|
ROPINIROLE 2 MG TABLET
|
Facility
|
IP
|
$122.20
|
|
|
Service Code
|
NDC 43547-271-10
|
| Hospital Charge Code |
21690
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.99 |
| Max. Negotiated Rate |
$109.98 |
| Rate for Payer: Aetna Commercial |
$103.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.43
|
| Rate for Payer: Cash Price |
$97.76
|
| Rate for Payer: Cofinity Commercial |
$105.09
|
| Rate for Payer: Cofinity Commercial |
$85.54
|
| Rate for Payer: Healthscope Commercial |
$109.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.87
|
| Rate for Payer: PHP Commercial |
$103.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$76.99
|
|
|
ROPIVACAINE 0.2 % FOR NERVE BLOCK INJECTION
|
Facility
|
IP
|
$96.98
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
161560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$87.28 |
| Rate for Payer: Aetna Commercial |
$82.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.04
|
| Rate for Payer: Cash Price |
$77.58
|
| Rate for Payer: Cofinity Commercial |
$67.89
|
| Rate for Payer: Cofinity Commercial |
$83.40
|
| Rate for Payer: Healthscope Commercial |
$87.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.43
|
| Rate for Payer: PHP Commercial |
$82.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.89
|
| Rate for Payer: Priority Health SBD |
$61.10
|
|
|
ROPIVACAINE(PF) 0.2% (2 MG/ML)-SODIUM CHLOR,ISO-OSM INJECTION SOLUTION
|
Facility
|
IP
|
$758.34
|
|
|
Service Code
|
HCPCS j7999
|
| Hospital Charge Code |
189538
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$477.75 |
| Max. Negotiated Rate |
$682.51 |
| Rate for Payer: Aetna Commercial |
$644.59
|
| Rate for Payer: Aetna Commercial |
$197.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$492.92
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Cash Price |
$606.67
|
| Rate for Payer: Cofinity Commercial |
$162.40
|
| Rate for Payer: Cofinity Commercial |
$199.52
|
| Rate for Payer: Cofinity Commercial |
$652.17
|
| Rate for Payer: Cofinity Commercial |
$530.84
|
| Rate for Payer: Healthscope Commercial |
$682.51
|
| Rate for Payer: Healthscope Commercial |
$208.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$644.59
|
| Rate for Payer: PHP Commercial |
$197.20
|
| Rate for Payer: PHP Commercial |
$644.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.40
|
| Rate for Payer: Priority Health SBD |
$146.16
|
| Rate for Payer: Priority Health SBD |
$477.75
|
|
|
ROPIVACAINE(PF) 0.2% (2 MG/ML)-SODIUM CHLOR,ISO-OSM SOLUTION WRAPPER
|
Facility
|
IP
|
$758.34
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
301466
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$477.75 |
| Max. Negotiated Rate |
$682.51 |
| Rate for Payer: Aetna Commercial |
$644.59
|
| Rate for Payer: Aetna Commercial |
$394.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$301.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$492.92
|
| Rate for Payer: Cash Price |
$606.67
|
| Rate for Payer: Cash Price |
$371.20
|
| Rate for Payer: Cofinity Commercial |
$399.04
|
| Rate for Payer: Cofinity Commercial |
$324.80
|
| Rate for Payer: Cofinity Commercial |
$530.84
|
| Rate for Payer: Cofinity Commercial |
$652.17
|
| Rate for Payer: Healthscope Commercial |
$417.60
|
| Rate for Payer: Healthscope Commercial |
$682.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$644.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$394.40
|
| Rate for Payer: PHP Commercial |
$644.59
|
| Rate for Payer: PHP Commercial |
$394.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$324.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.84
|
| Rate for Payer: Priority Health SBD |
$292.32
|
| Rate for Payer: Priority Health SBD |
$477.75
|
|
|
ROPIVACAINE (PF) 0.2 % IN 0.9 % SODIUM CHLORIDE EPIDURAL SOLUTION
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
116044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$223.65 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna Commercial |
