|
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18,548.19
|
|
|
Service Code
|
HCPCS J9177
|
| Hospital Charge Code |
192401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.16 |
| Max. Negotiated Rate |
$16,693.37 |
| Rate for Payer: Aetna Commercial |
$15,765.96
|
| Rate for Payer: Aetna Medicare |
$36.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,056.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$43.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$43.78
|
| Rate for Payer: BCBS Complete |
$20.12
|
| Rate for Payer: BCBS MAPPO |
$35.03
|
| Rate for Payer: BCBS Trust/PPO |
$103.68
|
| Rate for Payer: BCN Medicare Advantage |
$35.03
|
| Rate for Payer: Cash Price |
$14,838.55
|
| Rate for Payer: Cash Price |
$14,838.55
|
| Rate for Payer: Cofinity Commercial |
$12,983.73
|
| Rate for Payer: Cofinity Commercial |
$15,951.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35.03
|
| Rate for Payer: Healthscope Commercial |
$16,693.37
|
| Rate for Payer: Mclaren Medicaid |
$19.16
|
| Rate for Payer: Mclaren Medicare |
$35.03
|
| Rate for Payer: Meridian Medicaid |
$20.12
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$36.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15,765.96
|
| Rate for Payer: PACE Medicare |
$33.28
|
| Rate for Payer: PACE SWMI |
$35.03
|
| Rate for Payer: PHP Commercial |
$15,765.96
|
| Rate for Payer: PHP Medicare Advantage |
$35.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,983.73
|
| Rate for Payer: Priority Health Medicare |
$35.03
|
| Rate for Payer: Priority Health SBD |
$11,685.36
|
| Rate for Payer: Railroad Medicare Medicare |
$35.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$35.03
|
| Rate for Payer: UHC Medicare Advantage |
$36.08
|
| Rate for Payer: VA VA |
$35.03
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$38.12
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.02 |
| Max. Negotiated Rate |
$34.31 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Commercial |
$87.37
|
| Rate for Payer: Aetna Commercial |
$38.04
|
| Rate for Payer: Aetna Commercial |
$32.72
|
| Rate for Payer: Aetna Commercial |
$75.17
|
| Rate for Payer: Aetna Commercial |
$32.59
|
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.29
|
| Rate for Payer: Cash Price |
$70.75
|
| Rate for Payer: Cash Price |
$82.23
|
| Rate for Payer: Cash Price |
$26.21
|
| Rate for Payer: Cash Price |
$30.50
|
| Rate for Payer: Cash Price |
$35.80
|
| Rate for Payer: Cash Price |
$30.67
|
| Rate for Payer: Cash Price |
$30.79
|
| Rate for Payer: Cofinity Commercial |
$61.91
|
| Rate for Payer: Cofinity Commercial |
$31.32
|
| Rate for Payer: Cofinity Commercial |
$38.48
|
| Rate for Payer: Cofinity Commercial |
$33.10
|
| Rate for Payer: Cofinity Commercial |
$26.94
|
| Rate for Payer: Cofinity Commercial |
$71.95
|
| Rate for Payer: Cofinity Commercial |
$88.40
|
| Rate for Payer: Cofinity Commercial |
$28.17
|
| Rate for Payer: Cofinity Commercial |
$22.93
|
| Rate for Payer: Cofinity Commercial |
$32.78
|
| Rate for Payer: Cofinity Commercial |
$76.06
|
| Rate for Payer: Cofinity Commercial |
$26.68
|
| Rate for Payer: Cofinity Commercial |
$26.84
|
| Rate for Payer: Cofinity Commercial |
$32.97
|
| Rate for Payer: Healthscope Commercial |
$29.48
|
| Rate for Payer: Healthscope Commercial |
$34.64
|
| Rate for Payer: Healthscope Commercial |
$34.31
|
| Rate for Payer: Healthscope Commercial |
$79.60
|
| Rate for Payer: Healthscope Commercial |
$40.28
|
| Rate for Payer: Healthscope Commercial |
$34.51
|
| Rate for Payer: Healthscope Commercial |
$92.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.85
|
| Rate for Payer: PHP Commercial |
$32.59
|
| Rate for Payer: PHP Commercial |
$87.37
|
| Rate for Payer: PHP Commercial |
$27.85
|
| Rate for Payer: PHP Commercial |
$32.40
|
| Rate for Payer: PHP Commercial |
$32.72
|
| Rate for Payer: PHP Commercial |
$38.04
|
| Rate for Payer: PHP Commercial |
$75.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.68
|
| Rate for Payer: Priority Health SBD |
$24.02
|
| Rate for Payer: Priority Health SBD |
$20.64
|
| Rate for Payer: Priority Health SBD |
$64.76
|
| Rate for Payer: Priority Health SBD |
$24.25
|
| Rate for Payer: Priority Health SBD |
