|
MIDAZOLAM 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$37.66
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.73 |
| Max. Negotiated Rate |
$33.89 |
| Rate for Payer: Aetna Commercial |
$32.01
|
| Rate for Payer: Aetna Commercial |
$49.51
|
| Rate for Payer: Aetna Commercial |
$18.24
|
| Rate for Payer: Aetna Commercial |
$24.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.86
|
| Rate for Payer: Cash Price |
$22.94
|
| Rate for Payer: Cash Price |
$17.17
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cash Price |
$46.60
|
| Rate for Payer: Cofinity Commercial |
$15.02
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Cofinity Commercial |
$32.39
|
| Rate for Payer: Cofinity Commercial |
$20.08
|
| Rate for Payer: Cofinity Commercial |
$24.66
|
| Rate for Payer: Cofinity Commercial |
$26.36
|
| Rate for Payer: Cofinity Commercial |
$50.09
|
| Rate for Payer: Cofinity Commercial |
$40.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.60
|
| Rate for Payer: Healthscope Commercial |
$33.89
|
| Rate for Payer: Healthscope Commercial |
$25.81
|
| Rate for Payer: Healthscope Commercial |
$19.31
|
| Rate for Payer: Healthscope Commercial |
$52.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.38
|
| Rate for Payer: PHP Commercial |
$24.38
|
| Rate for Payer: PHP Commercial |
$18.24
|
| Rate for Payer: PHP Commercial |
$49.51
|
| Rate for Payer: PHP Commercial |
$32.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.48
|
| Rate for Payer: Priority Health SBD |
$13.52
|
| Rate for Payer: Priority Health SBD |
$23.73
|
| Rate for Payer: Priority Health SBD |
$18.07
|
| Rate for Payer: Priority Health SBD |
$36.70
|
|
|
MIDAZOLAM 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$37.66
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$33.89 |
| Rate for Payer: Aetna Commercial |
$32.01
|
| Rate for Payer: Aetna Commercial |
$24.38
|
| Rate for Payer: Aetna Commercial |
$49.51
|
| Rate for Payer: Aetna Commercial |
$18.24
|
| Rate for Payer: Aetna Medicare |
$29.12
|
| Rate for Payer: Aetna Medicare |
$18.83
|
| Rate for Payer: Aetna Medicare |
$14.34
|
| Rate for Payer: Aetna Medicare |
$10.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.86
|
| Rate for Payer: BCBS Complete |
$8.58
|
| Rate for Payer: BCBS Complete |
$23.30
|
| Rate for Payer: BCBS Complete |
$11.47
|
| Rate for Payer: BCBS Complete |
$15.06
|
| Rate for Payer: Cash Price |
$46.60
|
| Rate for Payer: Cash Price |
$22.94
|
| Rate for Payer: Cash Price |
$30.13
|
| Rate for Payer: Cash Price |
$17.17
|
| Rate for Payer: Cofinity Commercial |
$24.66
|
| Rate for Payer: Cofinity Commercial |
$50.09
|
| Rate for Payer: Cofinity Commercial |
$26.36
|
| Rate for Payer: Cofinity Commercial |
$40.77
|
| Rate for Payer: Cofinity Commercial |
$32.39
|
| Rate for Payer: Cofinity Commercial |
$15.02
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Cofinity Commercial |
$20.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.94
|
| Rate for Payer: Healthscope Commercial |
$19.31
|
| Rate for Payer: Healthscope Commercial |
$52.42
|
| Rate for Payer: Healthscope Commercial |
$25.81
|
| Rate for Payer: Healthscope Commercial |
$33.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.24
|
| Rate for Payer: PHP Commercial |
$24.38
|
| Rate for Payer: PHP Commercial |
$49.51
|
| Rate for Payer: PHP Commercial |
$32.01
|
| Rate for Payer: PHP Commercial |
$18.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.86
|
| Rate for Payer: Priority Health SBD |
$13.52
|
| Rate for Payer: Priority Health SBD |
$23.73
|
| Rate for Payer: Priority Health SBD |
$18.07
|
| Rate for Payer: Priority Health SBD |
$36.70
|
|
|
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$13.95
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
168786
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Aetna Commercial |
$11.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.07
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cofinity Commercial |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$9.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.16
|
| Rate for Payer: Healthscope Commercial |
$12.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.86
|
| Rate for Payer: PHP Commercial |
$11.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.07
|
| Rate for Payer: Priority Health SBD |
$8.79
|
|
|
MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$13.95
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
168786
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Aetna Commercial |
$11.86
|
| Rate for Payer: Aetna Medicare |
$6.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.07