$301.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.75
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cofinity Commercial |
$248.50
|
| Rate for Payer: Cofinity Commercial |
$305.30
|
| Rate for Payer: Healthscope Commercial |
$319.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$301.75
|
| Rate for Payer: PHP Commercial |
$301.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.50
|
| Rate for Payer: Priority Health SBD |
$223.65
|
|
|
ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$81.03
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
18194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$72.93 |
| Rate for Payer: Aetna Commercial |
$68.88
|
| Rate for Payer: Aetna Commercial |
$63.84
|
| Rate for Payer: Aetna Commercial |
$121.72
|
| Rate for Payer: Aetna Commercial |
$64.54
|
| Rate for Payer: Aetna Commercial |
$62.36
|
| Rate for Payer: Aetna Commercial |
$81.34
|
| Rate for Payer: Aetna Commercial |
$62.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.08
|
| Rate for Payer: Cash Price |
$114.56
|
| Rate for Payer: Cash Price |
$60.74
|
| Rate for Payer: Cash Price |
$60.08
|
| Rate for Payer: Cash Price |
$59.20
|
| Rate for Payer: Cash Price |
$76.56
|
| Rate for Payer: Cash Price |
$58.70
|
| Rate for Payer: Cash Price |
$64.82
|
| Rate for Payer: Cofinity Commercial |
$82.30
|
| Rate for Payer: Cofinity Commercial |
$51.36
|
| Rate for Payer: Cofinity Commercial |
$63.10
|
| Rate for Payer: Cofinity Commercial |
$53.15
|
| Rate for Payer: Cofinity Commercial |
$69.69
|
| Rate for Payer: Cofinity Commercial |
$56.72
|
| Rate for Payer: Cofinity Commercial |
$63.64
|
| Rate for Payer: Cofinity Commercial |
$64.59
|
| Rate for Payer: Cofinity Commercial |
$51.80
|
| Rate for Payer: Cofinity Commercial |
$65.30
|
| Rate for Payer: Cofinity Commercial |
$100.24
|
| Rate for Payer: Cofinity Commercial |
$123.15
|
| Rate for Payer: Cofinity Commercial |
$52.57
|
| Rate for Payer: Cofinity Commercial |
$66.99
|
| Rate for Payer: Healthscope Commercial |
$128.88
|
| Rate for Payer: Healthscope Commercial |
$66.03
|
| Rate for Payer: Healthscope Commercial |
$66.60
|
| Rate for Payer: Healthscope Commercial |
$67.59
|
| Rate for Payer: Healthscope Commercial |
$68.34
|
| Rate for Payer: Healthscope Commercial |
$72.93
|
| Rate for Payer: Healthscope Commercial |
$86.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$64.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.88
|
| Rate for Payer: PHP Commercial |
$121.72
|
| Rate for Payer: PHP Commercial |
$81.34
|
| Rate for Payer: PHP Commercial |
$62.90
|
| Rate for Payer: PHP Commercial |
$64.54
|
| Rate for Payer: PHP Commercial |
$62.36
|
| Rate for Payer: PHP Commercial |
$68.88
|
| Rate for Payer: PHP Commercial |
$63.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.57
|
| Rate for Payer: Priority Health SBD |
$46.62
|
| Rate for Payer: Priority Health SBD |
$47.84
|
| Rate for Payer: Priority Health SBD |
$46.22
|
| Rate for Payer: Priority Health SBD |
$51.05
|
| Rate for Payer: Priority Health SBD |
$90.22
|
| Rate for Payer: Priority Health SBD |
$47.31
|
| Rate for Payer: Priority Health SBD |
$60.29
|
|
|
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$304.39
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
169800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.77 |
| Max. Negotiated Rate |
$273.95 |
| Rate for Payer: Aetna Commercial |
$258.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.85
|
| Rate for Payer: Cash Price |
$243.51
|
| Rate for Payer: Cofinity Commercial |
$213.07
|
| Rate for Payer: Cofinity Commercial |
$261.78
|
| Rate for Payer: Healthscope Commercial |
$273.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.73
|
| Rate for Payer: PHP Commercial |
$258.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.07
|
| Rate for Payer: Priority Health SBD |
$191.77
|
|
|
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$304.39