$55.72
|
| Rate for Payer: Priority Health SBD |
$24.15
|
| Rate for Payer: Priority Health SBD |
$28.19
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$44.75
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$40.28 |
| Rate for Payer: Aetna Commercial |
$38.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.09
|
| Rate for Payer: BCBS Complete |
$17.90
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$35.80
|
| Rate for Payer: Cash Price |
$35.80
|
| Rate for Payer: Cofinity Commercial |
$31.32
|
| Rate for Payer: Cofinity Commercial |
$38.48
|
| Rate for Payer: Healthscope Commercial |
$40.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.04
|
| Rate for Payer: PHP Commercial |
$38.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.32
|
| Rate for Payer: Priority Health SBD |
$28.19
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$123.39
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.74 |
| Max. Negotiated Rate |
$111.05 |
| Rate for Payer: Aetna Commercial |
$104.88
|
| Rate for Payer: Aetna Commercial |
$33.36
|
| Rate for Payer: Aetna Commercial |
$38.56
|
| Rate for Payer: Aetna Commercial |
$38.77
|
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.51
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cash Price |
$98.71
|
| Rate for Payer: Cash Price |
$31.40
|
| Rate for Payer: Cash Price |
$60.88
|
| Rate for Payer: Cash Price |
$36.49
|
| Rate for Payer: Cofinity Commercial |
$31.93
|
| Rate for Payer: Cofinity Commercial |
$106.12
|
| Rate for Payer: Cofinity Commercial |
$86.37
|
| Rate for Payer: Cofinity Commercial |
$27.48
|
| Rate for Payer: Cofinity Commercial |
$33.76
|
| Rate for Payer: Cofinity Commercial |
$31.75
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Cofinity Commercial |
$39.22
|
| Rate for Payer: Cofinity Commercial |
$53.27
|
| Rate for Payer: Cofinity Commercial |
$65.45
|
| Rate for Payer: Healthscope Commercial |
$41.05
|
| Rate for Payer: Healthscope Commercial |
$40.82
|
| Rate for Payer: Healthscope Commercial |
$35.32
|
| Rate for Payer: Healthscope Commercial |
$68.49
|
| Rate for Payer: Healthscope Commercial |
$111.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$64.68
|
| Rate for Payer: PHP Commercial |
$64.68
|
| Rate for Payer: PHP Commercial |
$38.56
|
| Rate for Payer: PHP Commercial |
$38.77
|
| Rate for Payer: PHP Commercial |
$104.88
|
| Rate for Payer: PHP Commercial |
$33.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.27
|
| Rate for Payer: Priority Health SBD |
$28.73
|
| Rate for Payer: Priority Health SBD |
$77.74
|
| Rate for Payer: Priority Health SBD |
$28.58
|
| Rate for Payer: Priority Health SBD |
$47.94
|
| Rate for Payer: Priority Health SBD |
$24.73
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$123.39
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$111.05 |
| Rate for Payer: Aetna Commercial |
$104.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.20
|
| Rate for Payer: BCBS Complete |
$49.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$98.71
|
| Rate for Payer: Cash Price |
$98.71
|
| Rate for Payer: Cofinity Commercial |
$106.12
|
| Rate for Payer: Cofinity Commercial |
$86.37
|
| Rate for Payer: Healthscope Commercial |
$111.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.88
|
| Rate for Payer: PHP Commercial |
$104.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.37
|
| Rate for Payer: Priority Health SBD |
$77.74
|
|
|
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$154.23
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
31921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.16 |
| Max. Negotiated Rate |
$138.81 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Commercial |
$79.15
|
| Rate for Payer: Aetna Commercial |
$117.97
|
| Rate for Payer: Aetna Commercial |
$48.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.53
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cash Price |
$45.68
|
| Rate for Payer: Cash Price |
$123.38
|
| Rate for Payer: Cash Price |
$111.03
|
| Rate for Payer: Cofinity Commercial |
$80.08
|
| Rate for Payer: Cofinity Commercial |
$119.36
|
| Rate for Payer: Cofinity Commercial |
$97.15
|
| Rate for Payer: Cofinity Commercial |
