|
PEMETREXED DISODIUM 1,000 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$711.05
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
200483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$639.94 |
| Rate for Payer: Aetna Commercial |
$604.39
|
| Rate for Payer: Aetna Medicare |
$5.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$462.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.59
|
| Rate for Payer: BCBS Complete |
$2.97
|
| Rate for Payer: BCBS MAPPO |
$5.27
|
| Rate for Payer: BCBS Trust/PPO |
$14.61
|
| Rate for Payer: BCN Commercial |
$14.61
|
| Rate for Payer: BCN Medicare Advantage |
$5.27
|
| Rate for Payer: Cash Price |
$568.84
|
| Rate for Payer: Cash Price |
$568.84
|
| Rate for Payer: Cofinity Commercial |
$497.74
|
| Rate for Payer: Cofinity Commercial |
$611.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$497.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$568.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.27
|
| Rate for Payer: Healthscope Commercial |
$639.94
|
| Rate for Payer: Mclaren Medicaid |
$2.82
|
| Rate for Payer: Mclaren Medicare |
$5.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.53
|
| Rate for Payer: Meridian Medicaid |
$2.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$604.39
|
| Rate for Payer: Nomi Health Commercial |
$15.81
|
| Rate for Payer: PACE Medicare |
$5.01
|
| Rate for Payer: PACE SWMI |
$5.27
|
| Rate for Payer: PHP Commercial |
$604.39
|
| Rate for Payer: PHP Medicare Advantage |
$5.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$462.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.04
|
| Rate for Payer: Priority Health Medicare |
$5.27
|
| Rate for Payer: Priority Health Narrow Network |
$9.63
|
| Rate for Payer: Priority Health SBD |
$447.96
|
| Rate for Payer: Railroad Medicare Medicare |
$5.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.27
|
| Rate for Payer: UHC Medicare Advantage |
$5.27
|
| Rate for Payer: UHCCP Medicaid |
$2.97
|
| Rate for Payer: VA VA |
$5.27
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$2,522.85
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
89350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$2,270.56 |
| Rate for Payer: Aetna Commercial |
$2,144.42
|
| Rate for Payer: Aetna Medicare |
$5.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,639.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.59
|
| Rate for Payer: BCBS Complete |
$2.97
|
| Rate for Payer: BCBS MAPPO |
$5.27
|
| Rate for Payer: BCBS Trust/PPO |
$14.61
|
| Rate for Payer: BCN Commercial |
$14.61
|
| Rate for Payer: BCN Medicare Advantage |
$5.27
|
| Rate for Payer: Cash Price |
$2,018.28
|
| Rate for Payer: Cash Price |
$2,018.28
|
| Rate for Payer: Cofinity Commercial |
$2,169.65
|
| Rate for Payer: Cofinity Commercial |
$1,766.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,766.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,018.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.27
|
| Rate for Payer: Healthscope Commercial |
$2,270.56
|
| Rate for Payer: Mclaren Medicaid |
$2.82
|
| Rate for Payer: Mclaren Medicare |
$5.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.53
|
| Rate for Payer: Meridian Medicaid |
$2.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,144.42
|
| Rate for Payer: Nomi Health Commercial |
$15.81
|
| Rate for Payer: PACE Medicare |
$5.01
|
| Rate for Payer: PACE SWMI |
$5.27
|
| Rate for Payer: PHP Commercial |
$2,144.42
|
| Rate for Payer: PHP Medicare Advantage |
$5.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,639.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.04
|
| Rate for Payer: Priority Health Medicare |
$5.27
|
| Rate for Payer: Priority Health Narrow Network |
$9.63
|
| Rate for Payer: Priority Health SBD |
$1,589.40
|
| Rate for Payer: Railroad Medicare Medicare |
$5.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.27
|
| Rate for Payer: UHC Medicare Advantage |
$5.27
|
| Rate for Payer: UHCCP Medicaid |
$2.97
|
| Rate for Payer: VA VA |
$5.27
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$17,699.27
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
37894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,150.54 |
| Max. Negotiated Rate |
$15,929.34 |
| Rate for Payer: Aetna Commercial |
$15,044.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,504.53
|
| Rate for Payer: Cash Price |
$14,159.42
|
| Rate for Payer: Cofinity Commercial |
$12,389.49
|
| Rate for Payer: Cofinity Commercial |
$15,221.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,389.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,159.42
|
| Rate for Payer: Healthscope Commercial |
$15,929.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,044.38
|
| Rate for Payer: PHP Commercial |
$15,044.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,504.53
|
| Rate for Payer: Priority Health SBD |
$11,150.54
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$17,699.27
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