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
18192
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.77 |
| Max. Negotiated Rate |
$273.95 |
| Rate for Payer: Aetna Commercial |
$258.73
|
| Rate for Payer: Aetna Commercial |
$93.28
|
| Rate for Payer: Aetna Commercial |
$103.73
|
| Rate for Payer: Aetna Commercial |
$130.25
|
| Rate for Payer: Aetna Commercial |
$138.83
|
| Rate for Payer: Aetna Commercial |
$144.36
|
| Rate for Payer: Aetna Commercial |
$152.24
|
| Rate for Payer: Aetna Commercial |
$263.47
|
| Rate for Payer: Aetna Commercial |
$41.22
|
| Rate for Payer: Aetna Commercial |
$43.66
|
| Rate for Payer: Aetna Commercial |
$47.18
|
| Rate for Payer: Aetna Commercial |
$47.55
|
| Rate for Payer: Aetna Commercial |
$70.23
|
| Rate for Payer: Aetna Commercial |
$74.30
|
| Rate for Payer: Aetna Commercial |
$82.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.82
|
| Rate for Payer: Cash Price |
$41.09
|
| Rate for Payer: Cash Price |
$143.29
|
| Rate for Payer: Cash Price |
$38.79
|
| Rate for Payer: Cash Price |
$243.51
|
| Rate for Payer: Cash Price |
$97.63
|
| Rate for Payer: Cash Price |
$77.58
|
| Rate for Payer: Cash Price |
$130.66
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: Cash Price |
$69.93
|
| Rate for Payer: Cash Price |
$122.58
|
| Rate for Payer: Cash Price |
$44.75
|
| Rate for Payer: Cash Price |
$44.41
|
| Rate for Payer: Cash Price |
$87.79
|
| Rate for Payer: Cash Price |
$135.86
|
| Rate for Payer: Cash Price |
$247.97
|
| Rate for Payer: Cofinity Commercial |
$47.74
|
| Rate for Payer: Cofinity Commercial |
$131.78
|
| Rate for Payer: Cofinity Commercial |
$39.16
|
| Rate for Payer: Cofinity Commercial |
$48.11
|
| Rate for Payer: Cofinity Commercial |
$114.33
|
| Rate for Payer: Cofinity Commercial |
$140.46
|
| Rate for Payer: Cofinity Commercial |
$85.43
|
| Rate for Payer: Cofinity Commercial |
$94.38
|
| Rate for Payer: Cofinity Commercial |
$76.82
|
| Rate for Payer: Cofinity Commercial |
$118.88
|
| Rate for Payer: Cofinity Commercial |
$146.05
|
| Rate for Payer: Cofinity Commercial |
$104.95
|
| Rate for Payer: Cofinity Commercial |
$83.40
|
| Rate for Payer: Cofinity Commercial |
$125.38
|
| Rate for Payer: Cofinity Commercial |
$154.03
|
| Rate for Payer: Cofinity Commercial |
$67.89
|
| Rate for Payer: Cofinity Commercial |
$213.07
|
| Rate for Payer: Cofinity Commercial |
$261.78
|
| Rate for Payer: Cofinity Commercial |
$216.97
|
| Rate for Payer: Cofinity Commercial |
$266.57
|
| Rate for Payer: Cofinity Commercial |
$75.17
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$33.94
|
| Rate for Payer: Cofinity Commercial |
$41.70
|
| Rate for Payer: Cofinity Commercial |
$35.95
|
| Rate for Payer: Cofinity Commercial |
$44.17
|
| Rate for Payer: Cofinity Commercial |
$107.26
|
| Rate for Payer: Cofinity Commercial |
$71.05
|
| Rate for Payer: Cofinity Commercial |
$57.83
|
| Rate for Payer: Cofinity Commercial |
$38.86
|
| Rate for Payer: Healthscope Commercial |
$50.35
|
| Rate for Payer: Healthscope Commercial |
$46.22
|
| Rate for Payer: Healthscope Commercial |
$147.00
|
| Rate for Payer: Healthscope Commercial |
$98.77
|
| Rate for Payer: Healthscope Commercial |
$43.64
|
| Rate for Payer: Healthscope Commercial |
$109.84
|
| Rate for Payer: Healthscope Commercial |
$74.36
|
| Rate for Payer: Healthscope Commercial |
$161.20
|
| Rate for Payer: Healthscope Commercial |
$137.91
|
| Rate for Payer: Healthscope Commercial |
$273.95
|
| Rate for Payer: Healthscope Commercial |
$87.28
|
| Rate for Payer: Healthscope Commercial |
$78.67
|
| Rate for Payer: Healthscope Commercial |
$152.85
|
| Rate for Payer: Healthscope Commercial |
$49.96
|
| Rate for Payer: Healthscope Commercial |
$278.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$138.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$152.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$144.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$70.23
|
| Rate for Payer: PHP Commercial |