$107.96
|
| Rate for Payer: Cofinity Commercial |
$132.64
|
| Rate for Payer: Cofinity Commercial |
$39.97
|
| Rate for Payer: Cofinity Commercial |
$49.11
|
| Rate for Payer: Cofinity Commercial |
$65.18
|
| Rate for Payer: Healthscope Commercial |
$51.39
|
| Rate for Payer: Healthscope Commercial |
$83.81
|
| Rate for Payer: Healthscope Commercial |
$138.81
|
| Rate for Payer: Healthscope Commercial |
$124.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.15
|
| Rate for Payer: PHP Commercial |
$79.15
|
| Rate for Payer: PHP Commercial |
$131.10
|
| Rate for Payer: PHP Commercial |
$48.54
|
| Rate for Payer: PHP Commercial |
$117.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.96
|
| Rate for Payer: Priority Health SBD |
$87.44
|
| Rate for Payer: Priority Health SBD |
$97.16
|
| Rate for Payer: Priority Health SBD |
$58.67
|
| Rate for Payer: Priority Health SBD |
$35.97
|
|
|
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$154.23
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
31921
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$138.81 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.25
|
| Rate for Payer: BCBS Complete |
$61.69
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$123.38
|
| Rate for Payer: Cash Price |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$107.96
|
| Rate for Payer: Cofinity Commercial |
$132.64
|
| Rate for Payer: Healthscope Commercial |
$138.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.10
|
| Rate for Payer: PHP Commercial |
$131.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.96
|
| Rate for Payer: Priority Health SBD |
$97.16
|
|
|
ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$821.23
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.37 |
| Max. Negotiated Rate |
$739.11 |
| Rate for Payer: Aetna Commercial |
$698.05
|
| Rate for Payer: Aetna Commercial |
$121.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$533.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.53
|
| Rate for Payer: Cash Price |
$656.98
|
| Rate for Payer: Cash Price |
$113.89
|
| Rate for Payer: Cofinity Commercial |
$99.65
|
| Rate for Payer: Cofinity Commercial |
$122.43
|
| Rate for Payer: Cofinity Commercial |
$574.86
|
| Rate for Payer: Cofinity Commercial |
$706.26
|
| Rate for Payer: Healthscope Commercial |
$128.12
|
| Rate for Payer: Healthscope Commercial |
$739.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$698.05
|
| Rate for Payer: PHP Commercial |
$121.01
|
| Rate for Payer: PHP Commercial |
$698.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$574.86
|
| Rate for Payer: Priority Health SBD |
$517.37
|
| Rate for Payer: Priority Health SBD |
$89.69
|
|
|
ENOXAPARIN 300 MG/3 ML SUBCUTANEOUS SOLUTION (CUSTOM)
|
Facility
|
IP
|
$142.36
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
301239
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.69 |
| Max. Negotiated Rate |
$128.12 |
| Rate for Payer: Aetna Commercial |
$121.01
|
| Rate for Payer: Aetna Commercial |
$698.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$533.80
|
| Rate for Payer: Cash Price |
$656.98
|
| Rate for Payer: Cash Price |
$113.89
|
| Rate for Payer: Cofinity Commercial |
$99.65
|
| Rate for Payer: Cofinity Commercial |
$122.43
|
| Rate for Payer: Cofinity Commercial |
$706.26
|
| Rate for Payer: Cofinity Commercial |
$574.86
|
| Rate for Payer: Healthscope Commercial |
$128.12
|
| Rate for Payer: Healthscope Commercial |
$739.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$698.05
|
| Rate for Payer: PHP Commercial |
$698.05
|
| Rate for Payer: PHP Commercial |
$121.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$574.86
|
| Rate for Payer: Priority Health SBD |
$89.69
|
| Rate for Payer: Priority Health SBD |
$517.37
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$18.28
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105899
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$16.45 |
| Rate for Payer: Aetna Commercial |
$15.54
|
| Rate for Payer: Aetna Commercial |
$13.71
|
| Rate for Payer: Aetna Commercial |
$20.97
|
| Rate for Payer: Aetna Commercial |
$26.18
|
| Rate for Payer: Aetna Commercial |
$18.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.04
