|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
OP
|
$176.25
|
|
|
Service Code
|
NDC 57237004001
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.50 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna Medicare |
$88.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: BCBS Complete |
$70.50
|
| 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
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
OP
|
$173.90
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.56 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna Medicare |
$86.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: BCBS Complete |
$69.56
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.04
|
| Rate for Payer: Priority Health SBD |
$109.56
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.56 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.04
|
| Rate for Payer: Priority Health SBD |
$109.56
|
|
|
PENTAMIDINE 300 MG IM INJECTION
|
Facility
|
OP
|
$168.58
|
|
|
Service Code
|
NDC 63323011310
|
| Hospital Charge Code |
299999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.43 |
| Max. Negotiated Rate |
$151.72 |
| Rate for Payer: Aetna Commercial |
$143.29
|
| Rate for Payer: Aetna Medicare |
$84.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.58
|
| Rate for Payer: BCBS Complete |
$67.43
|
| Rate for Payer: Cash Price |
$134.86
|
| Rate for Payer: Cofinity Commercial |
$118.01
|
| Rate for Payer: Cofinity Commercial |
$144.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.86
|
| Rate for Payer: Healthscope Commercial |
$151.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.29
|
| Rate for Payer: PHP Commercial |
$143.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.58
|
| Rate for Payer: Priority Health SBD |
$106.21
|
|
|
PENTAMIDINE 300 MG IM INJECTION
|
Facility
|
IP
|
$168.58
|
|
|
Service Code
|
NDC 63323011310
|
| Hospital Charge Code |
299999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.21 |
| Max. Negotiated Rate |
$151.72 |
| Rate for Payer: Aetna Commercial |
$143.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.58
|
| Rate for Payer: Cash Price |
$134.86
|
| Rate for Payer: Cofinity Commercial |
$118.01
|
| Rate for Payer: Cofinity Commercial |
$144.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.86
|
| Rate for Payer: Healthscope Commercial |
$151.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.29
|
| Rate for Payer: PHP Commercial |
$143.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.58
|
| Rate for Payer: Priority Health SBD |
$106.21
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION
|
Facility
|
IP
|
$224.41
|
|
|
Service Code
|
HCPCS J2545
|
| Hospital Charge Code |
28235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.38 |
| Max. Negotiated Rate |
$201.97 |
| Rate for Payer: Aetna Commercial |
$190.75
|
| Rate for Payer: Aetna Commercial |
$283.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.67
|
| Rate for Payer: Cash Price |
$179.53
|
| Rate for Payer: Cash Price |
$266.67
|
| Rate for Payer: Cofinity Commercial |
$157.09
|
| Rate for Payer: Cofinity Commercial |
$233.34
|
| Rate for Payer: Cofinity Commercial |
$286.67
|
| Rate for Payer: Cofinity Commercial |
$192.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$233.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.67
|
| Rate for Payer: Healthscope Commercial |
$201.97
|
| Rate for Payer: Healthscope Commercial |
$300.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$283.34
|
| Rate for Payer: PHP Commercial |
$190.75
|
| Rate for Payer: PHP Commercial |
$283.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.87
|
| Rate for Payer: Priority Health SBD |
$210.00
|
| Rate for Payer: Priority Health SBD |
$141.38
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION
|
Facility
|
OP
|
$224.41
|
|
|
Service Code
|
HCPCS J2545
|
| Hospital Charge Code |
28235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.51 |
| Max. Negotiated Rate |
$201.97 |
| Rate for Payer: Aetna Commercial |
$190.75
|
| Rate for Payer: Aetna Commercial |
$283.34
|
| Rate for Payer: Aetna Medicare |
$166.67
|
| Rate for Payer: Aetna Medicare |
$112.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.67
|
| Rate for Payer: BCBS Complete |
$89.76
|
| Rate for Payer: BCBS Complete |
$133.34
|
| Rate for Payer: Cash Price |
$179.53
|
| Rate for Payer: Cash Price |
$266.67
|
| Rate for Payer: Cash Price |
$266.67
|
| Rate for Payer: Cash Price |
$179.53
|
| Rate for Payer: Cofinity Commercial |
$157.09
|
| Rate for Payer: Cofinity Commercial |
$192.99
|
| Rate for Payer: Cofinity Commercial |
$286.67
|
| Rate for Payer: Cofinity Commercial |
$233.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$233.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.53
|
| Rate for Payer: Healthscope Commercial |
$201.97
|
| Rate for Payer: Healthscope Commercial |
$300.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$283.34
|
| Rate for Payer: PHP Commercial |
$190.75
|
| Rate for Payer: PHP Commercial |
$283.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$79.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$79.39
|
| Rate for Payer: Priority Health Narrow Network |
$63.51
|
| Rate for Payer: Priority Health Narrow Network |
$63.51
|
| Rate for Payer: Priority Health SBD |
$210.00
|
| Rate for Payer: Priority Health SBD |
$141.38
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$168.58
|
|
|
Service Code
|
NDC 63323011310
|
| Hospital Charge Code |
27430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.43 |
| Max. Negotiated Rate |
$151.72 |
| Rate for Payer: Aetna Commercial |
$143.29
|
| Rate for Payer: Aetna Medicare |
$84.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.58
|
| Rate for Payer: BCBS Complete |
$67.43
|
| Rate for Payer: Cash Price |
$134.86
|
| Rate for Payer: Cofinity Commercial |