$41.22
|
| Rate for Payer: PHP Commercial |
$103.73
|
| Rate for Payer: PHP Commercial |
$130.25
|
| Rate for Payer: PHP Commercial |
$138.83
|
| Rate for Payer: PHP Commercial |
$144.36
|
| Rate for Payer: PHP Commercial |
$152.24
|
| Rate for Payer: PHP Commercial |
$258.73
|
| Rate for Payer: PHP Commercial |
$263.47
|
| Rate for Payer: PHP Commercial |
$43.66
|
| Rate for Payer: PHP Commercial |
$47.18
|
| Rate for Payer: PHP Commercial |
$47.55
|
| Rate for Payer: PHP Commercial |
$70.23
|
| Rate for Payer: PHP Commercial |
$74.30
|
| Rate for Payer: PHP Commercial |
$82.43
|
| Rate for Payer: PHP Commercial |
$93.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.89
|
| Rate for Payer: Priority Health SBD |
$112.84
|
| Rate for Payer: Priority Health SBD |
$102.90
|
| Rate for Payer: Priority Health SBD |
$35.24
|
| Rate for Payer: Priority Health SBD |
$32.36
|
| Rate for Payer: Priority Health SBD |
$191.77
|
| Rate for Payer: Priority Health SBD |
$61.10
|
| Rate for Payer: Priority Health SBD |
$30.55
|
| Rate for Payer: Priority Health SBD |
$76.89
|
| Rate for Payer: Priority Health SBD |
$55.07
|
| Rate for Payer: Priority Health SBD |
$52.05
|
| Rate for Payer: Priority Health SBD |
$34.97
|
| Rate for Payer: Priority Health SBD |
$96.53
|
| Rate for Payer: Priority Health SBD |
$69.14
|
| Rate for Payer: Priority Health SBD |
$195.27
|
| Rate for Payer: Priority Health SBD |
$106.99
|
|
|
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
IP
|
$20.43
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
153276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$18.39 |
| Rate for Payer: Aetna Commercial |
$17.37
|
| Rate for Payer: Aetna Commercial |
$24.91
|
| Rate for Payer: Aetna Commercial |
$17.82
|
| Rate for Payer: Aetna Commercial |
$17.48
|
| Rate for Payer: Aetna Commercial |
$28.60
|
| Rate for Payer: Aetna Commercial |
$24.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.62
|
| Rate for Payer: Cash Price |
$16.45
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Cash Price |
$16.77
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: Cash Price |
$23.45
|
| Rate for Payer: Cash Price |
$26.92
|
| Rate for Payer: Cofinity Commercial |
$14.39
|
| Rate for Payer: Cofinity Commercial |
$17.57
|
| Rate for Payer: Cofinity Commercial |
$24.46
|
| Rate for Payer: Cofinity Commercial |
$19.91
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Cofinity Commercial |
$14.67
|
| Rate for Payer: Cofinity Commercial |
$18.03
|
| Rate for Payer: Cofinity Commercial |
$25.21
|
| Rate for Payer: Cofinity Commercial |
$17.68
|
| Rate for Payer: Cofinity Commercial |
$23.56
|
| Rate for Payer: Cofinity Commercial |
$14.30
|
| Rate for Payer: Cofinity Commercial |
$20.52
|
| Rate for Payer: Healthscope Commercial |
$18.39
|
| Rate for Payer: Healthscope Commercial |
$26.38
|
| Rate for Payer: Healthscope Commercial |
$18.86
|
| Rate for Payer: Healthscope Commercial |
$30.28
|
| Rate for Payer: Healthscope Commercial |
$25.60
|
| Rate for Payer: Healthscope Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.37
|
| Rate for Payer: PHP Commercial |
$24.91
|
| Rate for Payer: PHP Commercial |
$17.82
|
| Rate for Payer: PHP Commercial |
$17.37
|
| Rate for Payer: PHP Commercial |
$24.17
|
| Rate for Payer: PHP Commercial |
$28.60
|
| Rate for Payer: PHP Commercial |
$17.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.56
|
| Rate for Payer: Priority Health SBD |
$18.47
|
| Rate for Payer: Priority Health SBD |
$13.20
|
| Rate for Payer: Priority Health SBD |
$12.95
|
| Rate for Payer: Priority Health SBD |
$12.87
|
| Rate for Payer: Priority Health SBD |
$21.20
|
| Rate for Payer: Priority Health SBD |
$17.92
|
|
|
ROPIVACAINE (PF) 7.5 MG/ML (0.75 %) INJECTION SOLUTION
|
Facility
|
IP
|
$26.79
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
18193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.88 |
| Max. Negotiated Rate |
$24.11 |
| Rate for Payer: Aetna Commercial |