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cash Price |
$24.64
|
| Rate for Payer: Cash Price |
$14.62
|
| Rate for Payer: Cash Price |
$19.74
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Cofinity Commercial |
$21.56
|
| Rate for Payer: Cofinity Commercial |
$15.20
|
| Rate for Payer: Cofinity Commercial |
$21.22
|
| Rate for Payer: Cofinity Commercial |
$17.27
|
| Rate for Payer: Cofinity Commercial |
$18.68
|
| Rate for Payer: Cofinity Commercial |
$26.49
|
| Rate for Payer: Cofinity Commercial |
$13.87
|
| Rate for Payer: Cofinity Commercial |
$12.80
|
| Rate for Payer: Cofinity Commercial |
$15.72
|
| Rate for Payer: Healthscope Commercial |
$27.72
|
| Rate for Payer: Healthscope Commercial |
$14.52
|
| Rate for Payer: Healthscope Commercial |
$16.45
|
| Rate for Payer: Healthscope Commercial |
$19.55
|
| Rate for Payer: Healthscope Commercial |
$22.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.46
|
| Rate for Payer: PHP Commercial |
$20.97
|
| Rate for Payer: PHP Commercial |
$15.54
|
| Rate for Payer: PHP Commercial |
$13.71
|
| Rate for Payer: PHP Commercial |
$26.18
|
| Rate for Payer: PHP Commercial |
$18.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.56
|
| Rate for Payer: Priority Health SBD |
$15.54
|
| Rate for Payer: Priority Health SBD |
$13.68
|
| Rate for Payer: Priority Health SBD |
$11.52
|
| Rate for Payer: Priority Health SBD |
$19.40
|
| Rate for Payer: Priority Health SBD |
$10.16
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$30.80
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105899
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$27.72 |
| Rate for Payer: Aetna Commercial |
$26.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.02
|
| Rate for Payer: BCBS Complete |
$12.32
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$24.64
|
| Rate for Payer: Cash Price |
$24.64
|
| Rate for Payer: Cofinity Commercial |
$26.49
|
| Rate for Payer: Cofinity Commercial |
$21.56
|
| Rate for Payer: Healthscope Commercial |
$27.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.18
|
| Rate for Payer: PHP Commercial |
$26.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.56
|
| Rate for Payer: Priority Health SBD |
$19.40
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$19.81
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105900
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$17.83 |
| Rate for Payer: Aetna Commercial |
$16.84
|
| Rate for Payer: Aetna Commercial |
$16.80
|
| Rate for Payer: Aetna Commercial |
$21.12
|
| Rate for Payer: Aetna Commercial |
$34.91
|
| Rate for Payer: Aetna Commercial |
$21.14
|
| Rate for Payer: Aetna Commercial |
$28.12
|
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Aetna Commercial |
$21.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.11
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$15.85
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Cash Price |
$20.30
|
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$32.86
|
| Rate for Payer: Cash Price |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$16.99
|
| Rate for Payer: Cofinity Commercial |
$13.83
|
| Rate for Payer: Cofinity Commercial |
$13.87
|
| Rate for Payer: Cofinity Commercial |
$17.04
|
| Rate for Payer: Cofinity Commercial |
$17.35
|
| Rate for Payer: Cofinity Commercial |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$17.40
|
| Rate for Payer: Cofinity Commercial |
$21.37
|
| Rate for Payer: Cofinity Commercial |
$17.41
|
| Rate for Payer: Cofinity Commercial |
$21.39
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$21.82
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Cofinity Commercial |
$28.45
|
| Rate for Payer: Cofinity Commercial |
$28.75
|
| Rate for Payer: Cofinity Commercial |
$35.32
|
| Rate for Payer: Healthscope Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$17.83
|
| Rate for Payer: Healthscope Commercial |
$36.96
|
| Rate for Payer: Healthscope Commercial |
$22.83
|
| Rate for Payer: Healthscope Commercial |
$29.77
|
| Rate for Payer: Healthscope Commercial |
$22.38
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$17.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.12