37894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$15,929.34 |
| Rate for Payer: Aetna Commercial |
$15,044.38
|
| Rate for Payer: Aetna Medicare |
$5.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,504.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.59
|
| Rate for Payer: BCBS Complete |
$2.97
|
| Rate for Payer: BCBS MAPPO |
$5.27
|
| Rate for Payer: BCBS Trust/PPO |
$14.61
|
| Rate for Payer: BCN Commercial |
$14.61
|
| Rate for Payer: BCN Medicare Advantage |
$5.27
|
| Rate for Payer: Cash Price |
$14,159.42
|
| Rate for Payer: Cash Price |
$14,159.42
|
| Rate for Payer: Cofinity Commercial |
$12,389.49
|
| Rate for Payer: Cofinity Commercial |
$15,221.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,389.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,159.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.27
|
| Rate for Payer: Healthscope Commercial |
$15,929.34
|
| Rate for Payer: Mclaren Medicaid |
$2.82
|
| Rate for Payer: Mclaren Medicare |
$5.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.53
|
| Rate for Payer: Meridian Medicaid |
$2.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,044.38
|
| Rate for Payer: Nomi Health Commercial |
$15.81
|
| Rate for Payer: PACE Medicare |
$5.01
|
| Rate for Payer: PACE SWMI |
$5.27
|
| Rate for Payer: PHP Commercial |
$15,044.38
|
| Rate for Payer: PHP Medicare Advantage |
$5.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,504.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.04
|
| Rate for Payer: Priority Health Medicare |
$5.27
|
| Rate for Payer: Priority Health Narrow Network |
$9.63
|
| Rate for Payer: Priority Health SBD |
$11,150.54
|
| Rate for Payer: Railroad Medicare Medicare |
$5.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.27
|
| Rate for Payer: UHC Medicare Advantage |
$5.27
|
| Rate for Payer: UHCCP Medicaid |
$2.97
|
| Rate for Payer: VA VA |
$5.27
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
112201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$628.95 |
| Max. Negotiated Rate |
$898.51 |
| Rate for Payer: Aetna Commercial |
$848.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$648.92
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$698.84
|
| Rate for Payer: Cofinity Commercial |
$858.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$698.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Healthscope Commercial |
$898.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: PHP Commercial |
$848.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: Priority Health SBD |
$628.95
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
112201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$898.51 |
| Rate for Payer: Aetna Commercial |
$848.59
|
| Rate for Payer: Aetna Medicare |
$27.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$648.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33.52
|
| Rate for Payer: BCBS Complete |
$15.09
|
| Rate for Payer: BCBS MAPPO |
$26.82
|
| Rate for Payer: BCBS Trust/PPO |
$71.64
|
| Rate for Payer: BCN Commercial |
$71.64
|
| Rate for Payer: BCN Medicare Advantage |
$26.82
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$858.57
|
| Rate for Payer: Cofinity Commercial |
$698.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$698.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26.82
|
| Rate for Payer: Healthscope Commercial |
$898.51
|
| Rate for Payer: Mclaren Medicaid |
$14.38
|
| Rate for Payer: Mclaren Medicare |
$26.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.16
|
| Rate for Payer: Meridian Medicaid |
$15.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: Nomi Health Commercial |
$80.46
|
| Rate for Payer: PACE Medicare |
$25.48
|
| Rate for Payer: PACE SWMI |
$26.82
|
| Rate for Payer: PHP Commercial |
$848.59
|
| Rate for Payer: PHP Medicare Advantage |
$26.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$70.14
|
| Rate for Payer: Priority Health Medicare |
$26.82
|
| Rate for Payer: Priority Health Narrow Network |
$56.11
|
| Rate for Payer: Priority Health SBD |
$628.95
|
| Rate for Payer: Railroad Medicare Medicare |
$26.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$26.82
|
| Rate for Payer: UHC Medicare Advantage |
$26.82
|
| Rate for Payer: UHCCP Medicaid |
$15.10
|
| Rate for Payer: VA VA |
$26.82
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE CUSTOM
|
Facility
|
OP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
301789
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$898.51 |
| Rate for Payer: Aetna Commercial |
$848.59
|
| Rate for Payer: Aetna Medicare |
$27.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$648.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33.52
|
| Rate for Payer: BCBS Complete |
$15.09
|
| Rate for Payer: BCBS MAPPO |
$26.82
|
| Rate for Payer: BCBS Trust/PPO |
$71.64
|
| Rate for Payer: BCN Commercial |
$71.64
|
| Rate for Payer: BCN Medicare Advantage |
$26.82
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$858.57
