|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
IP
|
$68.98
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.46 |
| Max. Negotiated Rate |
$62.08 |
| Rate for Payer: Aetna Commercial |
$58.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.84
|
| Rate for Payer: Cash Price |
$55.18
|
| Rate for Payer: Cofinity Commercial |
$48.29
|
| Rate for Payer: Cofinity Commercial |
$59.32
|
| Rate for Payer: Healthscope Commercial |
$62.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.63
|
| Rate for Payer: PHP Commercial |
$58.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.29
|
| Rate for Payer: Priority Health SBD |
$43.46
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$451.20
|
|
|
Service Code
|
NDC 0904-6993-61
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.26 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Commercial |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$383.52
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.84
|
| Rate for Payer: Priority Health SBD |
$284.26
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$252.70
|
|
|
Service Code
|
NDC 60687-437-01
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.20 |
| Max. Negotiated Rate |
$227.43 |
| Rate for Payer: Aetna Commercial |
$214.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.26
|
| Rate for Payer: Cash Price |
$202.16
|
| Rate for Payer: Cofinity Commercial |
$176.89
|
| Rate for Payer: Cofinity Commercial |
$217.32
|
| Rate for Payer: Healthscope Commercial |
$227.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$214.80
|
| Rate for Payer: PHP Commercial |
$214.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.89
|
| Rate for Payer: Priority Health SBD |
$159.20
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$2.53
|
|
|
Service Code
|
NDC 60687-437-11
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Aetna Commercial |
$2.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.15
|
| Rate for Payer: PHP Commercial |
$2.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.77
|
| Rate for Payer: Priority Health SBD |
$1.59
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$26.36
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
9065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.41
|
| Rate for Payer: Aetna Commercial |
$47.39
|
| Rate for Payer: Aetna Commercial |
$23.52
|
| Rate for Payer: Aetna Commercial |
$11.21
|
| Rate for Payer: Aetna Commercial |
$24.41
|
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Aetna Commercial |
$13.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.99
|
| Rate for Payer: Cash Price |
$21.09
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cash Price |
$22.14
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cash Price |
$44.60
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Cash Price |
$22.98
|
| Rate for Payer: Cofinity Commercial |
$22.67
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$9.23
|
| Rate for Payer: Cofinity Commercial |
$47.94
|
| Rate for Payer: Cofinity Commercial |
$39.02
|
| Rate for Payer: Cofinity Commercial |
$11.13
|
| Rate for Payer: Cofinity Commercial |
$13.67
|
| Rate for Payer: Cofinity Commercial |
$24.70
|
| Rate for Payer: Cofinity Commercial |
$20.10
|
| Rate for Payer: Cofinity Commercial |
$16.42
|
| Rate for Payer: Cofinity Commercial |
$20.17
|
| Rate for Payer: Cofinity Commercial |
$23.80
|
| Rate for Payer: Cofinity Commercial |
$19.37
|
| Rate for Payer: Cofinity Commercial |
$18.45
|
| Rate for Payer: Healthscope Commercial |
$14.31
|
| Rate for Payer: Healthscope Commercial |
$11.87
|
| Rate for Payer: Healthscope Commercial |
$21.10
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Healthscope Commercial |
$24.90
|
| Rate for Payer: Healthscope Commercial |
$25.85
|
| Rate for Payer: Healthscope Commercial |
$50.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.52
|
| Rate for Payer: PHP Commercial |
$22.41
|
| Rate for Payer: PHP Commercial |
$23.52
|
| Rate for Payer: PHP Commercial |
$19.93
|
| Rate for Payer: PHP Commercial |
$13.52
|
| Rate for Payer: PHP Commercial |
$24.41
|
| Rate for Payer: PHP Commercial |
$11.21
|
| Rate for Payer: PHP Commercial |
$47.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.23
|
| Rate for Payer: Priority Health SBD |
$17.43
|
| Rate for Payer: Priority Health SBD |
$16.61
|
| Rate for Payer: Priority Health SBD |
$18.09
|
| Rate for Payer: Priority Health SBD |
$8.31
|
| Rate for Payer: Priority Health SBD |
$14.77
|
| Rate for Payer: Priority Health SBD |
$35.12
|
| Rate for Payer: Priority Health SBD |
$10.02
|
|
|
AMIODARONE 50 MG/ML IV (CODE)
|
Facility
IP
|
$13.19
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
163703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$11.87 |
| Rate for Payer: Aetna Commercial |
$11.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.57
