|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$794.39
|
|
|
Service Code
|
NDC 60687074601
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$317.76 |
| Max. Negotiated Rate |
$714.95 |
| Rate for Payer: Aetna Commercial |
$675.23
|
| Rate for Payer: Aetna Medicare |
$397.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.35
|
| Rate for Payer: BCBS Complete |
$317.76
|
| Rate for Payer: Cash Price |
$635.51
|
| Rate for Payer: Cofinity Commercial |
$556.07
|
| Rate for Payer: Cofinity Commercial |
$683.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$556.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.51
|
| Rate for Payer: Healthscope Commercial |
$714.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.23
|
| Rate for Payer: PHP Commercial |
$675.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$516.35
|
| Rate for Payer: Priority Health SBD |
$500.47
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$334.08
|
|
|
Service Code
|
NDC 70954044420
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.63 |
| Max. Negotiated Rate |
$300.67 |
| Rate for Payer: Aetna Commercial |
$283.97
|
| Rate for Payer: Aetna Medicare |
$167.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.15
|
| Rate for Payer: BCBS Complete |
$133.63
|
| Rate for Payer: Cash Price |
$267.26
|
| Rate for Payer: Cofinity Commercial |
$233.86
|
| Rate for Payer: Cofinity Commercial |
$287.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$233.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.26
|
| Rate for Payer: Healthscope Commercial |
$300.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$283.97
|
| Rate for Payer: PHP Commercial |
$283.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.15
|
| Rate for Payer: Priority Health SBD |
$210.47
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$431.04
|
|
|
Service Code
|
NDC 43386016101
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.42 |
| Max. Negotiated Rate |
$387.94 |
| Rate for Payer: Aetna Commercial |
$366.38
|
| Rate for Payer: Aetna Medicare |
$215.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$280.18
|
| Rate for Payer: BCBS Complete |
$172.42
|
| Rate for Payer: Cash Price |
$344.83
|
| Rate for Payer: Cofinity Commercial |
$301.73
|
| Rate for Payer: Cofinity Commercial |
$370.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$301.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$344.83
|
| Rate for Payer: Healthscope Commercial |
$387.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$366.38
|
| Rate for Payer: PHP Commercial |
$366.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.18
|
| Rate for Payer: Priority Health SBD |
$271.56
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$431.04
|
|
|
Service Code
|
NDC 59762500802
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.56 |
| Max. Negotiated Rate |
$387.94 |
| Rate for Payer: Aetna Commercial |
$366.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$280.18
|
| Rate for Payer: Cash Price |
$344.83
|
| Rate for Payer: Cofinity Commercial |
$301.73
|
| Rate for Payer: Cofinity Commercial |
$370.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$301.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$344.83
|
| Rate for Payer: Healthscope Commercial |
$387.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$366.38
|
| Rate for Payer: PHP Commercial |
$366.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.18
|
| Rate for Payer: Priority Health SBD |
$271.56
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$7.95
|
|
|
Service Code
|
NDC 60687074611
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.01 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.17
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Cofinity Commercial |
$6.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.36
|
| Rate for Payer: Healthscope Commercial |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.76
|
| Rate for Payer: PHP Commercial |
$6.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.17
|
| Rate for Payer: Priority Health SBD |
$5.01
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$794.88
|
|
|
Service Code
|
NDC 68084004101
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$500.77 |
| Max. Negotiated Rate |
$715.39 |
| Rate for Payer: Aetna Commercial |
$675.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.67
|
| Rate for Payer: Cash Price |
$635.90
|
| Rate for Payer: Cofinity Commercial |
$556.42
|
| Rate for Payer: Cofinity Commercial |
$683.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$556.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.90
|
| Rate for Payer: Healthscope Commercial |
$715.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.65
|
| Rate for Payer: PHP Commercial |
$675.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$516.67
|
| Rate for Payer: Priority Health SBD |
$500.77
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$431.04
|
|
|
Service Code
|
NDC 43386016101
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.56 |
| Max. Negotiated Rate |
$387.94 |
| Rate for Payer: Aetna Commercial |
$366.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$280.18
|
| Rate for Payer: Cash Price |
$344.83
|
| Rate for Payer: Cofinity Commercial |
$301.73
|
| Rate for Payer: Cofinity Commercial |
$370.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$301.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$344.83
|
| Rate for Payer: Healthscope Commercial |
$387.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$366.38
|
| Rate for Payer: PHP Commercial |