|
| Rate for Payer: Cofinity Commercial |
$698.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$698.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26.82
|
| Rate for Payer: Healthscope Commercial |
$898.51
|
| Rate for Payer: Mclaren Medicaid |
$14.38
|
| Rate for Payer: Mclaren Medicare |
$26.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.16
|
| Rate for Payer: Meridian Medicaid |
$15.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: Nomi Health Commercial |
$80.46
|
| Rate for Payer: PACE Medicare |
$25.48
|
| Rate for Payer: PACE SWMI |
$26.82
|
| Rate for Payer: PHP Commercial |
$848.59
|
| Rate for Payer: PHP Medicare Advantage |
$26.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$70.14
|
| Rate for Payer: Priority Health Medicare |
$26.82
|
| Rate for Payer: Priority Health Narrow Network |
$56.11
|
| Rate for Payer: Priority Health SBD |
$628.95
|
| Rate for Payer: Railroad Medicare Medicare |
$26.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$26.82
|
| Rate for Payer: UHC Medicare Advantage |
$26.82
|
| Rate for Payer: UHCCP Medicaid |
$15.10
|
| Rate for Payer: VA VA |
$26.82
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE CUSTOM
|
Facility
|
IP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
301789
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$628.95 |
| Max. Negotiated Rate |
$898.51 |
| Rate for Payer: Aetna Commercial |
$848.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$648.92
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$698.84
|
| Rate for Payer: Cofinity Commercial |
$858.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$698.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Healthscope Commercial |
$898.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: PHP Commercial |
$848.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: Priority Health SBD |
$628.95
|
|
|
PENICILLIN G IV 16,000 UNITS/ML INFUSION FOR DESENSITIZATION
|
Facility
|
OP
|
$162.50
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
300138
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$146.25 |
| Rate for Payer: Aetna Commercial |
$138.12
|
| Rate for Payer: Aetna Medicare |
$81.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.62
|
| Rate for Payer: BCBS Complete |
$65.00
|
| Rate for Payer: BCBS Trust/PPO |
$2.86
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cofinity Commercial |
$113.75
|
| Rate for Payer: Cofinity Commercial |
$139.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.00
|
| Rate for Payer: Healthscope Commercial |
$146.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.12
|
| Rate for Payer: PHP Commercial |
$138.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.62
|
| Rate for Payer: Priority Health SBD |
$102.38
|
|
|
PENICILLIN G IV 16,000 UNITS/ML INFUSION FOR DESENSITIZATION
|
Facility
|
IP
|
$162.50
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
300138
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.38 |
| Max. Negotiated Rate |
$146.25 |
| Rate for Payer: Aetna Commercial |
$138.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.62
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cofinity Commercial |
$113.75
|
| Rate for Payer: Cofinity Commercial |
$139.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.00
|
| Rate for Payer: Healthscope Commercial |
$146.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.12
|
| Rate for Payer: PHP Commercial |
$138.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.62
|
| Rate for Payer: Priority Health SBD |
$102.38
|
|
|
PENICILLIN G IV 1,600 UNITS/ML INFUSION FOR DESENSITIZATION
|
Facility
|
OP
|
$18.75
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
300137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna Medicare |
$9.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.19
|
| Rate for Payer: BCBS Complete |
$7.50
|
| Rate for Payer: BCBS Trust/PPO |
$2.86
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.00
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.94
|
| Rate for Payer: PHP Commercial |
$15.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.19
|
| Rate for Payer: Priority Health SBD |
$11.81
|
|
|
PENICILLIN G IV 1,600 UNITS/ML INFUSION FOR DESENSITIZATION
|
Facility
|
IP
|
$18.75
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
300137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.19
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.00
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.94
|
| Rate for Payer: PHP Commercial |
$15.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.19
|
| Rate for Payer: Priority Health SBD |
$11.81
|
|
|
PENICILLIN G IV 160 UNITS/ML INFUSION FOR DESENSITIZATION
|
Facility
|
OP
|
$6.25
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
300136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.31
|
| Rate for Payer: Aetna Medicare |
$3.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.06
|
| Rate for Payer: BCBS Complete |
