclaren Medicare |
$18.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.02
|
| Rate for Payer: Meridian Medicaid |
$10.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.43
|
| Rate for Payer: PACE Medicare |
$17.20
|
| Rate for Payer: PACE SWMI |
$18.11
|
| Rate for Payer: PHP Commercial |
$137.43
|
| Rate for Payer: PHP Medicare Advantage |
$18.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.09
|
| Rate for Payer: Priority Health Medicare |
$18.11
|
| Rate for Payer: Priority Health SBD |
$101.86
|
| Rate for Payer: Railroad Medicare Medicare |
$18.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.11
|
| Rate for Payer: UHC Medicare Advantage |
$18.11
|
| Rate for Payer: UHCCP Medicaid |
$10.20
|
| Rate for Payer: VA VA |
$18.11
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$154.04
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$138.64 |
| Rate for Payer: Aetna Commercial |
$130.93
|
| Rate for Payer: Aetna Medicare |
$77.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.13
|
| Rate for Payer: BCBS Complete |
$61.62
|
| Rate for Payer: Cash Price |
$123.23
|
| Rate for Payer: Cofinity Commercial |
$107.83
|
| Rate for Payer: Cofinity Commercial |
$132.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.23
|
| Rate for Payer: Healthscope Commercial |
$138.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.93
|
| Rate for Payer: PHP Commercial |
$130.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.13
|
| Rate for Payer: Priority Health SBD |
$97.05
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$154.04
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.05 |
| Max. Negotiated Rate |
$138.64 |
| Rate for Payer: Aetna Commercial |
$130.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.13
|
| Rate for Payer: Cash Price |
$123.23
|
| Rate for Payer: Cofinity Commercial |
$107.83
|
| Rate for Payer: Cofinity Commercial |
$132.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.23
|
| Rate for Payer: Healthscope Commercial |
$138.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.93
|
| Rate for Payer: PHP Commercial |
$130.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.13
|
| Rate for Payer: Priority Health SBD |
$97.05
|
|
|
IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$246.62
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
152314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.37 |
| Max. Negotiated Rate |
$221.96 |
| Rate for Payer: Aetna Commercial |
$209.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.30
|
| Rate for Payer: Cash Price |
$197.30
|
| Rate for Payer: Cofinity Commercial |
$172.63
|
| Rate for Payer: Cofinity Commercial |
$212.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.30
|
| Rate for Payer: Healthscope Commercial |
$221.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.63
|
| Rate for Payer: PHP Commercial |
$209.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.30
|
| Rate for Payer: Priority Health SBD |
$155.37
|
|
|
IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$246.62
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
152314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.65 |
| Max. Negotiated Rate |
$221.96 |
| Rate for Payer: Aetna Commercial |
$209.63
|
| Rate for Payer: Aetna Medicare |
$123.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.30
|
| Rate for Payer: BCBS Complete |
$98.65
|
| Rate for Payer: Cash Price |
$197.30
|
| Rate for Payer: Cofinity Commercial |
$172.63
|
| Rate for Payer: Cofinity Commercial |
$212.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.30
|
| Rate for Payer: Healthscope Commercial |
$221.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.63
|
| Rate for Payer: PHP Commercial |
$209.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.30
|
| Rate for Payer: Priority Health SBD |
$155.37
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS
|
Facility
|
OP
|
$163.07
|
|
|
Service Code
|
CPT 96523
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$31.05 |
| Max. Negotiated Rate |
$163.07 |
| Rate for Payer: Aetna Medicare |
$60.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72.41
|
| Rate for Payer: BCBS Complete |
$32.60
|
| Rate for Payer: BCBS MAPPO |
$57.93
|
| Rate for Payer: BCN Medicare Advantage |
$57.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.93
|
| Rate for Payer: Mclaren Medicaid |
$31.05
|
| Rate for Payer: Mclaren Medicare |
$57.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.83
|
| Rate for Payer: Meridian Medicaid |
$32.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.62
|
| Rate for Payer: PACE Medicare |
$55.03
|
| Rate for Payer: PACE SWMI |
$57.93
|
| Rate for Payer: PHP Medicare Advantage |
$57.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.05
|
| Rate for Payer: Priority Health Medicare |
$57.93
|
| Rate for Payer: Railroad Medicare Medicare |
$57.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$57.93
|
| Rate for Payer: UHC Medicare Advantage |
$57.93
|
| Rate for Payer: UHCCP Medicaid |
$32.61
|
| Rate for Payer: VA VA |
