|
MIDODRINE 5 MG TABLET
|
Facility
|
IP
|
$3.39
|
|
|
Service Code
|
NDC 51079045301
|
| Hospital Charge Code |
10610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| 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
|
|
|
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK
|
Facility
|
IP
|
$91.80
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
14961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.83 |
| Max. Negotiated Rate |
$82.62 |
| Rate for Payer: Aetna Commercial |
$78.03
|
| Rate for Payer: Aetna Commercial |
$70.50
|
| Rate for Payer: Aetna Commercial |
$84.72
|
| Rate for Payer: Aetna Commercial |
$60.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.79
|
| Rate for Payer: Cash Price |
$73.44
|
| Rate for Payer: Cash Price |
$66.35
|
| Rate for Payer: Cash Price |
$57.29
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Cofinity Commercial |
$50.13
|
| Rate for Payer: Cofinity Commercial |
$85.72
|
| Rate for Payer: Cofinity Commercial |
$69.77
|
| Rate for Payer: Cofinity Commercial |
$58.06
|
| Rate for Payer: Cofinity Commercial |
$71.33
|
| Rate for Payer: Cofinity Commercial |
$78.95
|
| Rate for Payer: Cofinity Commercial |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$61.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$58.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$64.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.74
|
| Rate for Payer: Healthscope Commercial |
$74.65
|
| Rate for Payer: Healthscope Commercial |
$64.45
|
| Rate for Payer: Healthscope Commercial |
$89.70
|
| Rate for Payer: Healthscope Commercial |
$82.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.87
|
| Rate for Payer: PHP Commercial |
$60.87
|
| Rate for Payer: PHP Commercial |
$78.03
|
| Rate for Payer: PHP Commercial |
$70.50
|
| Rate for Payer: PHP Commercial |
$84.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.79
|
| Rate for Payer: Priority Health SBD |
$45.11
|
| Rate for Payer: Priority Health SBD |
$57.83
|
| Rate for Payer: Priority Health SBD |
$52.25
|
| Rate for Payer: Priority Health SBD |
$62.79
|
|
|
MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK
|
Facility
|
OP
|
$91.80
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
14961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.72 |
| Max. Negotiated Rate |
$82.62 |
| Rate for Payer: Aetna Commercial |
$78.03
|
| Rate for Payer: Aetna Commercial |
$70.50
|
| Rate for Payer: Aetna Commercial |
$84.72
|
| Rate for Payer: Aetna Commercial |
$60.87
|
| Rate for Payer: Aetna Medicare |
$49.84
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: Aetna Medicare |
$41.47
|
| Rate for Payer: Aetna Medicare |
$35.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.79
|
| Rate for Payer: BCBS Complete |
$28.64
|
| Rate for Payer: BCBS Complete |
$39.87
|
| Rate for Payer: BCBS Complete |
$33.18
|
| Rate for Payer: BCBS Complete |
$36.72
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Cash Price |
$66.35
|
| Rate for Payer: Cash Price |
$73.44
|
| Rate for Payer: Cash Price |
$57.29
|
| Rate for Payer: Cofinity Commercial |
$71.33
|
| Rate for Payer: Cofinity Commercial |
$85.72
|
| Rate for Payer: Cofinity Commercial |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$69.77
|
| Rate for Payer: Cofinity Commercial |
$78.95
|
| Rate for Payer: Cofinity Commercial |
$50.13
|
| Rate for Payer: Cofinity Commercial |
$61.58
|
| Rate for Payer: Cofinity Commercial |
$58.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$64.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$58.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.35
|
| Rate for Payer: Healthscope Commercial |
$64.45
|
| Rate for Payer: Healthscope Commercial |
$89.70
|
| Rate for Payer: Healthscope Commercial |
$74.65
|
| Rate for Payer: Healthscope Commercial |
$82.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.87
|
| Rate for Payer: PHP Commercial |
$70.50
|
| Rate for Payer: PHP Commercial |
$84.72
|
| Rate for Payer: PHP Commercial |
$78.03
|
| Rate for Payer: PHP Commercial |
$60.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.79
|
| Rate for Payer: Priority Health SBD |
$45.11
|
| Rate for Payer: Priority Health SBD |
$57.83
|
| Rate for Payer: Priority Health SBD |
$52.25
|
| Rate for Payer: Priority Health SBD |
$62.79
|
|
|
MINERAL OIL
|
Facility
|
IP
|
$68.71
|
|
|
Service Code
|
NDC 63323025410
|
| Hospital Charge Code |
109056
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.29 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Aetna Commercial |
$58.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.66
|
| Rate for Payer: Cash Price |
$54.97
|
| Rate for Payer: Cofinity Commercial |
$48.10
|
| Rate for Payer: Cofinity Commercial |
$59.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.97
|
| Rate for Payer: Healthscope Commercial |
$61.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.40
|
| Rate for Payer: PHP Commercial |
$58.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.66
|
| Rate for Payer: Priority Health SBD |
$43.29
|
|
|
MINERAL OIL
|
Facility
|
OP
|
$68.71
|
|
|
Service Code
|
NDC 63323025410
|
| Hospital Charge Code |
109056
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.48 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Aetna Commercial |
$58.40
|
| Rate for Payer: Aetna Medicare |