|
| Rate for Payer: PHP Commercial |
$28.12
|
| Rate for Payer: PHP Commercial |
$21.56
|
| Rate for Payer: PHP Commercial |
$16.80
|
| Rate for Payer: PHP Commercial |
$21.12
|
| Rate for Payer: PHP Commercial |
$21.07
|
| Rate for Payer: PHP Commercial |
$34.91
|
| Rate for Payer: PHP Commercial |
$21.14
|
| Rate for Payer: PHP Commercial |
$16.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.40
|
| Rate for Payer: Priority Health SBD |
$12.45
|
| Rate for Payer: Priority Health SBD |
$20.84
|
| Rate for Payer: Priority Health SBD |
$12.48
|
| Rate for Payer: Priority Health SBD |
$25.87
|
| Rate for Payer: Priority Health SBD |
$15.66
|
| Rate for Payer: Priority Health SBD |
$15.62
|
| Rate for Payer: Priority Health SBD |
$15.98
|
| Rate for Payer: Priority Health SBD |
$15.67
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$41.07
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105900
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$36.96 |
| Rate for Payer: Aetna Commercial |
$34.91
|
| Rate for Payer: Aetna Commercial |
$28.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.50
|
| Rate for Payer: BCBS Complete |
$13.23
|
| Rate for Payer: BCBS Complete |
$16.43
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$26.46
|
| Rate for Payer: Cash Price |
$32.86
|
| Rate for Payer: Cash Price |
$32.86
|
| Rate for Payer: Cash Price |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$28.75
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Cofinity Commercial |
$28.45
|
| Rate for Payer: Cofinity Commercial |
$35.32
|
| Rate for Payer: Healthscope Commercial |
$36.96
|
| Rate for Payer: Healthscope Commercial |
$29.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.91
|
| Rate for Payer: PHP Commercial |
$28.12
|
| Rate for Payer: PHP Commercial |
$34.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.16
|
| Rate for Payer: Priority Health SBD |
$25.87
|
| Rate for Payer: Priority Health SBD |
$20.84
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$38.05
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.97 |
| Max. Negotiated Rate |
$34.24 |
| Rate for Payer: Aetna Commercial |
$32.34
|
| Rate for Payer: Aetna Commercial |
$17.11
|
| Rate for Payer: Aetna Commercial |
$31.60
|
| Rate for Payer: Aetna Commercial |
$52.43
|
| Rate for Payer: Aetna Commercial |
$18.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.17
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$49.34
|
| Rate for Payer: Cash Price |
$29.74
|
| Rate for Payer: Cash Price |
$30.44
|
| Rate for Payer: Cash Price |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$32.72
|
| Rate for Payer: Cofinity Commercial |
$14.09
|
| Rate for Payer: Cofinity Commercial |
$26.64
|
| Rate for Payer: Cofinity Commercial |
$26.03
|
| Rate for Payer: Cofinity Commercial |
$31.97
|
| Rate for Payer: Cofinity Commercial |
$53.04
|
| Rate for Payer: Cofinity Commercial |
$17.31
|
| Rate for Payer: Cofinity Commercial |
$15.24
|
| Rate for Payer: Cofinity Commercial |
$18.72
|
| Rate for Payer: Cofinity Commercial |
$43.18
|
| Rate for Payer: Healthscope Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$19.59
|
| Rate for Payer: Healthscope Commercial |
$34.24
|
| Rate for Payer: Healthscope Commercial |
$55.51
|
| Rate for Payer: Healthscope Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.43
|
| Rate for Payer: PHP Commercial |
$31.60
|
| Rate for Payer: PHP Commercial |
$32.34
|
| Rate for Payer: PHP Commercial |
$18.50
|
| Rate for Payer: PHP Commercial |
$17.11
|
| Rate for Payer: PHP Commercial |
$52.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.24
|
| Rate for Payer: Priority Health SBD |
$23.97
|
| Rate for Payer: Priority Health SBD |
$38.86
|
| Rate for Payer: Priority Health SBD |
$12.68
|
| Rate for Payer: Priority Health SBD |
$23.42
|
| Rate for Payer: Priority Health SBD |
$13.72
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$61.68
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$55.51 |
| Rate for Payer: Aetna Commercial |
$52.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.09
|
| Rate for Payer: BCBS Complete |
$24.67
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$49.34
|
