|
AZATHIOPRINE 50 MG TABLET
|
Facility
|
OP
|
$398.05
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
9183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.22 |
| Max. Negotiated Rate |
$358.25 |
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna Commercial |
$2.26
|
| Rate for Payer: Aetna Commercial |
$348.84
|
| Rate for Payer: Aetna Commercial |
$226.03
|
| Rate for Payer: Aetna Medicare |
$205.20
|
| Rate for Payer: Aetna Medicare |
$199.03
|
| Rate for Payer: Aetna Medicare |
$1.33
|
| Rate for Payer: Aetna Medicare |
$132.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.76
|
| Rate for Payer: BCBS Complete |
$106.37
|
| Rate for Payer: BCBS Complete |
$164.16
|
| Rate for Payer: BCBS Complete |
$1.06
|
| Rate for Payer: BCBS Complete |
$159.22
|
| Rate for Payer: Cash Price |
$328.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cash Price |
$212.74
|
| Rate for Payer: Cofinity Commercial |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$352.94
|
| Rate for Payer: Cofinity Commercial |
$278.63
|
| Rate for Payer: Cofinity Commercial |
$287.28
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Cofinity Commercial |
$186.14
|
| Rate for Payer: Cofinity Commercial |
$228.69
|
| Rate for Payer: Cofinity Commercial |
$1.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$278.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.13
|
| Rate for Payer: Healthscope Commercial |
$239.33
|
| Rate for Payer: Healthscope Commercial |
$369.36
|
| Rate for Payer: Healthscope Commercial |
$2.39
|
| Rate for Payer: Healthscope Commercial |
$358.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$348.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.03
|
| Rate for Payer: PHP Commercial |
$2.26
|
| Rate for Payer: PHP Commercial |
$348.84
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: PHP Commercial |
$226.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.76
|
| Rate for Payer: Priority Health SBD |
$167.53
|
| Rate for Payer: Priority Health SBD |
$250.77
|
| Rate for Payer: Priority Health SBD |
$1.68
|
| Rate for Payer: Priority Health SBD |
$258.55
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$89.28
|
|
|
Service Code
|
NDC 59762314001
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna Medicare |
$44.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: BCBS Complete |
$35.71
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$89.28
|
|
|
Service Code
|
NDC 59762314001
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$124.55
|
|
|
Service Code
|
NDC 70710146002
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.82 |
| Max. Negotiated Rate |
$112.09 |
| Rate for Payer: Aetna Commercial |
$105.87
|
| Rate for Payer: Aetna Medicare |
$62.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.96
|
| Rate for Payer: BCBS Complete |
$49.82
|
| Rate for Payer: Cash Price |
$99.64
|
| Rate for Payer: Cofinity Commercial |
$107.11
|
| Rate for Payer: Cofinity Commercial |
$87.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$87.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.64
|
| Rate for Payer: Healthscope Commercial |
$112.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.87
|
| Rate for Payer: PHP Commercial |
$105.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.96
|
| Rate for Payer: Priority Health SBD |
$78.47
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$96.62
|
|
|
Service Code
|
NDC 42806015134
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.87 |
| Max. Negotiated Rate |
$86.96 |
| Rate for Payer: Aetna Commercial |
$82.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.80
|
| Rate for Payer: Cash Price |
$77.30
|
| Rate for Payer: Cofinity Commercial |
$67.63
|
| Rate for Payer: Cofinity Commercial |
$83.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.30
|
| Rate for Payer: Healthscope Commercial |
$86.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.13
|
| Rate for Payer: PHP Commercial |
$82.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.80
|
| Rate for Payer: Priority Health SBD |
$60.87
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$124.55
|
|
|
Service Code
|
NDC 70710146002
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.47 |
| Max. Negotiated Rate |
$112.09 |
| Rate for Payer: Aetna Commercial |
$105.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.96
|
| Rate for Payer: Cash Price |
$99.64
|
| Rate for Payer: Cofinity Commercial |
$107.11
|
| Rate for Payer: Cofinity Commercial |
$87.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$87.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.64
|
| Rate for Payer: Healthscope Commercial |