$118.01
|
| Rate for Payer: Cofinity Commercial |
$144.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.86
|
| Rate for Payer: Healthscope Commercial |
$151.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.29
|
| Rate for Payer: PHP Commercial |
$143.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.58
|
| Rate for Payer: Priority Health SBD |
$106.21
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$168.58
|
|
|
Service Code
|
NDC 63323011310
|
| Hospital Charge Code |
27430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.21 |
| Max. Negotiated Rate |
$151.72 |
| Rate for Payer: Aetna Commercial |
$143.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.58
|
| Rate for Payer: Cash Price |
$134.86
|
| Rate for Payer: Cofinity Commercial |
$118.01
|
| Rate for Payer: Cofinity Commercial |
$144.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.86
|
| Rate for Payer: Healthscope Commercial |
$151.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.29
|
| Rate for Payer: PHP Commercial |
$143.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.58
|
| Rate for Payer: Priority Health SBD |
$106.21
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$4,120.69
|
|
|
Service Code
|
NDC 50458009801
|
| Hospital Charge Code |
12912
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,596.03 |
| Max. Negotiated Rate |
$3,708.62 |
| Rate for Payer: Aetna Commercial |
$3,502.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,678.45
|
| Rate for Payer: Cash Price |
$3,296.55
|
| Rate for Payer: Cofinity Commercial |
$2,884.48
|
| Rate for Payer: Cofinity Commercial |
$3,543.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,884.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,296.55
|
| Rate for Payer: Healthscope Commercial |
$3,708.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,502.59
|
| Rate for Payer: PHP Commercial |
$3,502.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,678.45
|
| Rate for Payer: Priority Health SBD |
$2,596.03
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE
|
Facility
|
OP
|
$4,120.69
|
|
|
Service Code
|
NDC 50458009801
|
| Hospital Charge Code |
12912
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,648.28 |
| Max. Negotiated Rate |
$3,708.62 |
| Rate for Payer: Aetna Commercial |
$3,502.59
|
| Rate for Payer: Aetna Medicare |
$2,060.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,678.45
|
| Rate for Payer: BCBS Complete |
$1,648.28
|
| Rate for Payer: Cash Price |
$3,296.55
|
| Rate for Payer: Cofinity Commercial |
$2,884.48
|
| Rate for Payer: Cofinity Commercial |
$3,543.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,884.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,296.55
|
| Rate for Payer: Healthscope Commercial |
$3,708.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,502.59
|
| Rate for Payer: PHP Commercial |
$3,502.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,678.45
|
| Rate for Payer: Priority Health SBD |
$2,596.03
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$222.30
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: Aetna Medicare |
$111.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.50
|
| Rate for Payer: BCBS Complete |
$88.92
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$155.61
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$155.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.50
|
| Rate for Payer: Priority Health SBD |
$140.05
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 00904544861
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.05 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.50
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$155.61
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$155.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.50
|
| Rate for Payer: Priority Health SBD |
$140.05
|
|
|
PEPTAMEN INTENSE VHP BOLUS FEED
|
Facility
|
OP
|
$15.73
|
|
|
Service Code
|
NDC 43900043271
|
| Hospital Charge Code |
300293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.22
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$11.01
|
| Rate for Payer: Cofinity Commercial |
$13.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$14.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.37
|
| Rate for Payer: PHP Commercial |
$13.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health SBD |
$9.91
|
|
|
PEPTAMEN INTENSE VHP BOLUS FEED
|
Facility
|
IP
|
$15.73
|
|
|
Service Code
|
NDC 43900043271
|
| Hospital Charge Code |
300293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.22
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$11.01
|
| Rate for Payer: Cofinity Commercial |
$13.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$14.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.37
|
| Rate for Payer: PHP Commercial |
$13.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health SBD |
$9.91
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
IP
|
$70.30
|
|
|
Service Code
|
NDC 43900049322
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.70
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$49.21
|
| Rate for Payer: Cofinity Commercial |
$60.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: PHP Commercial |
$59.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health SBD |
$44.29
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
OP
|
$70.30
|
|
|
Service Code
|
NDC 43900049322
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna Medicare |
$35.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.70
|
| Rate for Payer: BCBS Complete |
$28.12
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$49.21
|
| Rate for Payer: Cofinity Commercial |
$60.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: PHP Commercial |
$59.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health SBD |