$57.93
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18,924.12
|
|
|
Service Code
|
HCPCS J9227
|
| Hospital Charge Code |
193032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,922.20 |
| Max. Negotiated Rate |
$17,031.71 |
| Rate for Payer: Aetna Commercial |
$16,085.50
|
| Rate for Payer: Aetna Commercial |
$3,217.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,300.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,460.13
|
| Rate for Payer: Cash Price |
$15,139.30
|
| Rate for Payer: Cash Price |
$3,027.85
|
| Rate for Payer: Cofinity Commercial |
$13,246.88
|
| Rate for Payer: Cofinity Commercial |
$2,649.37
|
| Rate for Payer: Cofinity Commercial |
$3,254.94
|
| Rate for Payer: Cofinity Commercial |
$16,274.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,649.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,246.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,139.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,027.85
|
| Rate for Payer: Healthscope Commercial |
$17,031.71
|
| Rate for Payer: Healthscope Commercial |
$3,406.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,217.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,085.50
|
| Rate for Payer: PHP Commercial |
$16,085.50
|
| Rate for Payer: PHP Commercial |
$3,217.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,460.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,300.68
|
| Rate for Payer: Priority Health SBD |
$11,922.20
|
| Rate for Payer: Priority Health SBD |
$2,384.43
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$3,784.81
|
|
|
Service Code
|
HCPCS J9227
|
| Hospital Charge Code |
193032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.90 |
| Max. Negotiated Rate |
$3,406.33 |
| Rate for Payer: Aetna Commercial |
$3,217.09
|
| Rate for Payer: Aetna Commercial |
$16,085.50
|
| Rate for Payer: Aetna Medicare |
$85.18
|
| Rate for Payer: Aetna Medicare |
$85.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,460.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,300.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$102.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$102.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$102.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$102.38
|
| Rate for Payer: BCBS Complete |
$46.09
|
| Rate for Payer: BCBS Complete |
$46.09
|
| Rate for Payer: BCBS MAPPO |
$81.90
|
| Rate for Payer: BCBS MAPPO |
$81.90
|
| Rate for Payer: BCN Medicare Advantage |
$81.90
|
| Rate for Payer: BCN Medicare Advantage |
$81.90
|
| Rate for Payer: Cash Price |
$15,139.30
|
| Rate for Payer: Cash Price |
$3,027.85
|
| Rate for Payer: Cash Price |
$3,027.85
|
| Rate for Payer: Cash Price |
$15,139.30
|
| Rate for Payer: Cofinity Commercial |
$16,274.74
|
| Rate for Payer: Cofinity Commercial |
$3,254.94
|
| Rate for Payer: Cofinity Commercial |
$2,649.37
|
| Rate for Payer: Cofinity Commercial |
$13,246.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,246.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,649.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,139.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,027.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$81.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$81.90
|
| Rate for Payer: Healthscope Commercial |
$3,406.33
|
| Rate for Payer: Healthscope Commercial |
$17,031.71
|
| Rate for Payer: Mclaren Medicaid |
$43.90
|
| Rate for Payer: Mclaren Medicaid |
$43.90
|
| Rate for Payer: Mclaren Medicare |
$81.90
|
| Rate for Payer: Mclaren Medicare |
$81.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$86.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$86.00
|
| Rate for Payer: Meridian Medicaid |
$46.09
|
| Rate for Payer: Meridian Medicaid |
$46.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$94.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$94.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,217.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,085.50
|
| Rate for Payer: PACE Medicare |
$77.81
|
| Rate for Payer: PACE Medicare |
$77.81
|
| Rate for Payer: PACE SWMI |
$81.90
|
| Rate for Payer: PACE SWMI |
$81.90
|
| Rate for Payer: PHP Commercial |
$3,217.09
|
| Rate for Payer: PHP Commercial |
$16,085.50
|
| Rate for Payer: PHP Medicare Advantage |
$81.90
|
| Rate for Payer: PHP Medicare Advantage |
$81.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,460.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,300.68
|
| Rate for Payer: Priority Health Medicare |
$81.90
|
| Rate for Payer: Priority Health Medicare |
$81.90
|
| Rate for Payer: Priority Health SBD |
$11,922.20
|
| Rate for Payer: Priority Health SBD |
$2,384.43
|
| Rate for Payer: Railroad Medicare Medicare |
$81.90
|
| Rate for Payer: Railroad Medicare Medicare |
$81.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$230.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$230.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$81.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$81.90
|
| Rate for Payer: UHC Medicare Advantage |