|
| Rate for Payer: BCBS Complete |
$5.58
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cofinity Commercial |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$9.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.16
|
| Rate for Payer: Healthscope Commercial |
$12.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.86
|
| Rate for Payer: PHP Commercial |
$11.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.07
|
| Rate for Payer: Priority Health SBD |
$8.79
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$15.49
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
168785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.76 |
| Max. Negotiated Rate |
$13.94 |
| Rate for Payer: Aetna Commercial |
$13.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.07
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: Cofinity Commercial |
$10.84
|
| Rate for Payer: Cofinity Commercial |
$13.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.39
|
| Rate for Payer: Healthscope Commercial |
$13.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.17
|
| Rate for Payer: PHP Commercial |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.07
|
| Rate for Payer: Priority Health SBD |
$9.76
|
|
|
MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$15.49
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
168785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.20 |
| Max. Negotiated Rate |
$13.94 |
| Rate for Payer: Aetna Commercial |
$13.17
|
| Rate for Payer: Aetna Medicare |
$7.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.07
|
| Rate for Payer: BCBS Complete |
$6.20
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: Cofinity Commercial |
$10.84
|
| Rate for Payer: Cofinity Commercial |
$13.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.39
|
| Rate for Payer: Healthscope Commercial |
$13.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.17
|
| Rate for Payer: PHP Commercial |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.07
|
| Rate for Payer: Priority Health SBD |
$9.76
|
|
|
MIDODRINE 10 MG TABLET
|
Facility
|
IP
|
$111.60
|
|
|
Service Code
|
NDC 00904681907
|
| Hospital Charge Code |
33083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.31 |
| Max. Negotiated Rate |
$100.44 |
| Rate for Payer: Aetna Commercial |
$94.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.54
|
| Rate for Payer: Cash Price |
$89.28
|
| Rate for Payer: Cofinity Commercial |
$78.12
|
| Rate for Payer: Cofinity Commercial |
$95.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.28
|
| Rate for Payer: Healthscope Commercial |
$100.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.86
|
| Rate for Payer: PHP Commercial |
$94.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.54
|
| Rate for Payer: Priority Health SBD |
$70.31
|
|
|
MIDODRINE 10 MG TABLET
|
Facility
|
OP
|
$111.60
|
|
|
Service Code
|
NDC 00904681907
|
| Hospital Charge Code |
33083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$100.44 |
| Rate for Payer: Aetna Commercial |
$94.86
|
| Rate for Payer: Aetna Medicare |
$55.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.54
|
| Rate for Payer: BCBS Complete |
$44.64
|
| Rate for Payer: Cash Price |
$89.28
|
| Rate for Payer: Cofinity Commercial |
$78.12
|
| Rate for Payer: Cofinity Commercial |
$95.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.28
|
| Rate for Payer: Healthscope Commercial |
$100.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.86
|
| Rate for Payer: PHP Commercial |
$94.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.54
|
| Rate for Payer: Priority Health SBD |
$70.31
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$306.85
|
|
|
Service Code
|
NDC 00904681861
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.74 |
| Max. Negotiated Rate |
$276.17 |
| Rate for Payer: Aetna Commercial |
$260.82
|
| Rate for Payer: Aetna Medicare |
$153.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.45
|
| Rate for Payer: BCBS Complete |
$122.74
|
| Rate for Payer: Cash Price |
$245.48
|
| Rate for Payer: Cofinity Commercial |
$214.79
|
| Rate for Payer: Cofinity Commercial |
$263.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.48
|
| Rate for Payer: Healthscope Commercial |
$276.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.82
|
| Rate for Payer: PHP Commercial |
$260.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.45
|
| Rate for Payer: Priority Health SBD |
$193.32
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$327.36
|
|
|
Service Code
|
NDC 60505132101
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.24 |
| Max. Negotiated Rate |
