|
AMLODIPINE 2.5 MG TABLET
|
Facility
IP
|
$195.05
|
|
|
Service Code
|
NDC 0904-6369-61
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.88 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| Rate for Payer: Priority Health SBD |
$122.88
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
OP
|
$164.50
|
|
|
Service Code
|
NDC 0904-6370-61
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.92
|
| Rate for Payer: BCBS Complete |
$65.80
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$115.15
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: Priority Health SBD |
$103.64
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$164.50
|
|
|
Service Code
|
NDC 0904-6370-61
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.92
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$115.15
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: Priority Health SBD |
$103.64
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$1.27
|
|
|
Service Code
|
NDC 50268-084-11
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna Commercial |
$1.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.83
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cofinity Commercial |
$0.89
|
| Rate for Payer: Cofinity Commercial |
$1.09
|
| Rate for Payer: Healthscope Commercial |
$1.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.08
|
| Rate for Payer: PHP Commercial |
$1.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.89
|
| Rate for Payer: Priority Health SBD |
$0.80
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$1.84
|
|
|
Service Code
|
NDC 51079-451-01
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna Commercial |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.20
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Commercial |
$1.58
|
| Rate for Payer: Healthscope Commercial |
$1.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.56
|
| Rate for Payer: PHP Commercial |
$1.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.29
|
| Rate for Payer: Priority Health SBD |
$1.16
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$63.45
|
|
|
Service Code
|
NDC 50268-084-15
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.97 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.42
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.42
|
| Rate for Payer: Priority Health SBD |
$39.97
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
IP
|
$26.22
|
|
|
Service Code
|
NDC 4580252555
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$23.60 |
| Rate for Payer: Aetna Commercial |
$22.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
| Rate for Payer: Cash Price |
$20.98
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Cofinity Commercial |
$22.55
|
| Rate for Payer: Healthscope Commercial |
$23.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.29
|
| Rate for Payer: PHP Commercial |
$22.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
| Rate for Payer: Priority Health SBD |
$16.52
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$82.25
|
|
|
Service Code
|
NDC 0093-4155-73
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.82 |
| Max. Negotiated Rate |
$74.02 |
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.46
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Healthscope Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: Priority Health SBD |
$51.82
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$77.55
|
|
|
Service Code
|
NDC 0781-6041-46
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.86 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: Priority Health SBD |
$48.86
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$67.68
|
|
|
Service Code
|
NDC 0781-6041-58
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.64 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.99
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$47.38
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Healthscope Commercial |
$60.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.53
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health SBD |
$42.64
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$8.23
|
|
|
Service Code
|
NDC 9900-0011-17
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Aetna Commercial |
$7.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.35
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cofinity Commercial |
$5.76
|
| Rate for Payer: Cofinity Commercial |
$7.08
|
| Rate for Payer: Healthscope Commercial |
$7.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.00
|
| Rate for Payer: PHP Commercial |
$7.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.76
|
| Rate for Payer: Priority Health SBD |
$5.18
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
IP
|
$159.80
|
|
|
Service Code
|
NDC 0781-2020-01
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.67 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.87
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$111.86
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: Priority Health SBD |
$100.67
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
IP
|
$142.18
|
|
|
Service Code
|
NDC 0093-3109-53
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.57 |
| Max. Negotiated Rate |
$127.96 |
| Rate for Payer: Aetna Commercial |
$120.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.42
|
| Rate for Payer: Cash Price |
$113.74
|
| Rate for Payer: Cofinity Commercial |
$122.27
|
| Rate for Payer: Cofinity Commercial |
$99.53
|
| Rate for Payer: Healthscope Commercial |
$127.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.85
|
| Rate for Payer: PHP Commercial |
$120.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.53
|
| Rate for Payer: Priority Health SBD |
$89.57
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
IP
|
$227.95
|
|
|
Service Code
|
NDC 0781-2613-01
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.61 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$193.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.17
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Commercial |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Healthscope Commercial |
$205.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.76
|
| Rate for Payer: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.56
|
| Rate for Payer: Priority Health SBD |
$143.61
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$52.82
|
|
|
Service Code
|
NDC 0093-2274-34
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.28 |
| Max. Negotiated Rate |
$47.54 |
| Rate for Payer: Aetna Commercial |
$44.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.33
|
| Rate for Payer: Cash Price |
$42.26
|
| Rate for Payer: Cofinity Commercial |
$36.97
|
| Rate for Payer: Cofinity Commercial |
$45.43
|
| Rate for Payer: Healthscope Commercial |
$47.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.90
|
| Rate for Payer: PHP Commercial |
$44.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.97
|
| Rate for Payer: Priority Health SBD |
$33.28
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$195.64
|
|
|
Service Code
|
NDC 65862-535-75
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.25 |
| Max. Negotiated Rate |