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$9.23
|
| Rate for Payer: Healthscope Commercial |
$11.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.21
|
| Rate for Payer: PHP Commercial |
$11.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.23
|
| Rate for Payer: Priority Health SBD |
$8.31
|
|
|
AMITRIPTYLINE 100 MG TABLET
|
Facility
IP
|
$365.28
|
|
|
Service Code
|
NDC 51079-563-20
|
| Hospital Charge Code |
433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.13 |
| Max. Negotiated Rate |
$328.75 |
| Rate for Payer: Aetna Commercial |
$310.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.43
|
| Rate for Payer: Cash Price |
$292.22
|
| Rate for Payer: Cofinity Commercial |
$255.70
|
| Rate for Payer: Cofinity Commercial |
$314.14
|
| Rate for Payer: Healthscope Commercial |
$328.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$310.49
|
| Rate for Payer: PHP Commercial |
$310.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.70
|
| Rate for Payer: Priority Health SBD |
$230.13
|
|
|
AMITRIPTYLINE 100 MG TABLET
|
Facility
IP
|
$218.55
|
|
|
Service Code
|
NDC 16729-175-01
|
| Hospital Charge Code |
433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$196.70 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$152.98
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Healthscope Commercial |
$196.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
| Rate for Payer: Priority Health SBD |
$137.69
|
|
|
AMITRIPTYLINE 100 MG TABLET
|
Facility
IP
|
$3.66
|
|
|
Service Code
|
NDC 51079-563-01
|
| Hospital Charge Code |
433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.29 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.38
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$2.56
|
| Rate for Payer: Cofinity Commercial |
$3.15
|
| Rate for Payer: Healthscope Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.11
|
| Rate for Payer: PHP Commercial |
$3.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.56
|
| Rate for Payer: Priority Health SBD |
$2.31
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$218.55
|
|
|
Service Code
|
NDC 51079-131-20
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$196.70 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$152.98
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Healthscope Commercial |
$196.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
| Rate for Payer: Priority Health SBD |
$137.69
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$2.19
|
|
|
Service Code
|
NDC 51079-131-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna Commercial |
$1.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.42
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Healthscope Commercial |
$1.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.86
|
| Rate for Payer: PHP Commercial |
$1.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.53
|
| Rate for Payer: Priority Health SBD |
$1.38
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$136.30
|
|
|
Service Code
|
NDC 16729-171-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.87 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health SBD |
$85.87
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$240.35
|
|
|
Service Code
|
NDC 0904-0201-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.42 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.24
|
| Rate for Payer: Priority Health SBD |
$151.42
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$258.40
|
|
|
Service Code
|
NDC 0781-1487-01
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.79 |
| Max. Negotiated Rate |
$232.56 |
| Rate for Payer: Aetna Commercial |
$219.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.96
|
| Rate for Payer: Cash Price |
$206.72
|
| Rate for Payer: Cofinity Commercial |
$222.22
|
| Rate for Payer: Cofinity Commercial |
$180.88
|
| Rate for Payer: Healthscope Commercial |
$232.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$219.64
|
| Rate for Payer: PHP Commercial |
$219.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.88
|
| Rate for Payer: Priority Health SBD |
$162.79
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$409.45
|
|
|
Service Code
|
NDC 0904-0202-61
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.95 |
| Max. Negotiated Rate |
$368.50 |
| Rate for Payer: Aetna Commercial |
$348.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.14
|
| Rate for Payer: Cash Price |
$327.56
|
| Rate for Payer: Cofinity Commercial |
$286.62
|
| Rate for Payer: Cofinity Commercial |
$352.13
|
| Rate for Payer: Healthscope Commercial |
$368.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$348.03
|
| Rate for Payer: PHP Commercial |
$348.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.62
|
| Rate for Payer: Priority Health SBD |
$257.95
