|
VIVONEX RTF INTERMITTENT FEED
|
Facility
IP
|
$59.20
|
|
|
Service Code
|
NDC 4390036280
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$50.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.48
|
| Rate for Payer: Cash Price |
$47.36
|
| Rate for Payer: Cofinity Commercial |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$50.91
|
| Rate for Payer: Healthscope Commercial |
$53.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.32
|
| Rate for Payer: PHP Commercial |
$50.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.44
|
| Rate for Payer: Priority Health SBD |
$37.30
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
IP
|
$44.40
|
|
|
Service Code
|
NDC 0212-3628-14
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$39.96 |
| Rate for Payer: Aetna Commercial |
$37.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.86
|
| Rate for Payer: Cash Price |
$35.52
|
| Rate for Payer: Cofinity Commercial |
$31.08
|
| Rate for Payer: Cofinity Commercial |
$38.18
|
| Rate for Payer: Healthscope Commercial |
$39.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.74
|
| Rate for Payer: PHP Commercial |
$37.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.08
|
| Rate for Payer: Priority Health SBD |
$27.97
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$90.03
|
|
|
Service Code
|
HCPCS J3465
|
| Hospital Charge Code |
33010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.72 |
| Max. Negotiated Rate |
$81.03 |
| Rate for Payer: Aetna Commercial |
$76.53
|
| Rate for Payer: Aetna Commercial |
$55.50
|
| Rate for Payer: Aetna Commercial |
$49.82
|
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.79
|
| Rate for Payer: Cash Price |
$52.23
|
| Rate for Payer: Cash Price |
$72.02
|
| Rate for Payer: Cash Price |
$56.36
|
| Rate for Payer: Cash Price |
$46.89
|
| Rate for Payer: Cofinity Commercial |
$77.43
|
| Rate for Payer: Cofinity Commercial |
$45.70
|
| Rate for Payer: Cofinity Commercial |
$56.15
|
| Rate for Payer: Cofinity Commercial |
$50.40
|
| Rate for Payer: Cofinity Commercial |
$63.02
|
| Rate for Payer: Cofinity Commercial |
$41.03
|
| Rate for Payer: Cofinity Commercial |
$49.32
|
| Rate for Payer: Cofinity Commercial |
$60.59
|
| Rate for Payer: Healthscope Commercial |
$63.40
|
| Rate for Payer: Healthscope Commercial |
$52.75
|
| Rate for Payer: Healthscope Commercial |
$58.76
|
| Rate for Payer: Healthscope Commercial |
$81.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.53
|
| Rate for Payer: PHP Commercial |
$49.82
|
| Rate for Payer: PHP Commercial |
$55.50
|
| Rate for Payer: PHP Commercial |
$59.88
|
| Rate for Payer: PHP Commercial |
$76.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.02
|
| Rate for Payer: Priority Health SBD |
$41.13
|
| Rate for Payer: Priority Health SBD |
$44.38
|
| Rate for Payer: Priority Health SBD |
$36.92
|
| Rate for Payer: Priority Health SBD |
$56.72
|
|
|
VORICONAZOLE 200 MG TABLET
|
Facility
IP
|
$180.58
|
|
|
Service Code
|
NDC 27241-063-03
|
| Hospital Charge Code |
33009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.77 |
| Max. Negotiated Rate |
$162.52 |
| Rate for Payer: Aetna Commercial |
$153.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.38
|
| Rate for Payer: Cash Price |
$144.46
|
| Rate for Payer: Cofinity Commercial |
$126.41
|
| Rate for Payer: Cofinity Commercial |
$155.30
|
| Rate for Payer: Healthscope Commercial |
$162.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.49
|
| Rate for Payer: PHP Commercial |
$153.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.41
|
| Rate for Payer: Priority Health SBD |
$113.77
|
|
|
VORICONAZOLE 200 MG TABLET
|
Facility
IP
|
$385.40
|
|
|
Service Code
|
NDC 0049-3180-30
|
| Hospital Charge Code |
33009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.80 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.78
|
| Rate for Payer: Priority Health SBD |
$242.80
|
|
|
VORTIOXETINE 10 MG TABLET
|
Facility
IP
|
$1,684.98
|
|
|
Service Code
|
NDC 64764-730-30
|
| Hospital Charge Code |
168416
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,061.54 |
| Max. Negotiated Rate |
$1,516.48 |
| Rate for Payer: Aetna Commercial |
$1,432.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,095.24
|
| Rate for Payer: Cash Price |
$1,347.98
|
| Rate for Payer: Cofinity Commercial |
$1,179.49
|
| Rate for Payer: Cofinity Commercial |
$1,449.08
|
| Rate for Payer: Healthscope Commercial |
$1,516.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,432.23
|
| Rate for Payer: PHP Commercial |
$1,432.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,179.49
|
| Rate for Payer: Priority Health SBD |
$1,061.54
|
|
|
VORTIOXETINE 5 MG TABLET
|
Facility
IP
|
$1,684.98
|
|
|
Service Code
|
NDC 64764-720-30
|
| Hospital Charge Code |
168415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,061.54 |
| Max. Negotiated Rate |
$1,516.48 |
| Rate for Payer: Aetna Commercial |
$1,432.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,095.24
|
| Rate for Payer: Cash Price |
$1,347.98
|
| Rate for Payer: Cofinity Commercial |
