|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$10,484.48
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$9,436.03 |
| Rate for Payer: Aetna Commercial |
$8,911.81
|
| Rate for Payer: Aetna Medicare |
$43.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,814.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.48
|
| Rate for Payer: BCBS Complete |
$23.63
|
| Rate for Payer: BCBS MAPPO |
$41.98
|
| Rate for Payer: BCN Medicare Advantage |
$41.98
|
| Rate for Payer: Cash Price |
$8,387.58
|
| Rate for Payer: Cash Price |
$8,387.58
|
| Rate for Payer: Cofinity Commercial |
$9,016.65
|
| Rate for Payer: Cofinity Commercial |
$7,339.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,339.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,387.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.98
|
| Rate for Payer: Healthscope Commercial |
$9,436.03
|
| Rate for Payer: Mclaren Medicaid |
$22.50
|
| Rate for Payer: Mclaren Medicare |
$41.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.08
|
| Rate for Payer: Meridian Medicaid |
$23.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,911.81
|
| Rate for Payer: PACE Medicare |
$39.88
|
| Rate for Payer: PACE SWMI |
$41.98
|
| Rate for Payer: PHP Commercial |
$8,911.81
|
| Rate for Payer: PHP Medicare Advantage |
$41.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$22.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,814.91
|
| Rate for Payer: Priority Health Medicare |
$41.98
|
| Rate for Payer: Priority Health SBD |
$6,605.22
|
| Rate for Payer: Railroad Medicare Medicare |
$41.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$118.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.98
|
| Rate for Payer: UHC Medicare Advantage |
$41.98
|
| Rate for Payer: UHCCP Medicaid |
$23.63
|
| Rate for Payer: VA VA |
$41.98
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$31,453.30
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$28,307.97 |
| Rate for Payer: Aetna Commercial |
$26,735.31
|
| Rate for Payer: Aetna Medicare |
$43.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20,444.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.48
|
| Rate for Payer: BCBS Complete |
$23.63
|
| Rate for Payer: BCBS MAPPO |
$41.98
|
| Rate for Payer: BCN Medicare Advantage |
$41.98
|
| Rate for Payer: Cash Price |
$25,162.64
|
| Rate for Payer: Cash Price |
$25,162.64
|
| Rate for Payer: Cofinity Commercial |
$27,049.84
|
| Rate for Payer: Cofinity Commercial |
$22,017.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$22,017.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,162.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.98
|
| Rate for Payer: Healthscope Commercial |
$28,307.97
|
| Rate for Payer: Mclaren Medicaid |
$22.50
|
| Rate for Payer: Mclaren Medicare |
$41.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.08
|
| Rate for Payer: Meridian Medicaid |
$23.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,735.31
|
| Rate for Payer: PACE Medicare |
$39.88
|
| Rate for Payer: PACE SWMI |
$41.98
|
| Rate for Payer: PHP Commercial |
$26,735.31
|
| Rate for Payer: PHP Medicare Advantage |
$41.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$22.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,444.65
|
| Rate for Payer: Priority Health Medicare |
$41.98
|
| Rate for Payer: Priority Health SBD |
$19,815.58
|
| Rate for Payer: Railroad Medicare Medicare |
$41.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$118.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.98
|
| Rate for Payer: UHC Medicare Advantage |
$41.98
|
| Rate for Payer: UHCCP Medicaid |
$23.63
|
| Rate for Payer: VA VA |
$41.98
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$31,453.30
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19,815.58 |
| Max. Negotiated Rate |
$28,307.97 |
| Rate for Payer: Aetna Commercial |
$26,735.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20,444.65
|
| Rate for Payer: Cash Price |
$25,162.64
|
| Rate for Payer: Cofinity Commercial |
$22,017.31
|
| Rate for Payer: Cofinity Commercial |
$27,049.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$22,017.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,162.64
|
| Rate for Payer: Healthscope Commercial |
$28,307.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,735.31
|
| Rate for Payer: PHP Commercial |
$26,735.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,444.65
|
| Rate for Payer: Priority Health SBD |
$19,815.58
|
|
|
LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$11,655.36
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
10475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,752.41 |
| Max. Negotiated Rate |
$14,454.76 |
| Rate for Payer: Aetna Commercial |
$9,907.06
|
| Rate for Payer: Aetna Medicare |
$5,340.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,575.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,418.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,418.86
|
| Rate for Payer: BCBS Complete |
$2,890.03
|
| Rate for Payer: BCBS MAPPO |
$5,135.09
|
| Rate for Payer: BCN Medicare Advantage |
$5,135.09
|
| Rate for Payer: Cash Price |
$9,324.29
|
| Rate for Payer: Cash Price |
$9,324.29
|
| Rate for Payer: Cofinity Commercial |
$10,023.61
|
| Rate for Payer: Cofinity Commercial |