$22.77
|
| Rate for Payer: Aetna Commercial |
$16.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.41
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: Cash Price |
$21.43
|
| Rate for Payer: Cofinity Commercial |
$16.30
|
| Rate for Payer: Cofinity Commercial |
$13.26
|
| Rate for Payer: Cofinity Commercial |
$23.04
|
| Rate for Payer: Cofinity Commercial |
$18.75
|
| Rate for Payer: Healthscope Commercial |
$24.11
|
| Rate for Payer: Healthscope Commercial |
$17.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.77
|
| Rate for Payer: PHP Commercial |
$16.11
|
| Rate for Payer: PHP Commercial |
$22.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.75
|
| Rate for Payer: Priority Health SBD |
$16.88
|
| Rate for Payer: Priority Health SBD |
$11.94
|
|
|
ROSUVASTATIN 5 MG TABLET
|
Facility
|
IP
|
$2,813.52
|
|
|
Service Code
|
NDC 0310-0755-90
|
| Hospital Charge Code |
36612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,772.52 |
| Max. Negotiated Rate |
$2,532.17 |
| Rate for Payer: Aetna Commercial |
$2,391.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,828.79
|
| Rate for Payer: Cash Price |
$2,250.82
|
| Rate for Payer: Cofinity Commercial |
$1,969.46
|
| Rate for Payer: Cofinity Commercial |
$2,419.63
|
| Rate for Payer: Healthscope Commercial |
$2,532.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,391.49
|
| Rate for Payer: PHP Commercial |
$2,391.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,969.46
|
| Rate for Payer: Priority Health SBD |
$1,772.52
|
|
|
ROSUVASTATIN 5 MG TABLET
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 0781-5400-92
|
| Hospital Charge Code |
36612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.05 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.50
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$155.61
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$188.96
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.61
|
| Rate for Payer: Priority Health SBD |
$140.05
|
|
|
ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH
|
Facility
|
IP
|
$2,900.32
|
|
|
Service Code
|
NDC 50474-802-03
|
| Hospital Charge Code |
82100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,827.20 |
| Max. Negotiated Rate |
$2,610.29 |
| Rate for Payer: Aetna Commercial |
$2,465.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,885.21
|
| Rate for Payer: Cash Price |
$2,320.26
|
| Rate for Payer: Cofinity Commercial |
$2,030.22
|
| Rate for Payer: Cofinity Commercial |
$2,494.28
|
| Rate for Payer: Healthscope Commercial |
$2,610.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,465.27
|
| Rate for Payer: PHP Commercial |
$2,465.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,030.22
|
| Rate for Payer: Priority Health SBD |
$1,827.20
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$10,793.34
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,799.80 |
| Max. Negotiated Rate |
$9,714.01 |
| Rate for Payer: Aetna Commercial |
$9,174.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,015.67
|
| Rate for Payer: Cash Price |
$8,634.67
|
| Rate for Payer: Cofinity Commercial |
$7,555.34
|
| Rate for Payer: Cofinity Commercial |
$9,282.27
|
| Rate for Payer: Healthscope Commercial |
$9,714.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,174.34
|
| Rate for Payer: PHP Commercial |
$9,174.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,555.34
|
| Rate for Payer: Priority Health SBD |
$6,799.80
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$10,793.34
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$9,714.01 |
| Rate for Payer: Aetna Commercial |
$9,174.34
|
| Rate for Payer: Aetna Medicare |
$35.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,015.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.60
|
| Rate for Payer: BCBS Complete |
$19.57
|
| Rate for Payer: BCBS MAPPO |
$34.08
|
| Rate for Payer: BCBS Trust/PPO |
$100.86
|
| Rate for Payer: BCN Medicare Advantage |
$34.08