$81.90
|
| Rate for Payer: UHC Medicare Advantage |
$81.90
|
| Rate for Payer: UHCCP Medicaid |
$46.11
|
| Rate for Payer: UHCCP Medicaid |
$46.11
|
| Rate for Payer: VA VA |
$81.90
|
| Rate for Payer: VA VA |
$81.90
|
|
|
ISONIAZID 300 MG TABLET
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
NDC 51079008301
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Aetna Medicare |
$2.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.06
|
| Rate for Payer: BCBS Complete |
$1.88
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Commercial |
$4.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.76
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.00
|
| Rate for Payer: PHP Commercial |
$4.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.06
|
| Rate for Payer: Priority Health SBD |
$2.96
|
|
|
ISONIAZID 300 MG TABLET
|
Facility
|
OP
|
$394.80
|
|
|
Service Code
|
NDC 00555007102
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.92 |
| Max. Negotiated Rate |
$355.32 |
| Rate for Payer: Aetna Commercial |
$335.58
|
| Rate for Payer: Aetna Medicare |
$197.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$256.62
|
| Rate for Payer: BCBS Complete |
$157.92
|
| Rate for Payer: Cash Price |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$276.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$315.84
|
| Rate for Payer: Healthscope Commercial |
$355.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$335.58
|
| Rate for Payer: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.62
|
| Rate for Payer: Priority Health SBD |
$248.72
|
|
|
ISONIAZID 300 MG TABLET
|
Facility
|
IP
|
$394.80
|
|
|
Service Code
|
NDC 00555007102
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.72 |
| Max. Negotiated Rate |
$355.32 |
| Rate for Payer: Aetna Commercial |
$335.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$256.62
|
| Rate for Payer: Cash Price |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$276.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$315.84
|
| Rate for Payer: Healthscope Commercial |
$355.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$335.58
|
| Rate for Payer: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.62
|
| Rate for Payer: Priority Health SBD |
$248.72
|
|
|
ISONIAZID 300 MG TABLET
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 51079008301
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.06
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Commercial |
$4.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.76
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.00
|
| Rate for Payer: PHP Commercial |
$4.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.06
|
| Rate for Payer: Priority Health SBD |
$2.96
|
|
|
ISONIAZID 300 MG TABLET
|
Facility
|
OP
|
$469.44
|
|
|
Service Code
|
NDC 51079008320
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.78 |
| Max. Negotiated Rate |
$422.50 |
| Rate for Payer: Aetna Commercial |
$399.02
|
| Rate for Payer: Aetna Medicare |
$234.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.14
|
| Rate for Payer: BCBS Complete |
$187.78
|
| Rate for Payer: Cash Price |
$375.55
|
| Rate for Payer: Cofinity Commercial |
$328.61
|
| Rate for Payer: Cofinity Commercial |
$403.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$328.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.55
|
| Rate for Payer: Healthscope Commercial |
$422.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.02
|
| Rate for Payer: PHP Commercial |
$399.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.14
|
| Rate for Payer: Priority Health SBD |
$295.75
|
|
|
ISONIAZID 300 MG TABLET
|
Facility
|
IP
|
$469.44
|
|
|
Service Code
|
NDC 51079008320
|
| Hospital Charge Code |
4027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$295.75 |
| Max. Negotiated Rate |
$422.50 |
| Rate for Payer: Aetna Commercial |
$399.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.14
|
| Rate for Payer: Cash Price |
$375.55
|
| Rate for Payer: Cofinity Commercial |
$328.61
|
| Rate for Payer: Cofinity Commercial |
$403.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$328.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.55
|
| Rate for Payer: Healthscope Commercial |
$422.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.02
|
| Rate for Payer: PHP Commercial |
$399.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.14
|
| Rate for Payer: Priority Health SBD |
$295.75
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
OP
|
$255.84
|
|
|
Service Code
|
NDC 68084008201
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.34 |
| Max. Negotiated Rate |
$230.26 |
| Rate for Payer: Aetna Commercial |
$217.46
|
| Rate for Payer: Aetna Medicare |
$127.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.30
|
| Rate for Payer: BCBS Complete |
$102.34
|
| Rate for Payer: Cash Price |
$204.67
|
| Rate for Payer: Cofinity Commercial |
$179.09
|
| Rate for Payer: Cofinity Commercial |
$220.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.67
|