$34.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.66
|
| Rate for Payer: BCBS Complete |
$27.48
|
| Rate for Payer: Cash Price |
$54.97
|
| Rate for Payer: Cofinity Commercial |
$48.10
|
| Rate for Payer: Cofinity Commercial |
$59.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.97
|
| Rate for Payer: Healthscope Commercial |
$61.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.40
|
| Rate for Payer: PHP Commercial |
$58.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.66
|
| Rate for Payer: Priority Health SBD |
$43.29
|
|
|
MINERAL OIL ORAL
|
Facility
|
IP
|
$8.88
|
|
|
Service Code
|
NDC 96295010183
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.77
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cofinity Commercial |
$6.22
|
| Rate for Payer: Cofinity Commercial |
$7.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.10
|
| Rate for Payer: Healthscope Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.55
|
| Rate for Payer: PHP Commercial |
$7.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.77
|
| Rate for Payer: Priority Health SBD |
$5.59
|
|
|
MINERAL OIL ORAL
|
Facility
|
OP
|
$8.88
|
|
|
Service Code
|
NDC 96295010183
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$7.99 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Aetna Medicare |
$4.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.77
|
| Rate for Payer: BCBS Complete |
$3.55
|
| Rate for Payer: Cash Price |
$7.10
|
| Rate for Payer: Cofinity Commercial |
$6.22
|
| Rate for Payer: Cofinity Commercial |
$7.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.10
|
| Rate for Payer: Healthscope Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.55
|
| Rate for Payer: PHP Commercial |
$7.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.77
|
| Rate for Payer: Priority Health SBD |
$5.59
|
|
|
MINERAL OIL ORAL
|
Facility
|
IP
|
$8.76
|
|
|
Service Code
|
NDC 09629514323
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.69
|
| Rate for Payer: Cash Price |
$7.01
|
| Rate for Payer: Cofinity Commercial |
$6.13
|
| Rate for Payer: Cofinity Commercial |
$7.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.01
|
| Rate for Payer: Healthscope Commercial |
$7.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.45
|
| Rate for Payer: PHP Commercial |
$7.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.69
|
| Rate for Payer: Priority Health SBD |
$5.52
|
|
|
MINERAL OIL ORAL
|
Facility
|
OP
|
$8.76
|
|
|
Service Code
|
NDC 09629514323
|
| Hospital Charge Code |
5086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Aetna Medicare |
$4.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.69
|
| Rate for Payer: BCBS Complete |
$3.50
|
| Rate for Payer: Cash Price |
$7.01
|
| Rate for Payer: Cofinity Commercial |
$6.13
|
| Rate for Payer: Cofinity Commercial |
$7.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.01
|
| Rate for Payer: Healthscope Commercial |
$7.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.45
|
| Rate for Payer: PHP Commercial |
$7.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.69
|
| Rate for Payer: Priority Health SBD |
$5.52
|
|
|
MINOCYCLINE 50 MG CAPSULE
|
Facility
|
IP
|
$234.65
|
|
|
Service Code
|
NDC 00591569401
|
| Hospital Charge Code |
5111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.83 |
| Max. Negotiated Rate |
$211.19 |
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$152.52
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$164.25
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.52
|
| Rate for Payer: Priority Health SBD |
$147.83
|
|
|
MINOCYCLINE 50 MG CAPSULE
|
Facility
|
OP
|
$234.65
|
|
|
Service Code
|
NDC 00591569401
|
| Hospital Charge Code |
5111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.86 |
| Max. Negotiated Rate |
$211.19 |
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna Medicare |
$117.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$152.52
|
| Rate for Payer: BCBS Complete |
$93.86
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$164.25
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.52
|
| Rate for Payer: Priority Health SBD |
$147.83
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 68084020411
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.99
|
| Rate for Payer: Cash Price |
$3.68
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.68
|
| Rate for Payer: Healthscope Commercial |
$4.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.91
|
| Rate for Payer: PHP Commercial |
$3.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.99
|
| Rate for Payer: Priority Health SBD |
$2.90
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
IP
|
$459.80
|
|
|
Service Code
|
NDC 68084020401
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.67 |
| Max. Negotiated Rate |
$413.82 |
| Rate for Payer: Aetna Commercial |
$390.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.87
|
| Rate for Payer: Cash Price |
$367.84
|
| Rate for Payer: Cofinity Commercial |
$321.86
|
| Rate for Payer: Cofinity Commercial |
$395.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$321.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.84
|
| Rate for Payer: Healthscope Commercial |
$413.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$390.83
|
| Rate for Payer: PHP Commercial |
