|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$96.35
|
|
|
Service Code
|
NDC 72888001001
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.70 |
| Max. Negotiated Rate |
$86.72 |
| Rate for Payer: Aetna Commercial |
$81.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.63
|
| Rate for Payer: Cash Price |
$77.08
|
| Rate for Payer: Cofinity Commercial |
$67.44
|
| Rate for Payer: Cofinity Commercial |
$82.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.08
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.90
|
| Rate for Payer: PHP Commercial |
$81.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.63
|
| Rate for Payer: Priority Health SBD |
$60.70
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$254.88
|
|
|
Service Code
|
NDC 60687050301
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.57 |
| Max. Negotiated Rate |
$229.39 |
| Rate for Payer: Aetna Commercial |
$216.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.67
|
| Rate for Payer: Cash Price |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$178.42
|
| Rate for Payer: Cofinity Commercial |
$219.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.90
|
| Rate for Payer: Healthscope Commercial |
$229.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.65
|
| Rate for Payer: PHP Commercial |
$216.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.67
|
| Rate for Payer: Priority Health SBD |
$160.57
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
NDC 50268010611
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.06
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Cofinity Commercial |
$2.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.54
|
| Rate for Payer: Healthscope Commercial |
$2.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.69
|
| Rate for Payer: PHP Commercial |
$2.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.06
|
| Rate for Payer: Priority Health SBD |
$2.00
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$131.60
|
|
|
Service Code
|
NDC 52817032010
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.91 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$82.91
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$406.60
|
|
|
Service Code
|
NDC 60687081501
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$256.16 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.29
|
| Rate for Payer: Priority Health SBD |
$256.16
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
OP
|
$406.60
|
|
|
Service Code
|
NDC 60687081501
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.64 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna Medicare |
$203.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: BCBS Complete |
$162.64
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.29
|
| Rate for Payer: Priority Health SBD |
$256.16
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
OP
|
$4.07
|
|
|
Service Code
|
NDC 60687081511
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Aetna Medicare |
$2.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.65
|
| Rate for Payer: BCBS Complete |
$1.63
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Cofinity Commercial |
$3.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.26
|
| Rate for Payer: Healthscope Commercial |
$3.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.46
|
| Rate for Payer: PHP Commercial |
$3.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.65
|
| Rate for Payer: Priority Health SBD |
$2.56
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
OP
|
$96.35
|
|
|
Service Code
|
NDC 72888001001
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.54 |
| Max. Negotiated Rate |
$86.72 |
| Rate for Payer: Aetna Commercial |
$81.90
|
| Rate for Payer: Aetna Medicare |
$48.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.63
|
| Rate for Payer: BCBS Complete |
$38.54
|
| Rate for Payer: Cash Price |
$77.08
|
| Rate for Payer: Cofinity Commercial |
$67.44
|
| Rate for Payer: Cofinity Commercial |
$82.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.08
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.90
|
| Rate for Payer: PHP Commercial |
$81.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.63
|
| Rate for Payer: Priority Health SBD |
$60.70
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 60687050311
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$341.05
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.86 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.68
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$238.74
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.89
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.68
|
| Rate for Payer: Priority Health SBD |
$214.86
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$158.18
|
|
|
Service Code
|
NDC 50268010615
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.65 |
| Max. Negotiated Rate |
$142.36 |
| Rate for Payer: Aetna Commercial |
$134.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.82
|
| Rate for Payer: Cash Price |
$126.54
|
| Rate for Payer: Cofinity Commercial |
$110.73
|
| Rate for Payer: Cofinity Commercial |
$136.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$110.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.54
|
| Rate for Payer: Healthscope Commercial |
$142.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.45
|
| Rate for Payer: PHP Commercial |
$134.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.82
|
| Rate for Payer: Priority Health SBD |
$99.65
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 00172409660
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.52 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health SBD |
$112.52
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
NDC 50268010611
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Aetna Medicare |
$1.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.06
|
| Rate for Payer: BCBS Complete |
$1.27
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Cofinity Commercial |
$2.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.54
|
| Rate for Payer: Healthscope Commercial |
$2.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.69
|
| Rate for Payer: PHP Commercial |
$2.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.06
|
| Rate for Payer: Priority Health SBD |
$2.00
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
OP
|
$341.05
|
|
|
Service Code
|
NDC 00904647561
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.42 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: Aetna Medicare |
$170.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.68
|
| Rate for Payer: BCBS Complete |
$136.42
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$238.74
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.89
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.68
|
| Rate for Payer: Priority Health SBD |
$214.86
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$1,692.00
|
|
|
Service Code
|
NDC 00172409680
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,065.96 |
| Max. Negotiated Rate |
$1,522.80 |
| Rate for Payer: Aetna Commercial |
$1,438.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,099.80