$2.50
|
| Rate for Payer: BCBS Trust/PPO |
$2.86
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$4.38
|
| Rate for Payer: Cofinity Commercial |
$5.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.00
|
| Rate for Payer: Healthscope Commercial |
$5.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.31
|
| Rate for Payer: PHP Commercial |
$5.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.06
|
| Rate for Payer: Priority Health SBD |
$3.94
|
|
|
PENICILLIN G IV 160 UNITS/ML INFUSION FOR DESENSITIZATION
|
Facility
|
IP
|
$6.25
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
300136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Aetna Commercial |
$5.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.06
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$4.38
|
| Rate for Payer: Cofinity Commercial |
$5.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.00
|
| Rate for Payer: Healthscope Commercial |
$5.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.31
|
| Rate for Payer: PHP Commercial |
$5.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.06
|
| Rate for Payer: Priority Health SBD |
$3.94
|
|
|
PENICILLIN G IV 3 MILLION UNITS IVPB 100 ML (IV PREMIX)
|
Facility
|
OP
|
$82.80
|
|
|
Service Code
|
NDC 09900000160
|
| Hospital Charge Code |
500537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.12 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$70.38
|
| Rate for Payer: Aetna Medicare |
$41.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.82
|
| Rate for Payer: BCBS Complete |
$33.12
|
| Rate for Payer: Cash Price |
$66.24
|
| Rate for Payer: Cofinity Commercial |
$57.96
|
| Rate for Payer: Cofinity Commercial |
$71.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.24
|
| Rate for Payer: Healthscope Commercial |
$74.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.38
|
| Rate for Payer: PHP Commercial |
$70.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.82
|
| Rate for Payer: Priority Health SBD |
$52.16
|
|
|
PENICILLIN G IV 3 MILLION UNITS IVPB 100 ML (IV PREMIX)
|
Facility
|
IP
|
$82.80
|
|
|
Service Code
|
NDC 09900000160
|
| Hospital Charge Code |
500537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.16 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$70.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.82
|
| Rate for Payer: Cash Price |
$66.24
|
| Rate for Payer: Cofinity Commercial |
$57.96
|
| Rate for Payer: Cofinity Commercial |
$71.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.24
|
| Rate for Payer: Healthscope Commercial |
$74.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.38
|
| Rate for Payer: PHP Commercial |
$70.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.82
|
| Rate for Payer: Priority Health SBD |
$52.16
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$210.36
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$189.32 |
| Rate for Payer: Aetna Commercial |
$178.81
|
| Rate for Payer: Aetna Commercial |
$178.99
|
| Rate for Payer: Aetna Medicare |
$105.29
|
| Rate for Payer: Aetna Medicare |
$105.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.88
|
| Rate for Payer: BCBS Complete |
$84.23
|
| Rate for Payer: BCBS Complete |
$84.14
|
| Rate for Payer: BCBS Trust/PPO |
$2.86
|
| Rate for Payer: BCBS Trust/PPO |
$2.86
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$168.46
|
| Rate for Payer: Cash Price |
$168.46
|
| Rate for Payer: Cash Price |
$168.29
|
| Rate for Payer: Cash Price |
$168.29
|
| Rate for Payer: Cofinity Commercial |
$147.25
|
| Rate for Payer: Cofinity Commercial |
$181.10
|
| Rate for Payer: Cofinity Commercial |
$147.41
|
| Rate for Payer: Cofinity Commercial |
$180.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.46
|
| Rate for Payer: Healthscope Commercial |
$189.32
|
| Rate for Payer: Healthscope Commercial |
$189.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.81
|
| Rate for Payer: PHP Commercial |
$178.99
|
| Rate for Payer: PHP Commercial |
$178.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.88
|
| Rate for Payer: Priority Health SBD |
$132.67
|
| Rate for Payer: Priority Health SBD |
$132.53
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$210.36
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.53 |
| Max. Negotiated Rate |
$189.32 |
| Rate for Payer: Aetna Commercial |
$178.81
|
| Rate for Payer: Aetna Commercial |
$178.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.88
|
| Rate for Payer: Cash Price |
$168.29
|
| Rate for Payer: Cash Price |
$168.46
|
| Rate for Payer: Cofinity Commercial |
$147.25
|
| Rate for Payer: Cofinity Commercial |
$147.41
|
| Rate for Payer: Cofinity Commercial |
$181.10
|
| Rate for Payer: Cofinity Commercial |
$180.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.46
|
| Rate for Payer: Healthscope Commercial |
$189.32
|
| Rate for Payer: Healthscope Commercial |
$189.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.99
|
| Rate for Payer: PHP Commercial |