| Rate for Payer: Healthscope Commercial |
$230.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.46
|
| Rate for Payer: PHP Commercial |
$217.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.30
|
| Rate for Payer: Priority Health SBD |
$161.18
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
IP
|
$458.25
|
|
|
Service Code
|
NDC 72888008201
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.70 |
| Max. Negotiated Rate |
$412.43 |
| Rate for Payer: Aetna Commercial |
$389.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.86
|
| Rate for Payer: Cash Price |
$366.60
|
| Rate for Payer: Cofinity Commercial |
$320.77
|
| Rate for Payer: Cofinity Commercial |
$394.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$320.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.60
|
| Rate for Payer: Healthscope Commercial |
$412.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.51
|
| Rate for Payer: PHP Commercial |
$389.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.86
|
| Rate for Payer: Priority Health SBD |
$288.70
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 68084008211
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 68084008211
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
OP
|
$2.87
|
|
|
Service Code
|
NDC 50268044811
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: Aetna Medicare |
$1.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.87
|
| Rate for Payer: BCBS Complete |
$1.15
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.01
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.30
|
| Rate for Payer: Healthscope Commercial |
$2.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.44
|
| Rate for Payer: PHP Commercial |
$2.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.87
|
| Rate for Payer: Priority Health SBD |
$1.81
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
OP
|
$458.25
|
|
|
Service Code
|
NDC 72888008201
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.30 |
| Max. Negotiated Rate |
$412.43 |
| Rate for Payer: Aetna Commercial |
$389.51
|
| Rate for Payer: Aetna Medicare |
$229.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.86
|
| Rate for Payer: BCBS Complete |
$183.30
|
| Rate for Payer: Cash Price |
$366.60
|
| Rate for Payer: Cofinity Commercial |
$320.77
|
| Rate for Payer: Cofinity Commercial |
$394.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$320.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.60
|
| Rate for Payer: Healthscope Commercial |
$412.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.51
|
| Rate for Payer: PHP Commercial |
$389.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.86
|
| Rate for Payer: Priority Health SBD |
$288.70
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
OP
|
$428.45
|
|
|
Service Code
|
NDC 00904661961
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.38 |
| Max. Negotiated Rate |
$385.61 |
| Rate for Payer: Aetna Commercial |
$364.18
|
| Rate for Payer: Aetna Medicare |
$214.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.49
|
| Rate for Payer: BCBS Complete |
$171.38
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$299.92
|
| Rate for Payer: Cofinity Commercial |
$368.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$385.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.18
|
| Rate for Payer: PHP Commercial |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.49
|
| Rate for Payer: Priority Health SBD |
$269.92
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
IP
|
$428.45
|
|
|
Service Code
|
NDC 00904661961
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$269.92 |
| Max. Negotiated Rate |
$385.61 |
| Rate for Payer: Aetna Commercial |
$364.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.49
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$299.92
|
| Rate for Payer: Cofinity Commercial |
$368.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$385.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.18
|
| Rate for Payer: PHP Commercial |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.49
|
| Rate for Payer: Priority Health SBD |
$269.92
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET
|
Facility
|
OP
|
$143.04
|
|
|
Service Code
|
NDC 50268044815
|
| Hospital Charge Code |
4064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.22 |
| Max. Negotiated Rate |
$128.74 |
| Rate for Payer: Aetna Commercial |
$121.58
|
| Rate for Payer: Aetna Medicare |
$71.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.98
|
| Rate for Payer: BCBS Complete |
$57.22
|
| Rate for Payer: Cash Price |
$114.43
|
| Rate for Payer: Cofinity Commercial |
$100.13
|
| Rate for Payer: Cofinity Commercial |
$123.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$100.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.43
|
| Rate for Payer: Healthscope Commercial |
$128.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.58
|
| Rate for Payer: PHP Commercial |
$121.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.98
|
| Rate for Payer: Priority Health SBD |
$90.12
|
|
