FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$2.21
|
|
Service Code
|
NDC 50268-303-11
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$1.39 |
Max. Negotiated Rate |
$1.99 |
Rate for Payer: Aetna Commercial |
$1.88
|
Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
Rate for Payer: Cash Price |
$1.77
|
Rate for Payer: Cofinity Commercial |
$1.55
|
Rate for Payer: Cofinity Commercial |
$1.90
|
Rate for Payer: Healthscope Commercial |
$1.99
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
Rate for Payer: PHP Commercial |
$1.88
|
Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
Rate for Payer: Priority Health SBD |
$1.39
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$109.28
|
|
Service Code
|
NDC 0904-7193-06
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$68.85 |
Max. Negotiated Rate |
$98.35 |
Rate for Payer: Aetna Commercial |
$92.89
|
Rate for Payer: Aetna New Business (MI Preferred) |
$71.03
|
Rate for Payer: Cash Price |
$87.42
|
Rate for Payer: Cofinity Commercial |
$76.50
|
Rate for Payer: Cofinity Commercial |
$93.98
|
Rate for Payer: Healthscope Commercial |
$98.35
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.89
|
Rate for Payer: PHP Commercial |
$92.89
|
Rate for Payer: Priority Health Cigna Priority Health |
$76.50
|
Rate for Payer: Priority Health SBD |
$68.85
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$99.88
|
|
Service Code
|
NDC 0904-5780-17
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$62.92 |
Max. Negotiated Rate |
$89.89 |
Rate for Payer: Aetna Commercial |
$84.90
|
Rate for Payer: Aetna New Business (MI Preferred) |
$64.92
|
Rate for Payer: Cash Price |
$79.90
|
Rate for Payer: Cofinity Commercial |
$69.92
|
Rate for Payer: Cofinity Commercial |
$85.90
|
Rate for Payer: Healthscope Commercial |
$89.89
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$84.90
|
Rate for Payer: PHP Commercial |
$84.90
|
Rate for Payer: Priority Health Cigna Priority Health |
$69.92
|
Rate for Payer: Priority Health SBD |
$62.92
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
Service Code
|
NDC 65862-859-01
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$137.69 |
Max. Negotiated Rate |
$196.70 |
Rate for Payer: Aetna Commercial |
$185.77
|
Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
Rate for Payer: Cash Price |
$174.84
|
Rate for Payer: Cofinity Commercial |
$152.98
|
Rate for Payer: Cofinity Commercial |
$187.95
|
Rate for Payer: Healthscope Commercial |
$196.70
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
Rate for Payer: PHP Commercial |
$185.77
|
Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
Rate for Payer: Priority Health SBD |
$137.69
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$190.35
|
|
Service Code
|
NDC 0536-1298-01
|
Hospital Charge Code |
10011
|
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
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
Service Code
|
NDC 0904-5780-51
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$112.52 |
Max. Negotiated Rate |
$160.74 |
Rate for Payer: Aetna Commercial |
$151.81
|
Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
Rate for Payer: Cash Price |
$142.88
|
Rate for Payer: Cofinity Commercial |
$125.02
|
Rate for Payer: Cofinity Commercial |
$153.60
|
Rate for Payer: Healthscope Commercial |
$160.74
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
Rate for Payer: PHP Commercial |
$151.81
|
Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
Rate for Payer: Priority Health SBD |
$112.52
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$98.80
|
|
Service Code
|
NDC 16837-855-25
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$62.24 |
Max. Negotiated Rate |
$88.92 |
Rate for Payer: Aetna Commercial |
$83.98
|
Rate for Payer: Aetna New Business (MI Preferred) |
$64.22
|
Rate for Payer: Cash Price |
$79.04
|
Rate for Payer: Cofinity Commercial |
$69.16
|
Rate for Payer: Cofinity Commercial |
$84.97
|
Rate for Payer: Healthscope Commercial |
$88.92
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.98
|
Rate for Payer: PHP Commercial |
$83.98
|
Rate for Payer: Priority Health Cigna Priority Health |
$69.16
|