$178.81
|
| Rate for Payer: PHP Commercial |
$178.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.73
|
| Rate for Payer: Priority Health SBD |
$132.67
|
| Rate for Payer: Priority Health SBD |
$132.53
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$18.34
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$16.51 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.92
|
| Rate for Payer: Cash Price |
$14.67
|
| Rate for Payer: Cofinity Commercial |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$15.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.67
|
| Rate for Payer: Healthscope Commercial |
$16.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.59
|
| Rate for Payer: PHP Commercial |
$15.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.92
|
| Rate for Payer: Priority Health SBD |
$11.55
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$18.34
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
6086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$16.51 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: Aetna Medicare |
$9.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.92
|
| Rate for Payer: BCBS Complete |
$7.34
|
| Rate for Payer: BCBS Trust/PPO |
$2.86
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$14.67
|
| Rate for Payer: Cash Price |
$14.67
|
| Rate for Payer: Cofinity Commercial |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$15.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.67
|
| Rate for Payer: Healthscope Commercial |
$16.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.59
|
| Rate for Payer: PHP Commercial |
$15.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.92
|
| Rate for Payer: Priority Health SBD |
$11.55
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$145.70
|
|
|
Service Code
|
NDC 00093412773
|
| Hospital Charge Code |
6091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.28 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Aetna Medicare |
$72.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.70
|
| Rate for Payer: BCBS Complete |
$58.28
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$101.99
|
| Rate for Payer: Cofinity Commercial |
$125.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.56
|
| Rate for Payer: Healthscope Commercial |
$131.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.70
|
| Rate for Payer: Priority Health SBD |
$91.79
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$249.10
|
|
|
Service Code
|
NDC 00093412774
|
| Hospital Charge Code |
6091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.64 |
| Max. Negotiated Rate |
$224.19 |
| Rate for Payer: Aetna Commercial |
$211.74
|
| Rate for Payer: Aetna Medicare |
$124.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.92
|
| Rate for Payer: BCBS Complete |
$99.64
|
| Rate for Payer: Cash Price |
$199.28
|
| Rate for Payer: Cofinity Commercial |
$174.37
|
| Rate for Payer: Cofinity Commercial |
$214.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$174.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.28
|
| Rate for Payer: Healthscope Commercial |
$224.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.74
|
| Rate for Payer: PHP Commercial |
$211.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.92
|
| Rate for Payer: Priority Health SBD |
$156.93
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$249.10
|
|
|
Service Code
|
NDC 00093412774
|
| Hospital Charge Code |
6091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.93 |
| Max. Negotiated Rate |
$224.19 |
| Rate for Payer: Aetna Commercial |
$211.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.92
|
| Rate for Payer: Cash Price |
$199.28
|
| Rate for Payer: Cofinity Commercial |
$174.37
|
| Rate for Payer: Cofinity Commercial |
$214.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$174.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.28
|
| Rate for Payer: Healthscope Commercial |
$224.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.74
|
| Rate for Payer: PHP Commercial |
$211.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.92
|
| Rate for Payer: Priority Health SBD |
$156.93
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$145.70
|
|
|
Service Code
|
NDC 00093412773
|
| Hospital Charge Code |
6091
|
|
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: Cofinity Medicare Advantage |
$101.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.56
|
| Rate for Payer: Healthscope Commercial |
$131.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.70
|
| Rate for Payer: Priority Health SBD |
$91.79
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
IP
|
$176.25
|
|
|
Service Code
|
NDC 57237004001
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.04 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$151.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: PHP Commercial |
$149.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.56
|
| Rate for Payer: Priority Health SBD |
$111.04
|
|