$390.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.87
|
| Rate for Payer: Priority Health SBD |
$289.67
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 68084020411
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.91
|
| Rate for Payer: Aetna Medicare |
$2.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.99
|
| Rate for Payer: BCBS Complete |
$1.84
|
| Rate for Payer: Cash Price |
$3.68
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.68
|
| Rate for Payer: Healthscope Commercial |
$4.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.91
|
| Rate for Payer: PHP Commercial |
$3.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.99
|
| Rate for Payer: Priority Health SBD |
$2.90
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 53489038601
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.58 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
OP
|
$462.95
|
|
|
Service Code
|
NDC 00591564201
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.18 |
| Max. Negotiated Rate |
$416.65 |
| Rate for Payer: Aetna Commercial |
$393.51
|
| Rate for Payer: Aetna Medicare |
$231.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$300.92
|
| Rate for Payer: BCBS Complete |
$185.18
|
| Rate for Payer: Cash Price |
$370.36
|
| Rate for Payer: Cofinity Commercial |
$324.06
|
| Rate for Payer: Cofinity Commercial |
$398.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$370.36
|
| Rate for Payer: Healthscope Commercial |
$416.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$393.51
|
| Rate for Payer: PHP Commercial |
$393.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$300.92
|
| Rate for Payer: Priority Health SBD |
$291.66
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
IP
|
$462.95
|
|
|
Service Code
|
NDC 00591564201
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$291.66 |
| Max. Negotiated Rate |
$416.65 |
| Rate for Payer: Aetna Commercial |
$393.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$300.92
|
| Rate for Payer: Cash Price |
$370.36
|
| Rate for Payer: Cofinity Commercial |
$324.06
|
| Rate for Payer: Cofinity Commercial |
$398.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$370.36
|
| Rate for Payer: Healthscope Commercial |
$416.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$393.51
|
| Rate for Payer: PHP Commercial |
$393.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$300.92
|
| Rate for Payer: Priority Health SBD |
$291.66
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
OP
|
$459.80
|
|
|
Service Code
|
NDC 68084020401
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.92 |
| Max. Negotiated Rate |
$413.82 |
| Rate for Payer: Aetna Commercial |
$390.83
|
| Rate for Payer: Aetna Medicare |
$229.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.87
|
| Rate for Payer: BCBS Complete |
$183.92
|
| Rate for Payer: Cash Price |
$367.84
|
| Rate for Payer: Cofinity Commercial |
$321.86
|
| Rate for Payer: Cofinity Commercial |
$395.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$321.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.84
|
| Rate for Payer: Healthscope Commercial |
$413.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$390.83
|
| Rate for Payer: PHP Commercial |
$390.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.87
|
| Rate for Payer: Priority Health SBD |
$289.67
|
|
|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 53489038601
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.56 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$997.83 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$633.54 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna Medicare |
$791.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: BCBS Complete |
$633.54
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$997.83 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$633.54 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna Medicare |
$791.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: BCBS Complete |
$633.54
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
OP
|
$448.85
|
|
|
Service Code
|
NDC 68084011911
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.54 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna Medicare |
$224.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: BCBS Complete |
$179.54
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.19
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.08
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.75
|
| Rate for Payer: Priority Health SBD |
$282.78
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
OP
|
$366.60
|
|
|
Service Code
|
NDC 51079008620
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$329.94 |
| Rate for Payer: Aetna Commercial |
$311.61
|
| Rate for Payer: Aetna Medicare |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.29
|
| Rate for Payer: BCBS Complete |
$146.64
|
| Rate for Payer: Cash Price |
$293.28
|
| Rate for Payer: Cofinity Commercial |
$256.62
|
| Rate for Payer: Cofinity Commercial |
$315.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.28
|
| Rate for Payer: Healthscope Commercial |
$329.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.61
|
| Rate for Payer: PHP Commercial |
$311.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.29
|
| Rate for Payer: Priority Health SBD |
$230.96
|
|
