|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
IP
|
$54.25
|
|
|
Service Code
|
NDC 51991070401
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$48.82 |
| Rate for Payer: Aetna Commercial |
$46.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.26
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: Cofinity Commercial |
$37.98
|
| Rate for Payer: Cofinity Commercial |
$46.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.40
|
| Rate for Payer: Healthscope Commercial |
$48.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.11
|
| Rate for Payer: PHP Commercial |
$46.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.26
|
| Rate for Payer: Priority Health SBD |
$34.18
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00781106101
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna Commercial |
$35.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.30
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$29.40
|
| Rate for Payer: Cofinity Commercial |
$36.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$37.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: PHP Commercial |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$26.46
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
NDC 00228202710
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.72 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna Commercial |
$68.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.32
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: Cofinity Commercial |
$56.35
|
| Rate for Payer: Cofinity Commercial |
$69.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.40
|
| Rate for Payer: Healthscope Commercial |
$72.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.42
|
| Rate for Payer: PHP Commercial |
$68.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.32
|
| Rate for Payer: Priority Health SBD |
$50.72
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
NDC 51079078820
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna Commercial |
$89.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.25
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cofinity Commercial |
$73.50
|
| Rate for Payer: Cofinity Commercial |
$90.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.00
|
| Rate for Payer: Healthscope Commercial |
$94.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.25
|
| Rate for Payer: PHP Commercial |
$89.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.25
|
| Rate for Payer: Priority Health SBD |
$66.15
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
NDC 51079078820
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna Commercial |
$89.25
|
| Rate for Payer: Aetna Medicare |
$52.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.25
|
| Rate for Payer: BCBS Complete |
$42.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cofinity Commercial |
$73.50
|
| Rate for Payer: Cofinity Commercial |
$90.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.00
|
| Rate for Payer: Healthscope Commercial |
$94.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.25
|
| Rate for Payer: PHP Commercial |
$89.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.25
|
| Rate for Payer: Priority Health SBD |
$66.15
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 51079078801
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna Commercial |
$0.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.68
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cofinity Commercial |
$0.74
|
| Rate for Payer: Cofinity Commercial |
$0.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.84
|
| Rate for Payer: Healthscope Commercial |
$0.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.89
|
| Rate for Payer: PHP Commercial |
$0.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.68
|
| Rate for Payer: Priority Health SBD |
$0.66
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00781106101
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna Commercial |
$35.70
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.30
|
| Rate for Payer: BCBS Complete |
$16.80
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cofinity Commercial |
$29.40
|
| Rate for Payer: Cofinity Commercial |
$36.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.60
|
| Rate for Payer: Healthscope Commercial |
$37.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.70
|
| Rate for Payer: PHP Commercial |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$26.46
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
OP
|
$495.25
|
|
|
Service Code
|
NDC 60687037701
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.10 |
| Max. Negotiated Rate |
$445.72 |
| Rate for Payer: Aetna Commercial |
$420.96
|
| Rate for Payer: Aetna Medicare |
$247.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$321.91
|
| Rate for Payer: BCBS Complete |
$198.10
|
| Rate for Payer: Cash Price |
$396.20
|
| Rate for Payer: Cofinity Commercial |
$346.68
|
| Rate for Payer: Cofinity Commercial |
$425.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$346.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$396.20
|
| Rate for Payer: Healthscope Commercial |
$445.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$420.96
|
| Rate for Payer: PHP Commercial |
$420.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.91
|
| Rate for Payer: Priority Health SBD |
$312.01
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 51079078801
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna Commercial |
$0.89
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.68
|
| Rate for Payer: BCBS Complete |
$0.42
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cofinity Commercial |
$0.74
|
| Rate for Payer: Cofinity Commercial |
$0.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.84
|
| Rate for Payer: Healthscope Commercial |
$0.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.89
|
| Rate for Payer: PHP Commercial |
$0.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.68
|
| Rate for Payer: Priority Health SBD |
$0.66
|
|
|
ALPRAZOLAM 0.25 MG TABLET
|
Facility
|
OP
|
$80.50
|
|
|
Service Code
|
NDC 00228202710
|
| Hospital Charge Code |
324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna Commercial |
$68.42
|
| Rate for Payer: Aetna Medicare |
$40.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.32
|
| Rate for Payer: BCBS Complete |
$32.20
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: Cofinity Commercial |
$56.35
|
| Rate for Payer: Cofinity Commercial |
$69.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.40
|
| Rate for Payer: Healthscope Commercial |
$72.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.42
|
| Rate for Payer: PHP Commercial |
$68.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.32
|
| Rate for Payer: Priority Health SBD |
$50.72
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
OP
|
$54.25
|
|
|
Service Code
|
NDC 00781107701
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$48.82 |
| Rate for Payer: Aetna Commercial |
$46.11
|
| Rate for Payer: Aetna Medicare |
$27.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.26
|
| Rate for Payer: BCBS Complete |
$21.70
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: Cofinity Commercial |
$37.98
|
| Rate for Payer: Cofinity Commercial |
$46.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.40
|
| Rate for Payer: Healthscope Commercial |
$48.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.11
|
| Rate for Payer: PHP Commercial |
$46.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.26
|
| Rate for Payer: Priority Health SBD |
$34.18
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
IP
|
$92.75
|
|
|
Service Code
|
NDC 51079078920
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.43 |
| Max. Negotiated Rate |
$83.48 |
| Rate for Payer: Aetna Commercial |