$176.08 |
| Rate for Payer: Aetna Commercial |
$166.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$127.17
|
| Rate for Payer: Cash Price |
$156.51
|
| Rate for Payer: Cofinity Commercial |
$136.95
|
| Rate for Payer: Cofinity Commercial |
$168.25
|
| Rate for Payer: Healthscope Commercial |
$176.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$166.29
|
| Rate for Payer: PHP Commercial |
$166.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.95
|
| Rate for Payer: Priority Health SBD |
$123.25
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$509.28
|
|
|
Service Code
|
NDC 66685-1001-1
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$320.85 |
| Max. Negotiated Rate |
$458.35 |
| Rate for Payer: Aetna Commercial |
$432.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$331.03
|
| Rate for Payer: Cash Price |
$407.42
|
| Rate for Payer: Cofinity Commercial |
$356.50
|
| Rate for Payer: Cofinity Commercial |
$437.98
|
| Rate for Payer: Healthscope Commercial |
$458.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$432.89
|
| Rate for Payer: PHP Commercial |
$432.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.50
|
| Rate for Payer: Priority Health SBD |
$320.85
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$64.03
|
|
|
Service Code
|
NDC 65862-503-20
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.34 |
| Max. Negotiated Rate |
$57.63 |
| Rate for Payer: Aetna Commercial |
$54.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.62
|
| Rate for Payer: Cash Price |
$51.22
|
| Rate for Payer: Cofinity Commercial |
$44.82
|
| Rate for Payer: Cofinity Commercial |
$55.07
|
| Rate for Payer: Healthscope Commercial |
$57.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.43
|
| Rate for Payer: PHP Commercial |
$54.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.82
|
| Rate for Payer: Priority Health SBD |
$40.34
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$101.28
|
|
|
Service Code
|
NDC 66685-1001-0
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.81 |
| Max. Negotiated Rate |
$91.15 |
| Rate for Payer: Aetna Commercial |
$86.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.83
|
| Rate for Payer: Cash Price |
$81.02
|
| Rate for Payer: Cofinity Commercial |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$87.10
|
| Rate for Payer: Healthscope Commercial |
$91.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.09
|
| Rate for Payer: PHP Commercial |
$86.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.90
|
| Rate for Payer: Priority Health SBD |
$63.81
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$54.72
|
|
|
Service Code
|
NDC 42571-162-42
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.47 |
| Max. Negotiated Rate |
$49.25 |
| Rate for Payer: Aetna Commercial |
$46.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.57
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Cofinity Commercial |
$38.30
|
| Rate for Payer: Cofinity Commercial |
$47.06
|
| Rate for Payer: Healthscope Commercial |
$49.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.51
|
| Rate for Payer: PHP Commercial |
$46.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.30
|
| Rate for Payer: Priority Health SBD |
$34.47
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$62.13
|
|
|
Service Code
|
NDC 0093-2275-34
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.14 |
| Max. Negotiated Rate |
$55.92 |
| Rate for Payer: Aetna Commercial |
$52.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.38
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: Cofinity Commercial |
$43.49
|
| Rate for Payer: Cofinity Commercial |
$53.43
|
| Rate for Payer: Healthscope Commercial |
$55.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.81
|
| Rate for Payer: PHP Commercial |
$52.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.49
|
| Rate for Payer: Priority Health SBD |
$39.14
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION
|
Facility
IP
|
$331.26
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
21900
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$208.69 |
| Max. Negotiated Rate |
$298.13 |
| Rate for Payer: Aetna Commercial |
$281.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.32
|
| Rate for Payer: Cash Price |
$265.01
|
| Rate for Payer: Cofinity Commercial |
$231.88
|
| Rate for Payer: Cofinity Commercial |
$284.88
|
| Rate for Payer: Healthscope Commercial |
$298.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.57
|
| Rate for Payer: PHP Commercial |
$281.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.88
|
| Rate for Payer: Priority Health SBD |
$208.69
|
|
|
AMPICILLIN 125 MG SOLUTION FOR INJECTION
|
Facility
IP
|
$18.88
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.89 |
| Max. Negotiated Rate |
$16.99 |
| Rate for Payer: Aetna Commercial |
$16.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.27
|
| Rate for Payer: Cash Price |
$15.10
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$16.24
|
| Rate for Payer: Healthscope Commercial |
$16.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.05
|
| Rate for Payer: PHP Commercial |
$16.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.22
|
| Rate for Payer: Priority Health SBD |
$11.89
|
|
|
AMPICILLIN 1 GRAM CUSTOM SOLUTION FOR INJECTION (CHARGE IN INCREMENTS)
|
Facility
IP
|
$23.55
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
180568
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$21.20 |
| Rate for Payer: Aetna Commercial |
$20.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.31
|
| Rate for Payer: Cash Price |
$18.84
|
| Rate for Payer: Cofinity Commercial |
$16.48
|
| Rate for Payer: Cofinity Commercial |
$20.25
|
| Rate for Payer: Healthscope Commercial |
$21.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.02
|
| Rate for Payer: PHP Commercial |
$20.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.48
|
| Rate for Payer: Priority Health SBD |
$14.84
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$20.57
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$18.51 |
| Rate for Payer: Aetna Commercial |
$17.48
|
| Rate for Payer: Aetna Commercial |
$22.70
|
| Rate for Payer: Aetna Commercial |
$19.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.37
|
| Rate for Payer: Cash Price |
$16.46
|
| Rate for Payer: Cash Price |
$21.36
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cofinity Commercial |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$19.26
|
| Rate for Payer: Cofinity Commercial |
$17.69
|
| Rate for Payer: Cofinity Commercial |
$14.40
|
| Rate for Payer: Cofinity Commercial |
$18.69
|
| Rate for Payer: Cofinity Commercial |
$15.67
|
| Rate for Payer: Healthscope Commercial |
$18.51
|
| Rate for Payer: Healthscope Commercial |
$20.15
|
| Rate for Payer: Healthscope Commercial |
$24.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.03
|
| Rate for Payer: PHP Commercial |
$19.03
|
| Rate for Payer: PHP Commercial |
$17.48
|
| Rate for Payer: PHP Commercial |
$22.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.69
|
| Rate for Payer: Priority Health SBD |
$12.96
|
| Rate for Payer: Priority Health SBD |
$14.11
|
| Rate for Payer: Priority Health SBD |
$16.82
|
|