| Rate for Payer: Cash Price |
$49.34
|
| Rate for Payer: Cofinity Commercial |
$43.18
|
| Rate for Payer: Cofinity Commercial |
$53.04
|
| Rate for Payer: Healthscope Commercial |
$55.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.43
|
| Rate for Payer: PHP Commercial |
$52.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.18
|
| Rate for Payer: Priority Health SBD |
$38.86
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$25.36
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.98 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Aetna Commercial |
$21.84
|
| Rate for Payer: Aetna Commercial |
$60.13
|
| Rate for Payer: Aetna Commercial |
$43.12
|
| Rate for Payer: Aetna Commercial |
$69.90
|
| Rate for Payer: Aetna Commercial |
$53.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.98
|
| Rate for Payer: Cash Price |
$20.55
|
| Rate for Payer: Cash Price |
$49.92
|
| Rate for Payer: Cash Price |
$56.59
|
| Rate for Payer: Cash Price |
$20.29
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cash Price |
$65.78
|
| Rate for Payer: Cofinity Commercial |
$49.52
|
| Rate for Payer: Cofinity Commercial |
$53.66
|
| Rate for Payer: Cofinity Commercial |
$17.75
|
| Rate for Payer: Cofinity Commercial |
$43.68
|
| Rate for Payer: Cofinity Commercial |
$70.72
|
| Rate for Payer: Cofinity Commercial |
$35.51
|
| Rate for Payer: Cofinity Commercial |
$43.63
|
| Rate for Payer: Cofinity Commercial |
$17.98
|
| Rate for Payer: Cofinity Commercial |
$22.09
|
| Rate for Payer: Cofinity Commercial |
$57.56
|
| Rate for Payer: Cofinity Commercial |
$21.81
|
| Rate for Payer: Cofinity Commercial |
$60.84
|
| Rate for Payer: Healthscope Commercial |
$45.66
|
| Rate for Payer: Healthscope Commercial |
$22.82
|
| Rate for Payer: Healthscope Commercial |
$23.12
|
| Rate for Payer: Healthscope Commercial |
$56.16
|
| Rate for Payer: Healthscope Commercial |
$63.67
|
| Rate for Payer: Healthscope Commercial |
$74.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.13
|
| Rate for Payer: PHP Commercial |
$60.13
|
| Rate for Payer: PHP Commercial |
$21.56
|
| Rate for Payer: PHP Commercial |
$69.90
|
| Rate for Payer: PHP Commercial |
$21.84
|
| Rate for Payer: PHP Commercial |
$43.12
|
| Rate for Payer: PHP Commercial |
$53.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.56
|
| Rate for Payer: Priority Health SBD |
$31.96
|
| Rate for Payer: Priority Health SBD |
$51.80
|
| Rate for Payer: Priority Health SBD |
$39.31
|
| Rate for Payer: Priority Health SBD |
$16.18
|
| Rate for Payer: Priority Health SBD |
$15.98
|
| Rate for Payer: Priority Health SBD |
$44.57
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$82.23
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$74.01 |
| Rate for Payer: Aetna Commercial |
$69.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.45
|
| Rate for Payer: BCBS Complete |
$32.89
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| Rate for Payer: Cash Price |
$65.78
|
| Rate for Payer: Cash Price |
$65.78
|
| Rate for Payer: Cofinity Commercial |
$70.72
|
| Rate for Payer: Cofinity Commercial |
$57.56
|
| Rate for Payer: Healthscope Commercial |
$74.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.90
|
| Rate for Payer: PHP Commercial |
$69.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.56
|
| Rate for Payer: Priority Health SBD |
$51.80
|
|
|
ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$14.17
|
|
|
Service Code
|
NDC 60687-188-11
|
| Hospital Charge Code |
26547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.93 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna Commercial |
$12.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.21
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$12.19
|
| Rate for Payer: Cofinity Commercial |
$9.92
|
| Rate for Payer: Healthscope Commercial |
$12.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.04
|
| Rate for Payer: PHP Commercial |
$12.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.92
|
| Rate for Payer: Priority Health SBD |
$8.93
|
|
|
ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$425.02
|
|
|
Service Code
|
NDC 60687-188-21
|
| Hospital Charge Code |
26547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.76 |