$112.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.87
|
| Rate for Payer: PHP Commercial |
$105.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.96
|
| Rate for Payer: Priority Health SBD |
$78.47
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$116.79
|
|
|
Service Code
|
NDC 00093202631
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.72 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: Aetna Commercial |
$99.27
|
| Rate for Payer: Aetna Medicare |
$58.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.91
|
| Rate for Payer: BCBS Complete |
$46.72
|
| Rate for Payer: Cash Price |
$93.43
|
| Rate for Payer: Cofinity Commercial |
$100.44
|
| Rate for Payer: Cofinity Commercial |
$81.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.43
|
| Rate for Payer: Healthscope Commercial |
$105.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.27
|
| Rate for Payer: PHP Commercial |
$99.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.91
|
| Rate for Payer: Priority Health SBD |
$73.58
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$96.62
|
|
|
Service Code
|
NDC 42806015134
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.65 |
| Max. Negotiated Rate |
$86.96 |
| Rate for Payer: Aetna Commercial |
$82.13
|
| Rate for Payer: Aetna Medicare |
$48.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.80
|
| Rate for Payer: BCBS Complete |
$38.65
|
| Rate for Payer: Cash Price |
$77.30
|
| Rate for Payer: Cofinity Commercial |
$67.63
|
| Rate for Payer: Cofinity Commercial |
$83.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.30
|
| Rate for Payer: Healthscope Commercial |
$86.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.13
|
| Rate for Payer: PHP Commercial |
$82.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.80
|
| Rate for Payer: Priority Health SBD |
$60.87
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$116.79
|
|
|
Service Code
|
NDC 00093202631
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.58 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: Aetna Commercial |
$99.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.91
|
| Rate for Payer: Cash Price |
$93.43
|
| Rate for Payer: Cofinity Commercial |
$100.44
|
| Rate for Payer: Cofinity Commercial |
$81.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.43
|
| Rate for Payer: Healthscope Commercial |
$105.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.27
|
| Rate for Payer: PHP Commercial |
$99.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.91
|
| Rate for Payer: Priority Health SBD |
$73.58
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$59.85
|
|
|
Service Code
|
NDC 59762219807
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.71 |
| Max. Negotiated Rate |
$53.87 |
| Rate for Payer: Aetna Commercial |
$50.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.90
|
| Rate for Payer: Cash Price |
$47.88
|
| Rate for Payer: Cofinity Commercial |
$41.90
|
| Rate for Payer: Cofinity Commercial |
$51.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.88
|
| Rate for Payer: Healthscope Commercial |
$53.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.87
|
| Rate for Payer: PHP Commercial |
$50.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.90
|
| Rate for Payer: Priority Health SBD |
$37.71
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$281.96
|
|
|
Service Code
|
NDC 64679096101
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.78 |
| Max. Negotiated Rate |
$253.76 |
| Rate for Payer: Aetna Commercial |
$239.67
|
| Rate for Payer: Aetna Medicare |
$140.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.27
|
| Rate for Payer: BCBS Complete |
$112.78
|
| Rate for Payer: Cash Price |
$225.57
|
| Rate for Payer: Cofinity Commercial |
$197.37
|
| Rate for Payer: Cofinity Commercial |
$242.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.57
|
| Rate for Payer: Healthscope Commercial |
$253.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.67
|
| Rate for Payer: PHP Commercial |
$239.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.27
|
| Rate for Payer: Priority Health SBD |
$177.63
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$513.60
|
|
|
Service Code
|
NDC 00904735061
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.44 |
| Max. Negotiated Rate |
$462.24 |
| Rate for Payer: Aetna Commercial |
$436.56
|
| Rate for Payer: Aetna Medicare |
$256.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$333.84
|
| Rate for Payer: BCBS Complete |
$205.44
|
| Rate for Payer: Cash Price |
$410.88
|
| Rate for Payer: Cofinity Commercial |
$359.52
|
| Rate for Payer: Cofinity Commercial |