Rate for Payer: Priority Health SBD |
$62.24
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$399.50
|
|
Service Code
|
NDC 0172-5728-70
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$251.68 |
Max. Negotiated Rate |
$359.55 |
Rate for Payer: Aetna Commercial |
$339.58
|
Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
Rate for Payer: Cash Price |
$319.60
|
Rate for Payer: Cofinity Commercial |
$279.65
|
Rate for Payer: Cofinity Commercial |
$343.57
|
Rate for Payer: Healthscope Commercial |
$359.55
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.58
|
Rate for Payer: PHP Commercial |
$339.58
|
Rate for Payer: Priority Health Cigna Priority Health |
$279.65
|
Rate for Payer: Priority Health SBD |
$251.68
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
Service Code
|
NDC 51079-966-20
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$93.27 |
Max. Negotiated Rate |
$133.24 |
Rate for Payer: Aetna Commercial |
$125.84
|
Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
Rate for Payer: Cash Price |
$118.44
|
Rate for Payer: Cofinity Commercial |
$103.64
|
Rate for Payer: Cofinity Commercial |
$127.32
|
Rate for Payer: Healthscope Commercial |
$133.24
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
Rate for Payer: PHP Commercial |
$125.84
|
Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
Rate for Payer: Priority Health SBD |
$93.27
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$4.33
|
|
Service Code
|
NDC 60687-595-11
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$2.73 |
Max. Negotiated Rate |
$3.90 |
Rate for Payer: Aetna Commercial |
$3.68
|
Rate for Payer: Aetna New Business (MI Preferred) |
$2.81
|
Rate for Payer: Cash Price |
$3.46
|
Rate for Payer: Cofinity Commercial |
$3.03
|
Rate for Payer: Cofinity Commercial |
$3.72
|
Rate for Payer: Healthscope Commercial |
$3.90
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.68
|
Rate for Payer: PHP Commercial |
$3.68
|
Rate for Payer: Priority Health Cigna Priority Health |
$3.03
|
Rate for Payer: Priority Health SBD |
$2.73
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$265.55
|
|
Service Code
|
NDC 72606-509-02
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$167.30 |
Max. Negotiated Rate |
$239.00 |
Rate for Payer: Aetna Commercial |
$225.72
|
Rate for Payer: Aetna New Business (MI Preferred) |
$172.61
|
Rate for Payer: Cash Price |
$212.44
|
Rate for Payer: Cofinity Commercial |
$185.88
|
Rate for Payer: Cofinity Commercial |
$228.37
|
Rate for Payer: Healthscope Commercial |
$239.00
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$225.72
|
Rate for Payer: PHP Commercial |
$225.72
|
Rate for Payer: Priority Health Cigna Priority Health |
$185.88
|
Rate for Payer: Priority Health SBD |
$167.30
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1,386.50
|
|
Service Code
|
NDC 61442-121-10
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$873.50 |
Max. Negotiated Rate |
$1,247.85 |
Rate for Payer: Aetna Commercial |
$1,178.52
|
Rate for Payer: Aetna New Business (MI Preferred) |
$901.22
|
Rate for Payer: Cash Price |
$1,109.20
|
Rate for Payer: Cofinity Commercial |
$1,192.39
|
Rate for Payer: Cofinity Commercial |
$970.55
|
Rate for Payer: Healthscope Commercial |
$1,247.85
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,178.52
|
Rate for Payer: PHP Commercial |
$1,178.52
|
Rate for Payer: Priority Health Cigna Priority Health |
$970.55
|
Rate for Payer: Priority Health SBD |
$873.50
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
Service Code
|
NDC 50268-303-15
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$69.58 |
Max. Negotiated Rate |
$99.40 |
Rate for Payer: Aetna Commercial |
$93.88
|
Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
Rate for Payer: Cash Price |
$88.36
|
Rate for Payer: Cofinity Commercial |
$77.32
|
Rate for Payer: Cofinity Commercial |
$94.99
|
Rate for Payer: Healthscope Commercial |
$99.40
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
Rate for Payer: PHP Commercial |
$93.88
|
Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
Rate for Payer: Priority Health SBD |
$69.58
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
Service Code