| Max. Negotiated Rate |
$382.52 |
| Rate for Payer: Aetna Commercial |
$361.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.26
|
| Rate for Payer: Cash Price |
$340.02
|
| Rate for Payer: Cofinity Commercial |
$297.51
|
| Rate for Payer: Cofinity Commercial |
$365.52
|
| Rate for Payer: Healthscope Commercial |
$382.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.27
|
| Rate for Payer: PHP Commercial |
$361.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.51
|
| Rate for Payer: Priority Health SBD |
$267.76
|
|
|
ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$2,650.31
|
|
|
Service Code
|
NDC 0078-0327-05
|
| Hospital Charge Code |
26547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,669.70 |
| Max. Negotiated Rate |
$2,385.28 |
| Rate for Payer: Aetna Commercial |
$2,252.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,722.70
|
| Rate for Payer: Cash Price |
$2,120.25
|
| Rate for Payer: Cofinity Commercial |
$1,855.22
|
| Rate for Payer: Cofinity Commercial |
$2,279.27
|
| Rate for Payer: Healthscope Commercial |
$2,385.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,252.76
|
| Rate for Payer: PHP Commercial |
$2,252.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,855.22
|
| Rate for Payer: Priority Health SBD |
$1,669.70
|
|
|
ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$250.08
|
|
|
Service Code
|
NDC 65862-654-01
|
| Hospital Charge Code |
26547
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.55 |
| Max. Negotiated Rate |
$225.07 |
| Rate for Payer: Aetna Commercial |
$212.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.55
|
| Rate for Payer: Cash Price |
$200.06
|
| Rate for Payer: Cofinity Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Healthscope Commercial |
$225.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.57
|
| Rate for Payer: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.06
|
| Rate for Payer: Priority Health SBD |
$157.55
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$41.39
|
|
|
Service Code
|
NDC 0641-6238-25
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cofinity Commercial |
$28.97
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.18
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.97
|
| Rate for Payer: Priority Health SBD |
$26.08
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$45.68
|
|
|
Service Code
|
NDC 76014-005-25
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$41.11 |
| Rate for Payer: Aetna Commercial |
$38.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.69
|
| Rate for Payer: Cash Price |
$36.54
|
| Rate for Payer: Cofinity Commercial |
$31.98
|
| Rate for Payer: Cofinity Commercial |
$39.28
|
| Rate for Payer: Healthscope Commercial |
$41.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.83
|
| Rate for Payer: PHP Commercial |
$38.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.98
|
| Rate for Payer: Priority Health SBD |
$28.78
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$34.71
|
|
|
Service Code
|
NDC 70121-1637-5
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.87 |
| Max. Negotiated Rate |
$31.24 |
| Rate for Payer: Aetna Commercial |
$29.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.56
|
| Rate for Payer: Cash Price |
$27.77
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Commercial |
$29.85
|
| Rate for Payer: Healthscope Commercial |
$31.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.50
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.30
|
| Rate for Payer: Priority Health SBD |
$21.87
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.11
|
|
|
Service Code
|
NDC 55150-373-01
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$25.30 |
| Rate for Payer: Aetna Commercial |
$23.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.27
|
| Rate for Payer: Cash Price |
$22.49
|
| Rate for Payer: Cofinity Commercial |
$19.68
|
| Rate for Payer: Cofinity Commercial |
$24.17
|
| Rate for Payer: Healthscope Commercial |
$25.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.89
|
| Rate for Payer: PHP Commercial |
$23.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.68
|
| Rate for Payer: Priority Health SBD |
$17.71
|
|