$366.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.18
|
| Rate for Payer: Priority Health SBD |
$271.56
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$7.95
|
|
|
Service Code
|
NDC 60687074611
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Aetna Medicare |
$3.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.17
|
| Rate for Payer: BCBS Complete |
$3.18
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Cofinity Commercial |
$6.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.36
|
| Rate for Payer: Healthscope Commercial |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.76
|
| Rate for Payer: PHP Commercial |
$6.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.17
|
| Rate for Payer: Priority Health SBD |
$5.01
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$7.95
|
|
|
Service Code
|
NDC 68084004111
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Aetna Medicare |
$3.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.17
|
| Rate for Payer: BCBS Complete |
$3.18
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Cofinity Commercial |
$6.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.36
|
| Rate for Payer: Healthscope Commercial |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.76
|
| Rate for Payer: PHP Commercial |
$6.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.17
|
| Rate for Payer: Priority Health SBD |
$5.01
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$334.08
|
|
|
Service Code
|
NDC 70954044420
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.47 |
| Max. Negotiated Rate |
$300.67 |
| Rate for Payer: Aetna Commercial |
$283.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.15
|
| Rate for Payer: Cash Price |
$267.26
|
| Rate for Payer: Cofinity Commercial |
$233.86
|
| Rate for Payer: Cofinity Commercial |
$287.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$233.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.26
|
| Rate for Payer: Healthscope Commercial |
$300.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$283.97
|
| Rate for Payer: PHP Commercial |
$283.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.15
|
| Rate for Payer: Priority Health SBD |
$210.47
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$794.39
|
|
|
Service Code
|
NDC 60687074601
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$500.47 |
| Max. Negotiated Rate |
$714.95 |
| Rate for Payer: Aetna Commercial |
$675.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.35
|
| Rate for Payer: Cash Price |
$635.51
|
| Rate for Payer: Cofinity Commercial |
$556.07
|
| Rate for Payer: Cofinity Commercial |
$683.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$556.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.51
|
| Rate for Payer: Healthscope Commercial |
$714.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.23
|
| Rate for Payer: PHP Commercial |
$675.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$516.35
|
| Rate for Payer: Priority Health SBD |
$500.47
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$431.04
|
|
|
Service Code
|
NDC 59762500802
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.42 |
| Max. Negotiated Rate |
$387.94 |
| Rate for Payer: Aetna Commercial |
$366.38
|
| Rate for Payer: Aetna Medicare |
$215.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$280.18
|
| Rate for Payer: BCBS Complete |
$172.42
|
| Rate for Payer: Cash Price |
$344.83
|
| Rate for Payer: Cofinity Commercial |
$301.73
|
| Rate for Payer: Cofinity Commercial |
$370.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$301.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$344.83
|
| Rate for Payer: Healthscope Commercial |
$387.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$366.38
|
| Rate for Payer: PHP Commercial |
$366.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.18
|
| Rate for Payer: Priority Health SBD |
$271.56
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
IP
|
$7.95
|
|
|
Service Code
|
NDC 68084004111
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.01 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.17
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Cofinity Commercial |
$6.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.36
|
| Rate for Payer: Healthscope Commercial |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.76
|
| Rate for Payer: PHP Commercial |
$6.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.17
|
| Rate for Payer: Priority Health SBD |
$5.01
|
|
|
MISOPROSTOL 25 MCG CUSTOM TAB
|
Facility
|
IP
|
$1,442.63
|
|
|
Service Code
|
NDC 09900000016
|
| Hospital Charge Code |
150707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$908.86 |
| Max. Negotiated Rate |
$1,298.37 |
| Rate for Payer: Aetna Commercial |
$1,226.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$937.71
|
| Rate for Payer: Cash Price |
$1,154.10
|
| Rate for Payer: Cofinity Commercial |
$1,009.84
|
| Rate for Payer: Cofinity Commercial |
$1,240.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,009.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.10
|
| Rate for Payer: Healthscope Commercial |
$1,298.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,226.24
|
| Rate for Payer: PHP Commercial |
$1,226.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$937.71
|
| Rate for Payer: Priority Health SBD |
$908.86
|
|
|
MISOPROSTOL 25 MCG CUSTOM TAB
|
Facility
|
OP
|
$1,442.63
|
|
|
Service Code
|
NDC 09900000016
|
| Hospital Charge Code |
150707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$577.05 |