|
| Rate for Payer: Cash Price |
$1,353.60
|
| Rate for Payer: Cofinity Commercial |
$1,184.40
|
| Rate for Payer: Cofinity Commercial |
$1,455.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,184.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,353.60
|
| Rate for Payer: Healthscope Commercial |
$1,522.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,438.20
|
| Rate for Payer: PHP Commercial |
$1,438.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,099.80
|
| Rate for Payer: Priority Health SBD |
$1,065.96
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$246.72
|
|
|
Service Code
|
NDC 00904647661
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.43 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
OP
|
$246.72
|
|
|
Service Code
|
NDC 00904647661
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.69 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna Medicare |
$123.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: BCBS Complete |
$98.69
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$261.84
|
|
|
Service Code
|
NDC 50268010515
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.96 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna Commercial |
$222.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.20
|
| Rate for Payer: Cash Price |
$209.47
|
| Rate for Payer: Cofinity Commercial |
$183.29
|
| Rate for Payer: Cofinity Commercial |
$225.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.47
|
| Rate for Payer: Healthscope Commercial |
$235.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.56
|
| Rate for Payer: PHP Commercial |
$222.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.20
|
| Rate for Payer: Priority Health SBD |
$164.96
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$261.84
|
|
|
Service Code
|
NDC 50268010515
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.74 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna Commercial |
$222.56
|
| Rate for Payer: Aetna Medicare |
$130.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.20
|
| Rate for Payer: BCBS Complete |
$104.74
|
| Rate for Payer: Cash Price |
$209.47
|
| Rate for Payer: Cofinity Commercial |
$183.29
|
| Rate for Payer: Cofinity Commercial |
$225.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.47
|
| Rate for Payer: Healthscope Commercial |
$235.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.56
|
| Rate for Payer: PHP Commercial |
$222.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.20
|
| Rate for Payer: Priority Health SBD |
$164.96
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$5.24
|
|
|
Service Code
|
NDC 50268010511
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Aetna Medicare |
$2.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.41
|
| Rate for Payer: BCBS Complete |
$2.10
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Cofinity Commercial |
$4.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.19
|
| Rate for Payer: Healthscope Commercial |
$4.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.45
|
| Rate for Payer: PHP Commercial |
$4.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.41
|
| Rate for Payer: Priority Health SBD |
$3.30
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$5.24
|
|
|
Service Code
|
NDC 50268010511
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.41
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Cofinity Commercial |
$4.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.19
|
| Rate for Payer: Healthscope Commercial |
$4.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.45
|
| Rate for Payer: PHP Commercial |
$4.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.41
|
| Rate for Payer: Priority Health SBD |
$3.30
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH
|
Facility
|
OP
|
$88.62
|
|
|
Service Code
|
NDC 00065053001
|
| Hospital Charge Code |
10780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.45 |
| Max. Negotiated Rate |
$79.76 |
| Rate for Payer: Aetna Commercial |
$75.33
|
| Rate for Payer: Aetna Medicare |
$44.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.60
|
| Rate for Payer: BCBS Complete |
$35.45
|
| Rate for Payer: Cash Price |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$62.03
|
| Rate for Payer: Cofinity Commercial |
$76.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.90
|
| Rate for Payer: Healthscope Commercial |
$79.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.33
|
| Rate for Payer: PHP Commercial |
$75.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.60
|
| Rate for Payer: Priority Health SBD |
$55.83
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH
|
Facility
|
IP
|
$88.62
|
|
|
Service Code
|
NDC 00065053001
|
| Hospital Charge Code |
10780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$79.76 |
| Rate for Payer: Aetna Commercial |
$75.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.60
|
| Rate for Payer: Cash Price |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$62.03
|
| Rate for Payer: Cofinity Commercial |
$76.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.90
|
| Rate for Payer: Healthscope Commercial |
$79.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.33
|
| Rate for Payer: PHP Commercial |
$75.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.60
|
| Rate for Payer: Priority Health SBD |
$55.83
|
|
|
BARICITINIB 2 MG TABLET
|
Facility
|
IP
|
$9,736.26
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
186973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,133.84 |
| Max. Negotiated Rate |
$8,762.63 |
| Rate for Payer: Aetna Commercial |
$8,275.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,328.57
|
| Rate for Payer: Cash Price |
$7,789.01
|
| Rate for Payer: Cofinity Commercial |
$6,815.38
|
| Rate for Payer: Cofinity Commercial |
$8,373.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,815.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,789.01
|
| Rate for Payer: Healthscope Commercial |
$8,762.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,275.82
|
| Rate for Payer: PHP Commercial |
$8,275.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,328.57
|
| Rate for Payer: Priority Health SBD |
$6,133.84
|
|
|
BARICITINIB 2 MG TABLET
|
Facility
|
OP
|
$9,736.26
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
186973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,894.50 |
| Max. Negotiated Rate |
$8,762.63 |
| Rate for Payer: Aetna Commercial |
$8,275.82
|
| Rate for Payer: Aetna Medicare |
$4,868.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,328.57
|
| Rate for Payer: BCBS Complete |
$3,894.50
|
| Rate for Payer: Cash Price |
$7,789.01
|
| Rate for Payer: Cofinity Commercial |
$6,815.38
|
| Rate for Payer: Cofinity Commercial |
$8,373.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,815.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,789.01
|
| Rate for Payer: Healthscope Commercial |
$8,762.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,275.82
|
| Rate for Payer: PHP Commercial |
$8,275.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,328.57
|
| Rate for Payer: Priority Health SBD |
$6,133.84
|
|