$441.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$359.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$410.88
|
| Rate for Payer: Healthscope Commercial |
$462.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$436.56
|
| Rate for Payer: PHP Commercial |
$436.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$333.84
|
| Rate for Payer: Priority Health SBD |
$323.57
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$140.51
|
|
|
Service Code
|
NDC 00781808931
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.52 |
| Max. Negotiated Rate |
$126.46 |
| Rate for Payer: Aetna Commercial |
$119.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.33
|
| Rate for Payer: Cash Price |
$112.41
|
| Rate for Payer: Cofinity Commercial |
$120.84
|
| Rate for Payer: Cofinity Commercial |
$98.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.41
|
| Rate for Payer: Healthscope Commercial |
$126.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.43
|
| Rate for Payer: PHP Commercial |
$119.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.33
|
| Rate for Payer: Priority Health SBD |
$88.52
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$384.80
|
|
|
Service Code
|
NDC 59762306003
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.92 |
| Max. Negotiated Rate |
$346.32 |
| Rate for Payer: Aetna Commercial |
$327.08
|
| Rate for Payer: Aetna Medicare |
$192.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.12
|
| Rate for Payer: BCBS Complete |
$153.92
|
| Rate for Payer: Cash Price |
$307.84
|
| Rate for Payer: Cofinity Commercial |
$269.36
|
| Rate for Payer: Cofinity Commercial |
$330.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.84
|
| Rate for Payer: Healthscope Commercial |
$346.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.08
|
| Rate for Payer: PHP Commercial |
$327.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.12
|
| Rate for Payer: Priority Health SBD |
$242.42
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$775.20
|
|
|
Service Code
|
NDC 60687028201
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$310.08 |
| Max. Negotiated Rate |
$697.68 |
| Rate for Payer: Aetna Commercial |
$658.92
|
| Rate for Payer: Aetna Medicare |
$387.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.88
|
| Rate for Payer: BCBS Complete |
$310.08
|
| Rate for Payer: Cash Price |
$620.16
|
| Rate for Payer: Cofinity Commercial |
$542.64
|
| Rate for Payer: Cofinity Commercial |
$666.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$620.16
|
| Rate for Payer: Healthscope Commercial |
$697.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.92
|
| Rate for Payer: PHP Commercial |
$658.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.88
|
| Rate for Payer: Priority Health SBD |
$488.38
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$140.51
|
|
|
Service Code
|
NDC 00781808931
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$126.46 |
| Rate for Payer: Aetna Commercial |
$119.43
|
| Rate for Payer: Aetna Medicare |
$70.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.33
|
| Rate for Payer: BCBS Complete |
$56.20
|
| Rate for Payer: Cash Price |
$112.41
|
| Rate for Payer: Cofinity Commercial |
$120.84
|
| Rate for Payer: Cofinity Commercial |
$98.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.41
|
| Rate for Payer: Healthscope Commercial |
$126.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.43
|
| Rate for Payer: PHP Commercial |
$119.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.33
|
| Rate for Payer: Priority Health SBD |
$88.52
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$121.41
|
|
|
Service Code
|
NDC 68094090030
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.56 |
| Max. Negotiated Rate |
$109.27 |
| Rate for Payer: Aetna Commercial |
$103.20
|
| Rate for Payer: Aetna Medicare |
$60.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.92
|
| Rate for Payer: BCBS Complete |
$48.56
|
| Rate for Payer: Cash Price |
$97.13
|
| Rate for Payer: Cofinity Commercial |
$104.41
|
| Rate for Payer: Cofinity Commercial |
$84.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$84.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.13
|
| Rate for Payer: Healthscope Commercial |
$109.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$103.20
|
| Rate for Payer: PHP Commercial |
$103.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.92
|
| Rate for Payer: Priority Health SBD |
$76.49
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$775.20
|
|
|
Service Code
|
NDC 60687028201
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$488.38 |
| Max. Negotiated Rate |