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$254.40
|
|
|
Service Code
|
NDC 0378-2650-01
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.27 |
| Max. Negotiated Rate |
$228.96 |
| Rate for Payer: Aetna Commercial |
$216.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.36
|
| Rate for Payer: Cash Price |
$203.52
|
| Rate for Payer: Cofinity Commercial |
$178.08
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Healthscope Commercial |
$228.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.24
|
| Rate for Payer: PHP Commercial |
$216.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.08
|
| Rate for Payer: Priority Health SBD |
$160.27
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$226.10
|
|
|
Service Code
|
NDC 50268-039-15
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.44 |
| Max. Negotiated Rate |
$203.49 |
| Rate for Payer: Aetna Commercial |
$192.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.96
|
| Rate for Payer: Cash Price |
$180.88
|
| Rate for Payer: Cofinity Commercial |
$158.27
|
| Rate for Payer: Cofinity Commercial |
$194.45
|
| Rate for Payer: Healthscope Commercial |
$203.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.18
|
| Rate for Payer: PHP Commercial |
$192.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.27
|
| Rate for Payer: Priority Health SBD |
$142.44
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$331.55
|
|
|
Service Code
|
NDC 51079-133-20
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.88 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.08
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.08
|
| Rate for Payer: Priority Health SBD |
$208.88
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$3.32
|
|
|
Service Code
|
NDC 51079-133-01
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.09
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$4.53
|
|
|
Service Code
|
NDC 50268-039-11
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.94
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cofinity Commercial |
$3.17
|
| Rate for Payer: Cofinity Commercial |
$3.90
|
| Rate for Payer: Healthscope Commercial |
$4.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.85
|
| Rate for Payer: PHP Commercial |
$3.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.17
|
| Rate for Payer: Priority Health SBD |
$2.85
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$35.96
|
|
|
Service Code
|
NDC 69097-128-05
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.65 |
| Max. Negotiated Rate |
$32.36 |
| Rate for Payer: Aetna Commercial |
$30.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.37
|
| Rate for Payer: Cash Price |
$28.77
|
| Rate for Payer: Cofinity Commercial |
$25.17
|
| Rate for Payer: Cofinity Commercial |
$30.93
|
| Rate for Payer: Healthscope Commercial |
$32.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.57
|
| Rate for Payer: PHP Commercial |
$30.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.17
|
| Rate for Payer: Priority Health SBD |
$22.65
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$145.70
|
|
|
Service Code
|
NDC 63739-631-10
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.79 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.70
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$101.99
|
| Rate for Payer: Cofinity Commercial |
$125.30
|
| Rate for Payer: Healthscope Commercial |
$131.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.99
|
| Rate for Payer: Priority Health SBD |
$91.79
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$326.65
|
|
|
Service Code
|
NDC 60687-496-01
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.79 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: Priority Health SBD |
$205.79
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$157.45
|
|
|
Service Code
|
NDC 0904-6371-61
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$141.70 |
| Rate for Payer: Aetna Commercial |
$133.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.34
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$110.22
|
| Rate for Payer: Cofinity Commercial |
$135.41
|
| Rate for Payer: Healthscope Commercial |
$141.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.83
|
| Rate for Payer: PHP Commercial |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.22
|
| Rate for Payer: Priority Health SBD |
$99.19
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$3.27
|
|
|
Service Code
|
NDC 60687-496-11
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna Commercial |
$2.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.13
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$2.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.78
|
| Rate for Payer: PHP Commercial |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.29
|
| Rate for Payer: Priority Health SBD |
$2.06
|
|