$1,449.08
|
| Rate for Payer: Cofinity Commercial |
$1,179.49
|
| Rate for Payer: Healthscope Commercial |
$1,516.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,432.23
|
| Rate for Payer: PHP Commercial |
$1,432.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,179.49
|
| Rate for Payer: Priority Health SBD |
$1,061.54
|
|
|
WARFARIN 10 MG TABLET
|
Facility
IP
|
$203.30
|
|
|
Service Code
|
NDC 0832-1219-01
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.08 |
| Max. Negotiated Rate |
$182.97 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.14
|
| Rate for Payer: Cash Price |
$162.64
|
| Rate for Payer: Cofinity Commercial |
$142.31
|
| Rate for Payer: Cofinity Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$182.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.80
|
| Rate for Payer: PHP Commercial |
$172.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.31
|
| Rate for Payer: Priority Health SBD |
$128.08
|
|
|
WARFARIN 10 MG TABLET
|
Facility
IP
|
$2.04
|
|
|
Service Code
|
NDC 0832-1219-89
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.33
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cofinity Commercial |
$1.43
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Healthscope Commercial |
$1.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.73
|
| Rate for Payer: PHP Commercial |
$1.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.43
|
| Rate for Payer: Priority Health SBD |
$1.29
|
|
|
WARFARIN 10 MG TABLET
|
Facility
IP
|
$317.25
|
|
|
Service Code
|
NDC 0093-1720-01
|
| Hospital Charge Code |
8748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.87 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.21
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$222.08
|
| Rate for Payer: Cofinity Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$269.66
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.08
|
| Rate for Payer: Priority Health SBD |
$199.87
|
|
|
WARFARIN 1 MG TABLET
|
Facility
IP
|
$361.90
|
|
|
Service Code
|
NDC 0832-1211-01
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.00 |
| Max. Negotiated Rate |
$325.71 |
| Rate for Payer: Aetna Commercial |
$307.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.24
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$253.33
|
| Rate for Payer: Cofinity Commercial |
$311.23
|
| Rate for Payer: Healthscope Commercial |
$325.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.62
|
| Rate for Payer: PHP Commercial |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.33
|
| Rate for Payer: Priority Health SBD |
$228.00
|
|
|
WARFARIN 1 MG TABLET
|
Facility
IP
|
$275.50
|
|
|
Service Code
|
NDC 51672-4027-1
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.56 |
| Max. Negotiated Rate |
$247.95 |
| Rate for Payer: Aetna Commercial |
$234.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.08
|
| Rate for Payer: Cash Price |
$220.40
|
| Rate for Payer: Cofinity Commercial |
$192.85
|
| Rate for Payer: Cofinity Commercial |
$236.93
|
| Rate for Payer: Healthscope Commercial |
$247.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.18
|
| Rate for Payer: PHP Commercial |
$234.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.85
|
| Rate for Payer: Priority Health SBD |
$173.56
|
|
|
WARFARIN 1 MG TABLET
|
Facility
IP
|
$3.62
|
|
|
Service Code
|
NDC 0832-1211-89
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$3.11
|
| Rate for Payer: Healthscope Commercial |
$3.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.08
|
| Rate for Payer: PHP Commercial |
$3.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: Priority Health SBD |
$2.28
|
|
|
WARFARIN 1 MG TABLET
|
Facility
IP
|
$173.90
|
|
|
Service Code
|
NDC 0093-1712-01
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.56 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| Rate for Payer: Priority Health SBD |
$109.56
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
IP
|
$3.62
|
|
|
Service Code
|
NDC 0832-1213-89
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$3.11
|
| Rate for Payer: Healthscope Commercial |
$3.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.08
|
| Rate for Payer: PHP Commercial |
$3.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: Priority Health SBD |
$2.28
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
IP
|
$219.45
|
|
|
Service Code
|
NDC 68084-027-01
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$197.50 |
| Rate for Payer: Aetna Commercial |
$186.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.64
|
| Rate for Payer: Cash Price |
$175.56
|
| Rate for Payer: Cofinity Commercial |
$153.62
|
| Rate for Payer: Cofinity Commercial |
$188.73
|
| Rate for Payer: Healthscope Commercial |
$197.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.53
|
| Rate for Payer: PHP Commercial |
$186.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.62
|
| Rate for Payer: Priority Health SBD |
$138.25
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
IP
|
$219.45
|
|
|
Service Code
|
NDC 68084-027-11