|
| Rate for Payer: Cash Price |
$8,634.67
|
| Rate for Payer: Cash Price |
$8,634.67
|
| Rate for Payer: Cofinity Commercial |
$9,282.27
|
| Rate for Payer: Cofinity Commercial |
$7,555.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.08
|
| Rate for Payer: Healthscope Commercial |
$9,714.01
|
| Rate for Payer: Mclaren Medicaid |
$18.64
|
| Rate for Payer: Mclaren Medicare |
$34.08
|
| Rate for Payer: Meridian Medicaid |
$19.57
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$35.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,174.34
|
| Rate for Payer: PACE Medicare |
$32.37
|
| Rate for Payer: PACE SWMI |
$34.08
|
| Rate for Payer: PHP Commercial |
$9,174.34
|
| Rate for Payer: PHP Medicare Advantage |
$34.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$18.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,555.34
|
| Rate for Payer: Priority Health Medicare |
$34.08
|
| Rate for Payer: Priority Health SBD |
$6,799.80
|
| Rate for Payer: Railroad Medicare Medicare |
$34.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.08
|
| Rate for Payer: UHC Medicare Advantage |
$35.10
|
| Rate for Payer: VA VA |
$34.08
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,433.56 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,479.08
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,592.85
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health SBD |
$1,433.56
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,433.56 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,479.08
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,592.85
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health SBD |
$1,433.56
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,433.56 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,479.08
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,592.85
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health SBD |
$1,433.56
|
|
|
SALIVARY GLAND PROCEDURES
|
Facility
|
IP
|
$21,377.09
|
|
|
Service Code
|
MS-DRG 139
|
| Min. Negotiated Rate |
$8,593.99 |
| Max. Negotiated Rate |
$21,377.09 |
| Rate for Payer: Aetna Medicare |
$9,408.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,307.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,307.89
|
| Rate for Payer: BCBS MAPPO |
$9,046.31
|
| Rate for Payer: BCBS Trust/PPO |
$21,377.09
|
| Rate for Payer: BCN Medicare Advantage |
$9,046.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,046.31
|
| Rate for Payer: Mclaren Medicare |
$9,046.31
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,498.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,403.26
|
| Rate for Payer: PACE Medicare |
$8,593.99
|
| Rate for Payer: PACE SWMI |
$9,046.31
|
| Rate for Payer: PHP Medicare Advantage |
$9,046.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,043.40
|
| Rate for Payer: Priority Health Medicare |
$9,046.31
|
| Rate for Payer: Priority Health Narrow Network |
$13,634.72
|
| Rate for Payer: Railroad Medicare Medicare |
$9,046.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18,117.18
|
| Rate for Payer: UHC Core |
$11,116.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,046.31
|
| Rate for Payer: UHC Exchange |
$11,906.69
|
| Rate for Payer: UHC Medicare Advantage |
$9,317.70
|
| Rate for Payer: VA VA |
$9,046.31
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
IP
|
$24.97
|
|
|
Service Code
|
NDC 4858200155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.48
|
| Rate for Payer: Priority Health SBD |
$15.73
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$934.41
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
11338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.45 |
| Max. Negotiated Rate |
$840.97 |
| Rate for Payer: Aetna Commercial |
$794.25
|
| Rate for Payer: Aetna Medicare |
$61.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$607.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$74.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$74.15