$697.68 |
| Rate for Payer: Aetna Commercial |
$658.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.88
|
| Rate for Payer: Cash Price |
$620.16
|
| Rate for Payer: Cofinity Commercial |
$542.64
|
| Rate for Payer: Cofinity Commercial |
$666.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$620.16
|
| Rate for Payer: Healthscope Commercial |
$697.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.92
|
| Rate for Payer: PHP Commercial |
$658.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.88
|
| Rate for Payer: Priority Health SBD |
$488.38
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$154.08
|
|
|
Service Code
|
NDC 00904670806
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.07 |
| Max. Negotiated Rate |
$138.67 |
| Rate for Payer: Aetna Commercial |
$130.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.15
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cofinity Commercial |
$107.86
|
| Rate for Payer: Cofinity Commercial |
$132.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.26
|
| Rate for Payer: Healthscope Commercial |
$138.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.97
|
| Rate for Payer: PHP Commercial |
$130.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.15
|
| Rate for Payer: Priority Health SBD |
$97.07
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$158.40
|
|
|
Service Code
|
NDC 00904735006
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.36 |
| Max. Negotiated Rate |
$142.56 |
| Rate for Payer: Aetna Commercial |
$134.64
|
| Rate for Payer: Aetna Medicare |
$79.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.96
|
| Rate for Payer: BCBS Complete |
$63.36
|
| Rate for Payer: Cash Price |
$126.72
|
| Rate for Payer: Cofinity Commercial |
$110.88
|
| Rate for Payer: Cofinity Commercial |
$136.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$110.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.72
|
| Rate for Payer: Healthscope Commercial |
$142.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.64
|
| Rate for Payer: PHP Commercial |
$134.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.96
|
| Rate for Payer: Priority Health SBD |
$99.79
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$281.96
|
|
|
Service Code
|
NDC 64679096101
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.63 |
| Max. Negotiated Rate |
$253.76 |
| Rate for Payer: Aetna Commercial |
$239.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.27
|
| Rate for Payer: Cash Price |
$225.57
|
| Rate for Payer: Cofinity Commercial |
$197.37
|
| Rate for Payer: Cofinity Commercial |
$242.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.57
|
| Rate for Payer: Healthscope Commercial |
$253.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.67
|
| Rate for Payer: PHP Commercial |
$239.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.27
|
| Rate for Payer: Priority Health SBD |
$177.63
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$174.24
|
|
|
Service Code
|
NDC 50268007415
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.77 |
| Max. Negotiated Rate |
$156.82 |
| Rate for Payer: Aetna Commercial |
$148.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.26
|
| Rate for Payer: Cash Price |
$139.39
|
| Rate for Payer: Cofinity Commercial |
$121.97
|
| Rate for Payer: Cofinity Commercial |
$149.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.39
|
| Rate for Payer: Healthscope Commercial |
$156.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.10
|
| Rate for Payer: PHP Commercial |
$148.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.26
|
| Rate for Payer: Priority Health SBD |
$109.77
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 50268009811
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: BCBS Complete |
$1.25
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 50268009811
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
OP
|
$7.76
|
|
|
Service Code
|
NDC 60687028211
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$6.98 |
| Rate for Payer: Aetna Commercial |
$6.60
|
| Rate for Payer: Aetna Medicare |
$3.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.04
|
| Rate for Payer: BCBS Complete |
$3.10
|
| Rate for Payer: Cash Price |
$6.21
|
| Rate for Payer: Cofinity Commercial |
$5.43
|
| Rate for Payer: Cofinity Commercial |
$6.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.21
|
| Rate for Payer: Healthscope Commercial |
$6.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.60
|
| Rate for Payer: PHP Commercial |
$6.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.04
|
| Rate for Payer: Priority Health SBD |
$4.89
|
|