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$197.50 |
| Rate for Payer: Aetna Commercial |
$186.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.64
|
| Rate for Payer: Cash Price |
$175.56
|
| Rate for Payer: Cofinity Commercial |
$153.62
|
| Rate for Payer: Cofinity Commercial |
$188.73
|
| Rate for Payer: Healthscope Commercial |
$197.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.53
|
| Rate for Payer: PHP Commercial |
$186.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.62
|
| Rate for Payer: Priority Health SBD |
$138.25
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
IP
|
$361.90
|
|
|
Service Code
|
NDC 0832-1213-01
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.00 |
| Max. Negotiated Rate |
$325.71 |
| Rate for Payer: Aetna Commercial |
$307.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.24
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$253.33
|
| Rate for Payer: Cofinity Commercial |
$311.23
|
| Rate for Payer: Healthscope Commercial |
$325.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.62
|
| Rate for Payer: PHP Commercial |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.33
|
| Rate for Payer: Priority Health SBD |
$228.00
|
|
|
WARFARIN 2 MG TABLET
|
Facility
IP
|
$190.35
|
|
|
Service Code
|
NDC 0093-1713-01
|
| Hospital Charge Code |
8749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.92 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.24
|
| Rate for Payer: Priority Health SBD |
$119.92
|
|
|
WARFARIN 5 MG TABLET
|
Facility
IP
|
$2.28
|
|
|
Service Code
|
NDC 62584-994-11
|
| Hospital Charge Code |
8751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna Commercial |
$1.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.48
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$1.60
|
| Rate for Payer: Cofinity Commercial |
$1.96
|
| Rate for Payer: Healthscope Commercial |
$2.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.94
|
| Rate for Payer: PHP Commercial |
$1.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.60
|
| Rate for Payer: Priority Health SBD |
$1.44
|
|
|
WARFARIN 5 MG TABLET
|
Facility
IP
|
$3.62
|
|
|
Service Code
|
NDC 0832-1216-89
|
| Hospital Charge Code |
8751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Aetna Commercial |
$3.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$3.11
|
| Rate for Payer: Healthscope Commercial |
$3.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.08
|
| Rate for Payer: PHP Commercial |
$3.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: Priority Health SBD |
$2.28
|
|
|
WARFARIN 5 MG TABLET
|
Facility
IP
|
$361.90
|
|
|
Service Code
|
NDC 0832-1216-01
|
| Hospital Charge Code |
8751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.00 |
| Max. Negotiated Rate |
$325.71 |
| Rate for Payer: Aetna Commercial |
$307.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.24
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$253.33
|
| Rate for Payer: Cofinity Commercial |
$311.23
|
| Rate for Payer: Healthscope Commercial |
$325.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.62
|
| Rate for Payer: PHP Commercial |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.33
|
| Rate for Payer: Priority Health SBD |
$228.00
|
|
|
WARFARIN 5 MG TABLET
|
Facility
IP
|
$228.00
|
|
|
Service Code
|
NDC 62584-994-01
|
| Hospital Charge Code |
8751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.64 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna Commercial |
$193.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.20
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Cofinity Commercial |
$159.60
|
| Rate for Payer: Cofinity Commercial |
$196.08
|
| Rate for Payer: Healthscope Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.80
|
| Rate for Payer: PHP Commercial |
$193.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.60
|
| Rate for Payer: Priority Health SBD |
$143.64
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION
|
Facility
IP
|
$39.00
|
|
|
Service Code
|
NDC 0409-3977-03
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Aetna Commercial |
$33.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.35
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Cofinity Commercial |
$33.54
|
| Rate for Payer: Healthscope Commercial |
$35.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.15
|
| Rate for Payer: PHP Commercial |
$33.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$24.57
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION
|
Facility
IP
|
$39.00
|
|
|
Service Code
|
NDC 0409-3977-01
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Aetna Commercial |
$33.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.35
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cofinity Commercial |
$33.54
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Healthscope Commercial |
$35.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.15
|
| Rate for Payer: PHP Commercial |
$33.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.30
|
| Rate for Payer: Priority Health SBD |
$24.57
|
|