$8,158.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,158.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,324.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,135.09
|
| Rate for Payer: Healthscope Commercial |
$10,489.82
|
| Rate for Payer: Mclaren Medicaid |
$2,752.41
|
| Rate for Payer: Mclaren Medicare |
$5,135.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,391.84
|
| Rate for Payer: Meridian Medicaid |
$2,890.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,905.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,907.06
|
| Rate for Payer: PACE Medicare |
$4,878.34
|
| Rate for Payer: PACE SWMI |
$5,135.09
|
| Rate for Payer: PHP Commercial |
$9,907.06
|
| Rate for Payer: PHP Medicare Advantage |
$5,135.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,752.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,575.98
|
| Rate for Payer: Priority Health Medicare |
$5,135.09
|
| Rate for Payer: Priority Health SBD |
$7,342.88
|
| Rate for Payer: Railroad Medicare Medicare |
$5,135.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,454.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,135.09
|
| Rate for Payer: UHC Medicare Advantage |
$5,135.09
|
| Rate for Payer: UHCCP Medicaid |
$2,891.06
|
| Rate for Payer: VA VA |
$5,135.09
|
|
|
LYSIS OF LABIAL ADHESIONS
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 56441
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,745.82
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS
|
Facility
|
OP
|
$5,623.80
|
|
|
Service Code
|
CPT 54162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,070.86 |
| Max. Negotiated Rate |
$5,623.80 |
| Rate for Payer: Aetna Medicare |
$2,077.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,497.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,497.34
|
| Rate for Payer: BCBS Complete |
$1,124.40
|
| Rate for Payer: BCBS MAPPO |
$1,997.87
|
| Rate for Payer: BCN Medicare Advantage |
$1,997.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,997.87
|
| Rate for Payer: Mclaren Medicaid |
$1,070.86
|
| Rate for Payer: Mclaren Medicare |
$1,997.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,097.76
|
| Rate for Payer: Meridian Medicaid |
$1,124.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,297.55
|
| Rate for Payer: PACE Medicare |
$1,897.98
|
| Rate for Payer: PACE SWMI |
$1,997.87
|
| Rate for Payer: PHP Medicare Advantage |
$1,997.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,070.86
|
| Rate for Payer: Priority Health Medicare |
$1,997.87
|
| Rate for Payer: Railroad Medicare Medicare |
$1,997.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,623.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,997.87
|
| Rate for Payer: UHC Medicare Advantage |
$1,997.87
|
| Rate for Payer: UHCCP Medicaid |
$1,124.80
|
| Rate for Payer: VA VA |
$1,997.87
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
OP
|
$65.80
|
|
|
Service Code
|
NDC 31604001269
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna Medicare |
$32.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: BCBS Complete |
$26.32
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.77
|
| Rate for Payer: Priority Health SBD |
$41.45
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
OP
|
$108.10
|
|
|
Service Code
|
NDC 07610028320
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.24 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna Medicare |
$54.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: BCBS Complete |
$43.24
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.27
|
| Rate for Payer: Priority Health SBD |
$68.10
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
OP
|
$58.75
|
|
|
Service Code
|
NDC 43292055738
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna Medicare |
$29.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: BCBS Complete |
$23.50
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
IP
|
$65.80
|
|
|
Service Code
|
NDC 31604001269
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.45 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.77
|
| Rate for Payer: Priority Health SBD |
$41.45
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 43292055738
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 07610028320
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.27
|
| Rate for Payer: Priority Health SBD |
$68.10
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
OP
|
$17.32
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: Priority Health SBD |
$10.91
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399005101
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: Priority Health SBD |
$10.91
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: Priority Health SBD |
$10.91
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
OP
|
$17.32
|
|
|
Service Code
|
NDC 71399005101
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: Priority Health SBD |
$10.91
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.62
|
| Rate for Payer: Cash Price |
$6.91
|
| Rate for Payer: Cofinity Commercial |
$6.05
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.91
|
| Rate for Payer: Healthscope Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.34
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.62
|
| Rate for Payer: Priority Health SBD |
$5.44
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00904684673