$294.62 |
| Rate for Payer: Aetna Commercial |
$278.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.78
|
| Rate for Payer: Cash Price |
$261.89
|
| Rate for Payer: Cofinity Commercial |
$229.15
|
| Rate for Payer: Cofinity Commercial |
$281.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$229.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.89
|
| Rate for Payer: Healthscope Commercial |
$294.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.26
|
| Rate for Payer: PHP Commercial |
$278.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.78
|
| Rate for Payer: Priority Health SBD |
$206.24
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$327.36
|
|
|
Service Code
|
NDC 60505132101
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.94 |
| Max. Negotiated Rate |
$294.62 |
| Rate for Payer: Aetna Commercial |
$278.26
|
| Rate for Payer: Aetna Medicare |
$163.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.78
|
| Rate for Payer: BCBS Complete |
$130.94
|
| Rate for Payer: Cash Price |
$261.89
|
| Rate for Payer: Cofinity Commercial |
$229.15
|
| Rate for Payer: Cofinity Commercial |
$281.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$229.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.89
|
| Rate for Payer: Healthscope Commercial |
$294.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.26
|
| Rate for Payer: PHP Commercial |
$278.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.78
|
| Rate for Payer: Priority Health SBD |
$206.24
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$306.85
|
|
|
Service Code
|
NDC 00904681861
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.32 |
| Max. Negotiated Rate |
$276.17 |
| Rate for Payer: Aetna Commercial |
$260.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.45
|
| Rate for Payer: Cash Price |
$245.48
|
| Rate for Payer: Cofinity Commercial |
$214.79
|
| Rate for Payer: Cofinity Commercial |
$263.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.48
|
| Rate for Payer: Healthscope Commercial |
$276.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.82
|
| Rate for Payer: PHP Commercial |
$260.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.45
|
| Rate for Payer: Priority Health SBD |
$193.32
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
NDC 00245021289
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.87
|
| Rate for Payer: Aetna Medicare |
$1.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| Rate for Payer: BCBS Complete |
$1.35
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.70
|
| Rate for Payer: Healthscope Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.87
|
| Rate for Payer: PHP Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.20
|
| Rate for Payer: Priority Health SBD |
$2.13
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$217.55
|
|
|
Service Code
|
NDC 00245021211
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.06 |
| Max. Negotiated Rate |
$195.79 |
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.41
|
| Rate for Payer: Priority Health SBD |
$137.06
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$337.25
|
|
|
Service Code
|
NDC 00245021201
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.90 |
| Max. Negotiated Rate |
$303.52 |
| Rate for Payer: Aetna Commercial |
$286.66
|
| Rate for Payer: Aetna Medicare |
$168.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.21
|
| Rate for Payer: BCBS Complete |
$134.90
|
| Rate for Payer: Cash Price |
$269.80
|
| Rate for Payer: Cofinity Commercial |
$236.07
|
| Rate for Payer: Cofinity Commercial |
$290.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.80
|
| Rate for Payer: Healthscope Commercial |
$303.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$286.66
|
| Rate for Payer: PHP Commercial |
$286.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.21
|
| Rate for Payer: Priority Health SBD |
$212.47
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$338.88
|
|
|
Service Code
|
NDC 51079045320
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.55 |
| Max. Negotiated Rate |
$304.99 |
| Rate for Payer: Aetna Commercial |
$288.05
|
| Rate for Payer: Aetna Medicare |
$169.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.27
|
| Rate for Payer: BCBS Complete |
$135.55
|
| Rate for Payer: Cash Price |
$271.10
|
| Rate for Payer: Cofinity Commercial |
$237.22
|
| Rate for Payer: Cofinity Commercial |
$291.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$237.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.10
|
| Rate for Payer: Healthscope Commercial |
$304.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.05