|
| Rate for Payer: BCBS Complete |
$34.07
|
| Rate for Payer: BCBS MAPPO |
$59.32
|
| Rate for Payer: BCBS Trust/PPO |
$175.59
|
| Rate for Payer: BCN Medicare Advantage |
$59.32
|
| Rate for Payer: Cash Price |
$747.53
|
| Rate for Payer: Cash Price |
$747.53
|
| Rate for Payer: Cofinity Commercial |
$803.59
|
| Rate for Payer: Cofinity Commercial |
$654.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.32
|
| Rate for Payer: Healthscope Commercial |
$840.97
|
| Rate for Payer: Mclaren Medicaid |
$32.45
|
| Rate for Payer: Mclaren Medicare |
$59.32
|
| Rate for Payer: Meridian Medicaid |
$34.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$62.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$794.25
|
| Rate for Payer: PACE Medicare |
$56.35
|
| Rate for Payer: PACE SWMI |
$59.32
|
| Rate for Payer: PHP Commercial |
$794.25
|
| Rate for Payer: PHP Medicare Advantage |
$59.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$32.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$654.09
|
| Rate for Payer: Priority Health Medicare |
$59.32
|
| Rate for Payer: Priority Health SBD |
$588.68
|
| Rate for Payer: Railroad Medicare Medicare |
$59.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$59.32
|
| Rate for Payer: UHC Medicare Advantage |
$61.10
|
| Rate for Payer: VA VA |
$59.32
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$67.37
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$60.63 |
| Rate for Payer: Aetna Commercial |
$57.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.79
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: Cofinity Commercial |
$47.16
|
| Rate for Payer: Cofinity Commercial |
$57.94
|
| Rate for Payer: Healthscope Commercial |
$60.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.26
|
| Rate for Payer: PHP Commercial |
$57.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.16
|
| Rate for Payer: Priority Health SBD |
$42.44
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$63.25
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.85 |
| Max. Negotiated Rate |
$56.92 |
| Rate for Payer: Aetna Commercial |
$53.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.11
|
| Rate for Payer: Cash Price |
$50.60
|
| Rate for Payer: Cofinity Commercial |
$44.28
|
| Rate for Payer: Cofinity Commercial |
$54.40
|
| Rate for Payer: Healthscope Commercial |
$56.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.76
|
| Rate for Payer: PHP Commercial |
$53.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.28
|
| Rate for Payer: Priority Health SBD |
$39.85
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$27.27
|
|
|
Service Code
|
NDC 50742-505-01
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.18 |
| Max. Negotiated Rate |
$24.54 |
| Rate for Payer: Aetna Commercial |
$23.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.73
|
| Rate for Payer: Cash Price |
$21.82
|
| Rate for Payer: Cofinity Commercial |
$19.09
|
| Rate for Payer: Cofinity Commercial |
$23.45
|
| Rate for Payer: Healthscope Commercial |
$24.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.18
|
| Rate for Payer: PHP Commercial |
$23.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.09
|
| Rate for Payer: Priority Health SBD |
$17.18
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$1,051.31
|
|
|
Service Code
|
NDC 10019-553-04
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$662.33 |
| Max. Negotiated Rate |
$946.18 |
| Rate for Payer: Aetna Commercial |
$893.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$683.35
|
| Rate for Payer: Cash Price |
$841.05
|
| Rate for Payer: Cofinity Commercial |
$735.92
|
| Rate for Payer: Cofinity Commercial |
$904.13
|
| Rate for Payer: Healthscope Commercial |
$946.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$893.61
|
| Rate for Payer: PHP Commercial |
$893.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$735.92
|
| Rate for Payer: Priority Health SBD |
$662.33
|
|