| Max. Negotiated Rate |
$1,298.37 |
| Rate for Payer: Aetna Commercial |
$1,226.24
|
| Rate for Payer: Aetna Medicare |
$721.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$937.71
|
| Rate for Payer: BCBS Complete |
$577.05
|
| Rate for Payer: Cash Price |
$1,154.10
|
| Rate for Payer: Cofinity Commercial |
$1,009.84
|
| Rate for Payer: Cofinity Commercial |
$1,240.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,009.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.10
|
| Rate for Payer: Healthscope Commercial |
$1,298.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,226.24
|
| Rate for Payer: PHP Commercial |
$1,226.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$937.71
|
| Rate for Payer: Priority Health SBD |
$908.86
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$770.95
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
10630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$485.70 |
| Max. Negotiated Rate |
$693.86 |
| Rate for Payer: Aetna Commercial |
$655.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$501.12
|
| Rate for Payer: Cash Price |
$616.76
|
| Rate for Payer: Cofinity Commercial |
$539.66
|
| Rate for Payer: Cofinity Commercial |
$663.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$539.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$616.76
|
| Rate for Payer: Healthscope Commercial |
$693.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$655.31
|
| Rate for Payer: PHP Commercial |
$655.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.12
|
| Rate for Payer: Priority Health SBD |
$485.70
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$463.71
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
10630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$417.34 |
| Rate for Payer: Aetna Commercial |
$394.15
|
| Rate for Payer: Aetna Commercial |
$655.31
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$301.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$501.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.44
|
| Rate for Payer: BCBS Complete |
$11.45
|
| Rate for Payer: BCBS Complete |
$11.45
|
| Rate for Payer: BCBS MAPPO |
$20.35
|
| Rate for Payer: BCBS MAPPO |
$20.35
|
| Rate for Payer: BCN Medicare Advantage |
$20.35
|
| Rate for Payer: BCN Medicare Advantage |
$20.35
|
| Rate for Payer: Cash Price |
$616.76
|
| Rate for Payer: Cash Price |
$616.76
|
| Rate for Payer: Cash Price |
$370.97
|
| Rate for Payer: Cash Price |
$370.97
|
| Rate for Payer: Cofinity Commercial |
$539.66
|
| Rate for Payer: Cofinity Commercial |
$663.02
|
| Rate for Payer: Cofinity Commercial |
$398.79
|
| Rate for Payer: Cofinity Commercial |
$324.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$539.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$616.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$370.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$417.34
|
| Rate for Payer: Healthscope Commercial |
$693.86
|
| Rate for Payer: Mclaren Medicaid |
$10.91
|
| Rate for Payer: Mclaren Medicaid |
$10.91
|
| Rate for Payer: Mclaren Medicare |
$20.35
|
| Rate for Payer: Mclaren Medicare |
$20.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.37
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.37
|
| Rate for Payer: Meridian Medicaid |
$11.45
|
| Rate for Payer: Meridian Medicaid |
$11.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$394.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$655.31
|
| Rate for Payer: PACE Medicare |
$19.33
|
| Rate for Payer: PACE Medicare |
$19.33
|
| Rate for Payer: PACE SWMI |
$20.35
|
| Rate for Payer: PACE SWMI |
$20.35
|
| Rate for Payer: PHP Commercial |
$655.31
|
| Rate for Payer: PHP Commercial |
$394.15
|
| Rate for Payer: PHP Medicare Advantage |
$20.35
|
| Rate for Payer: PHP Medicare Advantage |
$20.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.41
|
| Rate for Payer: Priority Health Medicare |
$20.35
|
| Rate for Payer: Priority Health Medicare |
$20.35
|
| Rate for Payer: Priority Health SBD |
$485.70
|
| Rate for Payer: Priority Health SBD |
$292.14
|
| Rate for Payer: Railroad Medicare Medicare |
$20.35
|
| Rate for Payer: Railroad Medicare Medicare |
$20.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$20.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$20.35
|
| Rate for Payer: UHC Medicare Advantage |
$20.35
|
| Rate for Payer: UHC Medicare Advantage |
$20.35
|
| Rate for Payer: UHCCP Medicaid |
$11.46
|
| Rate for Payer: UHCCP Medicaid |
$11.46
|
| Rate for Payer: VA VA |
$20.35
|
| Rate for Payer: VA VA |
$20.35
|
|
|
MITOMYCIN 20 MG SOLUTION FOR BLADDER IRRIGATION (CUSTOM)
|
Facility
|
OP
|
$463.71
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
300956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$417.34 |
| Rate for Payer: Aetna Commercial |
$394.15
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$301.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.44
|
| Rate for Payer: BCBS Complete |
$11.45
|
| Rate for Payer: BCBS MAPPO |
$20.35
|
| Rate for Payer: BCN Medicare Advantage |
$20.35
|
| Rate for Payer: Cash Price |
$370.97
|
| Rate for Payer: Cash Price |
$370.97
|
| Rate for Payer: Cofinity Commercial |
$324.60
|
| Rate for Payer: Cofinity Commercial |
$398.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$370.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$417.34
|
| Rate for Payer: Mclaren Medicaid |
$10.91
|
| Rate for Payer: Mclaren Medicare |
$20.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.37
|
| Rate for Payer: Meridian Medicaid |