$44.29
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
IP
|
$70.30
|
|
|
Service Code
|
NDC 43900072395
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.70
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$49.21
|
| Rate for Payer: Cofinity Commercial |
$60.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: PHP Commercial |
$59.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health SBD |
$44.29
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
OP
|
$70.30
|
|
|
Service Code
|
NDC 43900072395
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna Medicare |
$35.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.70
|
| Rate for Payer: BCBS Complete |
$28.12
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$49.21
|
| Rate for Payer: Cofinity Commercial |
$60.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: PHP Commercial |
$59.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health SBD |
$44.29
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
OP
|
$15.73
|
|
|
Service Code
|
NDC 43900073049
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.22
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$11.01
|
| Rate for Payer: Cofinity Commercial |
$13.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$14.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.37
|
| Rate for Payer: PHP Commercial |
$13.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health SBD |
$9.91
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
IP
|
$15.73
|
|
|
Service Code
|
NDC 43900073049
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$14.16 |
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.22
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$11.01
|
| Rate for Payer: Cofinity Commercial |
$13.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$14.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.37
|
| Rate for Payer: PHP Commercial |
$13.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health SBD |
$9.91
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
IP
|
$70.30
|
|
|
Service Code
|
NDC 43900072395
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.29 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.70
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$60.46
|
| Rate for Payer: Cofinity Commercial |
$49.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: PHP Commercial |
$59.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health SBD |
$44.29
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
OP
|
$70.30
|
|
|
Service Code
|
NDC 43900072395
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna Medicare |
$35.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.70
|
| Rate for Payer: BCBS Complete |
$28.12
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$49.21
|
| Rate for Payer: Cofinity Commercial |
$60.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: PHP Commercial |
$59.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health SBD |
$44.29
|
|
|
PERAMIVIR (PF) 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,035.68
|
|
|
Service Code
|
HCPCS J2547
|
| Hospital Charge Code |
119324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$932.11 |
| Rate for Payer: Aetna Commercial |
$880.33
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$673.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.10
|
| Rate for Payer: BCBS Complete |
$0.95
|
| Rate for Payer: BCBS MAPPO |
$1.68
|
| Rate for Payer: BCBS Trust/PPO |
$4.44
|
| Rate for Payer: BCN Commercial |
$4.44
|
| Rate for Payer: BCN Medicare Advantage |
$1.68
|
| Rate for Payer: Cash Price |
$828.54
|
| Rate for Payer: Cash Price |
$828.54
|
| Rate for Payer: Cofinity Commercial |
$890.68
|
| Rate for Payer: Cofinity Commercial |
$724.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$724.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$828.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.68
|
| Rate for Payer: Healthscope Commercial |
$932.11
|
| Rate for Payer: Mclaren Medicaid |
$0.90
|
| Rate for Payer: Mclaren Medicare |
$1.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.76
|
| Rate for Payer: Meridian Medicaid |
$0.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$880.33
|
| Rate for Payer: Nomi Health Commercial |
$5.04
|
| Rate for Payer: PACE Medicare |
$1.60
|
| Rate for Payer: PACE SWMI |
$1.68
|
| Rate for Payer: PHP Commercial |
$880.33
|
| Rate for Payer: PHP Medicare Advantage |
$1.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$673.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.82
|
| Rate for Payer: Priority Health Medicare |
$1.68
|
| Rate for Payer: Priority Health Narrow Network |
$3.86
|
| Rate for Payer: Priority Health SBD |
$652.48
|
| Rate for Payer: Railroad Medicare Medicare |
$1.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.68
|
| Rate for Payer: UHC Medicare Advantage |
$1.68
|
| Rate for Payer: UHCCP Medicaid |
$0.95
|
| Rate for Payer: VA VA |
$1.68
|
|
|
PERAMIVIR (PF) 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,035.68
|
|
|
Service Code
|
HCPCS J2547
|
| Hospital Charge Code |
119324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$652.48 |
| Max. Negotiated Rate |
$932.11 |
| Rate for Payer: Aetna Commercial |
$880.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$673.19
|
| Rate for Payer: Cash Price |
$828.54
|
| Rate for Payer: Cofinity Commercial |
$724.98
|
| Rate for Payer: Cofinity Commercial |
$890.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$724.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$828.54
|
| Rate for Payer: Healthscope Commercial |
$932.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$880.33
|
| Rate for Payer: PHP Commercial |
$880.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$673.19
|
| Rate for Payer: Priority Health SBD |
$652.48
|
|