$78.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.29
|
| Rate for Payer: Cash Price |
$74.20
|
| Rate for Payer: Cofinity Commercial |
$64.92
|
| Rate for Payer: Cofinity Commercial |
$79.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$64.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.20
|
| Rate for Payer: Healthscope Commercial |
$83.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.84
|
| Rate for Payer: PHP Commercial |
$78.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.29
|
| Rate for Payer: Priority Health SBD |
$58.43
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
IP
|
$68.25
|
|
|
Service Code
|
NDC 51991070501
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.00 |
| Max. Negotiated Rate |
$61.42 |
| Rate for Payer: Aetna Commercial |
$58.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.36
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$47.78
|
| Rate for Payer: Cofinity Commercial |
$58.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.01
|
| Rate for Payer: PHP Commercial |
$58.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.36
|
| Rate for Payer: Priority Health SBD |
$43.00
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
OP
|
$68.25
|
|
|
Service Code
|
NDC 51991070501
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$61.42 |
| Rate for Payer: Aetna Commercial |
$58.01
|
| Rate for Payer: Aetna Medicare |
$34.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.36
|
| Rate for Payer: BCBS Complete |
$27.30
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$47.78
|
| Rate for Payer: Cofinity Commercial |
$58.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.01
|
| Rate for Payer: PHP Commercial |
$58.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.36
|
| Rate for Payer: Priority Health SBD |
$43.00
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
IP
|
$54.25
|
|
|
Service Code
|
NDC 00781107701
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$48.82 |
| Rate for Payer: Aetna Commercial |
$46.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.26
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: Cofinity Commercial |
$37.98
|
| Rate for Payer: Cofinity Commercial |
$46.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.40
|
| Rate for Payer: Healthscope Commercial |
$48.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.11
|
| Rate for Payer: PHP Commercial |
$46.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.26
|
| Rate for Payer: Priority Health SBD |
$34.18
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
OP
|
$92.75
|
|
|
Service Code
|
NDC 51079078920
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$83.48 |
| Rate for Payer: Aetna Commercial |
$78.84
|
| Rate for Payer: Aetna Medicare |
$46.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.29
|
| Rate for Payer: BCBS Complete |
$37.10
|
| Rate for Payer: Cash Price |
$74.20
|
| Rate for Payer: Cofinity Commercial |
$64.92
|
| Rate for Payer: Cofinity Commercial |
$79.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$64.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.20
|
| Rate for Payer: Healthscope Commercial |
$83.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.84
|
| Rate for Payer: PHP Commercial |
$78.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.29
|
| Rate for Payer: Priority Health SBD |
$58.43
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 51079078901
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna Commercial |
$0.79
|
| Rate for Payer: Aetna Medicare |
$0.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.60
|
| Rate for Payer: BCBS Complete |
$0.37
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cofinity Commercial |
$0.65
|
| Rate for Payer: Cofinity Commercial |
$0.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.74
|
| Rate for Payer: Healthscope Commercial |
$0.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.79
|
| Rate for Payer: PHP Commercial |
$0.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.60
|
| Rate for Payer: Priority Health SBD |
$0.59
|
|
|
ALPRAZOLAM 0.5 MG TABLET
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 51079078901
|
| Hospital Charge Code |
325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna Commercial |
$0.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.60
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cofinity Commercial |
$0.65
|
| Rate for Payer: Cofinity Commercial |
$0.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.74
|
| Rate for Payer: Healthscope Commercial |
$0.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.79
|
| Rate for Payer: PHP Commercial |
$0.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.60
|
| Rate for Payer: Priority Health SBD |
$0.59
|
|
|
ALPRAZOLAM 1 MG TABLET
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 51079079020
|
| Hospital Charge Code |
326
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.52 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna Medicare |
$68.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.60
|
| Rate for Payer: Priority Health SBD |
$85.87
|
|
|
ALPRAZOLAM 1 MG TABLET
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 65862067801
|
| Hospital Charge Code |
326
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.26 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$75.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.04
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.90
|
| Rate for Payer: PHP Commercial |
$75.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.04
|
| Rate for Payer: Priority Health SBD |
$56.26
|
|
|
ALPRAZOLAM 1 MG TABLET
|
Facility
|
OP
|
$89.30
|
|
|
Service Code
|
NDC 65862067801
|
| Hospital Charge Code |
326
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.72 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$75.90
|
| Rate for Payer: Aetna Medicare |
$44.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.04
|
| Rate for Payer: BCBS Complete |
$35.72
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.90
|
| Rate for Payer: PHP Commercial |
$75.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.04
|
| Rate for Payer: Priority Health SBD |
$56.26
|
|
|
ALPRAZOLAM 1 MG TABLET
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 51079079001
|
| Hospital Charge Code |
326
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna Medicare |
$0.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.89
|
| Rate for Payer: BCBS Complete |
$0.55
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$0.96
|
| Rate for Payer: Cofinity Commercial |
$1.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.10
|
| Rate for Payer: Healthscope Commercial |
$1.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.16
|
| Rate for Payer: PHP Commercial |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.89
|
| Rate for Payer: Priority Health SBD |
$0.86
|
|
|
ALPRAZOLAM 1 MG TABLET
|
Facility
|
IP
|
$1.37
|
|
|
Service Code
|
NDC 51079079001
|
| Hospital Charge Code |
326
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.89
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$0.96
|
| Rate for Payer: Cofinity Commercial |
$1.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.10
|
| Rate for Payer: Healthscope Commercial |
$1.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.16
|
| Rate for Payer: PHP Commercial |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.89
|
| Rate for Payer: Priority Health SBD |
$0.86
|
|
|
ALPRAZOLAM 1 MG TABLET
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 51079079020
|
| Hospital Charge Code |
326
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.87 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.60
|
| Rate for Payer: Priority Health SBD |
$85.87
|
|
|
ALTEPLASE 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
|