|
| Rate for Payer: PHP Commercial |
$288.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.27
|
| Rate for Payer: Priority Health SBD |
$213.49
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
NDC 51079045301
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.71
|
| Rate for Payer: Healthscope Commercial |
$3.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.88
|
| Rate for Payer: PHP Commercial |
$2.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.20
|
| Rate for Payer: Priority Health SBD |
$2.14
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$311.52
|
|
|
Service Code
|
NDC 60687039801
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.61 |
| Max. Negotiated Rate |
$280.37 |
| Rate for Payer: Aetna Commercial |
$264.79
|
| Rate for Payer: Aetna Medicare |
$155.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.49
|
| Rate for Payer: BCBS Complete |
$124.61
|
| Rate for Payer: Cash Price |
$249.22
|
| Rate for Payer: Cofinity Commercial |
$218.06
|
| Rate for Payer: Cofinity Commercial |
$267.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.22
|
| Rate for Payer: Healthscope Commercial |
$280.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.79
|
| Rate for Payer: PHP Commercial |
$264.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.49
|
| Rate for Payer: Priority Health SBD |
$196.26
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
NDC 00245021289
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.70
|
| Rate for Payer: Healthscope Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.87
|
| Rate for Payer: PHP Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.20
|
| Rate for Payer: Priority Health SBD |
$2.13
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$217.55
|
|
|
Service Code
|
NDC 00245021211
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.02 |
| Max. Negotiated Rate |
$195.79 |
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna Medicare |
$108.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: BCBS Complete |
$87.02
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.41
|
| Rate for Payer: Priority Health SBD |
$137.06
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$337.25
|
|
|
Service Code
|
NDC 00245021201
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$212.47 |
| Max. Negotiated Rate |
$303.52 |
| Rate for Payer: Aetna Commercial |
$286.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.21
|
| Rate for Payer: Cash Price |
$269.80
|
| Rate for Payer: Cofinity Commercial |
$236.07
|
| Rate for Payer: Cofinity Commercial |
$290.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.80
|
| Rate for Payer: Healthscope Commercial |
$303.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$286.66
|
| Rate for Payer: PHP Commercial |
$286.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.21
|
| Rate for Payer: Priority Health SBD |
$212.47
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 60687039811
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: BCBS Complete |
$1.25
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 60687039811
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$311.52
|
|
|
Service Code
|
NDC 60687039801
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.26 |
| Max. Negotiated Rate |
$280.37 |
| Rate for Payer: Aetna Commercial |
$264.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.49
|
| Rate for Payer: Cash Price |
$249.22
|
| Rate for Payer: Cofinity Commercial |
$218.06
|
| Rate for Payer: Cofinity Commercial |
$267.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.22
|
| Rate for Payer: Healthscope Commercial |
$280.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.79
|
| Rate for Payer: PHP Commercial |
$264.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.49
|
| Rate for Payer: Priority Health SBD |
$196.26
|
|
|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$338.88
|
|
|
Service Code
|
NDC 51079045320
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.49 |
| Max. Negotiated Rate |
$304.99 |
| Rate for Payer: Aetna Commercial |
$288.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.27
|
| Rate for Payer: Cash Price |
$271.10
|
| Rate for Payer: Cofinity Commercial |
$237.22
|
| Rate for Payer: Cofinity Commercial |
$291.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$237.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.10
|
| Rate for Payer: Healthscope Commercial |
$304.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.05
|
| Rate for Payer: PHP Commercial |
$288.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.27
|
| Rate for Payer: Priority Health SBD |
$213.49
|
|