$11.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$394.15
|
| Rate for Payer: PACE Medicare |
$19.33
|
| Rate for Payer: PACE SWMI |
$20.35
|
| Rate for Payer: PHP Commercial |
$394.15
|
| Rate for Payer: PHP Medicare Advantage |
$20.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.41
|
| Rate for Payer: Priority Health Medicare |
$20.35
|
| Rate for Payer: Priority Health SBD |
$292.14
|
| Rate for Payer: Railroad Medicare Medicare |
$20.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$20.35
|
| Rate for Payer: UHC Medicare Advantage |
$20.35
|
| Rate for Payer: UHCCP Medicaid |
$11.46
|
| Rate for Payer: VA VA |
$20.35
|
|
|
MODAFINIL 100 MG TABLET
|
Facility
|
OP
|
$353.40
|
|
|
Service Code
|
NDC 65862060101
|
| Hospital Charge Code |
24702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.36 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna Medicare |
$176.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: BCBS Complete |
$141.36
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$247.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.71
|
| Rate for Payer: Priority Health SBD |
$222.64
|
|
|
MODAFINIL 100 MG TABLET
|
Facility
|
IP
|
$353.40
|
|
|
Service Code
|
NDC 65862060101
|
| Hospital Charge Code |
24702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.64 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$247.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.71
|
| Rate for Payer: Priority Health SBD |
$222.64
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$716.95
|
|
|
Service Code
|
NDC 55253080230
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$451.68 |
| Max. Negotiated Rate |
$645.25 |
| Rate for Payer: Aetna Commercial |
$609.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$466.02
|
| Rate for Payer: Cash Price |
$573.56
|
| Rate for Payer: Cofinity Commercial |
$501.87
|
| Rate for Payer: Cofinity Commercial |
$616.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$501.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$573.56
|
| Rate for Payer: Healthscope Commercial |
$645.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$609.41
|
| Rate for Payer: PHP Commercial |
$609.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$466.02
|
| Rate for Payer: Priority Health SBD |
$451.68
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
OP
|
$716.95
|
|
|
Service Code
|
NDC 55253080230
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.78 |
| Max. Negotiated Rate |
$645.25 |
| Rate for Payer: Aetna Commercial |
$609.41
|
| Rate for Payer: Aetna Medicare |
$358.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$466.02
|
| Rate for Payer: BCBS Complete |
$286.78
|
| Rate for Payer: Cash Price |
$573.56
|
| Rate for Payer: Cofinity Commercial |
$501.87
|
| Rate for Payer: Cofinity Commercial |
$616.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$501.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$573.56
|
| Rate for Payer: Healthscope Commercial |
$645.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$609.41
|
| Rate for Payer: PHP Commercial |
$609.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$466.02
|
| Rate for Payer: Priority Health SBD |
$451.68
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
OP
|
$300.68
|
|
|
Service Code
|
NDC 62332038690
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$270.61 |
| Rate for Payer: Aetna Commercial |
$255.58
|
| Rate for Payer: Aetna Medicare |
$150.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.44
|
| Rate for Payer: BCBS Complete |
$120.27
|
| Rate for Payer: Cash Price |
$240.54
|
| Rate for Payer: Cofinity Commercial |
$210.48
|
| Rate for Payer: Cofinity Commercial |
$258.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.54
|
| Rate for Payer: Healthscope Commercial |
$270.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.58
|
| Rate for Payer: PHP Commercial |
$255.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.44
|
| Rate for Payer: Priority Health SBD |
$189.43
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
OP
|
$107.43
|
|
|
Service Code
|
NDC 62332038630
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.97 |
| Max. Negotiated Rate |
$96.69 |
| Rate for Payer: Aetna Commercial |
$91.32
|
| Rate for Payer: Aetna Medicare |
$53.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.83
|
| Rate for Payer: BCBS Complete |
$42.97
|
| Rate for Payer: Cash Price |
$85.94
|
| Rate for Payer: Cofinity Commercial |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$92.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.94
|
| Rate for Payer: Healthscope Commercial |
$96.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.32
|
| Rate for Payer: PHP Commercial |
$91.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.83
|
| Rate for Payer: Priority Health SBD |
$67.68
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$107.43
|
|
|
Service Code
|
NDC 62332038630
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.68 |
| Max. Negotiated Rate |
$96.69 |
| Rate for Payer: Aetna Commercial |
$91.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.83
|
| Rate for Payer: Cash Price |
$85.94
|
| Rate for Payer: Cofinity Commercial |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$92.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.94
|
| Rate for Payer: Healthscope Commercial |
$96.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.32
|
| Rate for Payer: PHP Commercial |
$91.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.83
|
| Rate for Payer: Priority Health SBD |
$67.68
|
|