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna Commercial |
$6.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.20
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cofinity Commercial |
$5.60
|
| Rate for Payer: Cofinity Commercial |
$6.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.40
|
| Rate for Payer: Healthscope Commercial |
$7.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.80
|
| Rate for Payer: PHP Commercial |
$6.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.20
|
| Rate for Payer: Priority Health SBD |
$5.04
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$8.64
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna Medicare |
$4.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.62
|
| Rate for Payer: BCBS Complete |
$3.46
|
| Rate for Payer: Cash Price |
$6.91
|
| Rate for Payer: Cofinity Commercial |
$6.05
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.91
|
| Rate for Payer: Healthscope Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.34
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.62
|
| Rate for Payer: Priority Health SBD |
$5.44
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00904684673
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna Commercial |
$6.80
|
| Rate for Payer: Aetna Medicare |
$4.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.20
|
| Rate for Payer: BCBS Complete |
$3.20
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cofinity Commercial |
$5.60
|
| Rate for Payer: Cofinity Commercial |
$6.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.40
|
| Rate for Payer: Healthscope Commercial |
$7.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.80
|
| Rate for Payer: PHP Commercial |
$6.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.20
|
| Rate for Payer: Priority Health SBD |
$5.04
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.28 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$217.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.40
|
| Rate for Payer: Cash Price |
$204.80
|
| Rate for Payer: Cofinity Commercial |
$179.20
|
| Rate for Payer: Cofinity Commercial |
$220.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.80
|
| Rate for Payer: Healthscope Commercial |
$230.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.60
|
| Rate for Payer: PHP Commercial |
$217.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.40
|
| Rate for Payer: Priority Health SBD |
$161.28
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 64980033990
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.70
|
| Rate for Payer: BCBS Complete |
$0.43
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cofinity Commercial |
$0.76
|
| Rate for Payer: Cofinity Commercial |
$0.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.86
|
| Rate for Payer: Healthscope Commercial |
$0.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.92
|
| Rate for Payer: PHP Commercial |
$0.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.70
|
| Rate for Payer: Priority Health SBD |
$0.68
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$107.80
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.91 |
| Max. Negotiated Rate |
$97.02 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.07
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cofinity Commercial |
$75.46
|
| Rate for Payer: Cofinity Commercial |
$92.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.24
|
| Rate for Payer: Healthscope Commercial |
$97.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.63
|
| Rate for Payer: PHP Commercial |
$91.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.07
|
| Rate for Payer: Priority Health SBD |
$67.91
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$393.60
|
|
|
Service Code
|
NDC 60258017101
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.44 |
| Max. Negotiated Rate |
$354.24 |
| Rate for Payer: Aetna Commercial |
$334.56
|
| Rate for Payer: Aetna Medicare |
$196.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.84
|
| Rate for Payer: BCBS Complete |
$157.44
|
| Rate for Payer: Cash Price |
$314.88
|
| Rate for Payer: Cofinity Commercial |
$275.52
|
| Rate for Payer: Cofinity Commercial |
$338.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$275.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$314.88
|
| Rate for Payer: Healthscope Commercial |
$354.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$334.56
|
| Rate for Payer: PHP Commercial |
$334.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.84
|
| Rate for Payer: Priority Health SBD |
$247.97
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$107.80
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$97.02 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Aetna Medicare |
$53.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.07
|
| Rate for Payer: BCBS Complete |
$43.12
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cofinity Commercial |
$75.46
|
| Rate for Payer: Cofinity Commercial |
$92.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.24
|
| Rate for Payer: Healthscope Commercial |
$97.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.63
|
| Rate for Payer: PHP Commercial |
$91.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.07
|
| Rate for Payer: Priority Health SBD |
$67.91
|
|