|
NDC 61442-121-01
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$94.75 |
Max. Negotiated Rate |
$135.36 |
Rate for Payer: Aetna Commercial |
$127.84
|
Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
Rate for Payer: Cash Price |
$120.32
|
Rate for Payer: Cofinity Commercial |
$105.28
|
Rate for Payer: Cofinity Commercial |
$129.34
|
Rate for Payer: Healthscope Commercial |
$135.36
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
Rate for Payer: PHP Commercial |
$127.84
|
Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
Rate for Payer: Priority Health SBD |
$94.75
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
Service Code
|
NDC 62332-001-31
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$137.69 |
Max. Negotiated Rate |
$196.70 |
Rate for Payer: Aetna Commercial |
$185.77
|
Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
Rate for Payer: Cash Price |
$174.84
|
Rate for Payer: Cofinity Commercial |
$187.95
|
Rate for Payer: Cofinity Commercial |
$152.98
|
Rate for Payer: Healthscope Commercial |
$196.70
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
Rate for Payer: PHP Commercial |
$185.77
|
Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
Rate for Payer: Priority Health SBD |
$137.69
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$4,550.26
|
|
Service Code
|
NDC 0187-4420-10
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$2,866.66 |
Max. Negotiated Rate |
$4,095.23 |
Rate for Payer: Aetna Commercial |
$3,867.72
|
Rate for Payer: Aetna New Business (MI Preferred) |
$2,957.67
|
Rate for Payer: Cash Price |
$3,640.21
|
Rate for Payer: Cofinity Commercial |
$3,185.18
|
Rate for Payer: Cofinity Commercial |
$3,913.22
|
Rate for Payer: Healthscope Commercial |
$4,095.23
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,867.72
|
Rate for Payer: PHP Commercial |
$3,867.72
|
Rate for Payer: Priority Health Cigna Priority Health |
$3,185.18
|
Rate for Payer: Priority Health SBD |
$2,866.66
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1.49
|
|
Service Code
|
NDC 51079-966-01
|
Hospital Charge Code |
10011
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.94 |
Max. Negotiated Rate |
$1.34 |
Rate for Payer: Aetna Commercial |
$1.27
|
Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
Rate for Payer: Cash Price |
$1.19
|
Rate for Payer: Cofinity Commercial |
$1.04
|
Rate for Payer: Cofinity Commercial |
$1.28
|
Rate for Payer: Healthscope Commercial |
$1.34
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.27
|
Rate for Payer: PHP Commercial |
$1.27
|
Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
Rate for Payer: Priority Health SBD |
$0.94
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$4.47
|
|
Service Code
|
NDC 50268-304-11
|
Hospital Charge Code |
10012
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$2.82 |
Max. Negotiated Rate |
$4.02 |
Rate for Payer: Aetna Commercial |
$3.80
|
Rate for Payer: Aetna New Business (MI Preferred) |
$2.91
|
Rate for Payer: Cash Price |
$3.58
|
Rate for Payer: Cofinity Commercial |
$3.13
|
Rate for Payer: Cofinity Commercial |
$3.84
|
Rate for Payer: Healthscope Commercial |
$4.02
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.80
|
Rate for Payer: PHP Commercial |
$3.80
|
Rate for Payer: Priority Health Cigna Priority Health |
$3.13
|
Rate for Payer: Priority Health SBD |
$2.82
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$8,794.90
|
|
Service Code
|
NDC 0187-4440-10
|
Hospital Charge Code |
10012
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$5,540.79 |
Max. Negotiated Rate |
$7,915.41 |
Rate for Payer: Aetna Commercial |
$7,475.66
|
Rate for Payer: Aetna New Business (MI Preferred) |
$5,716.68
|
Rate for Payer: Cash Price |
$7,035.92
|
Rate for Payer: Cofinity Commercial |
$6,156.43
|
Rate for Payer: Cofinity Commercial |
$7,563.61
|
Rate for Payer: Healthscope Commercial |
$7,915.41
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,475.66
|
Rate for Payer: PHP Commercial |
$7,475.66
|
Rate for Payer: Priority Health Cigna Priority Health |
$6,156.43
|
Rate for Payer: Priority Health SBD |
$5,540.79
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$152.75
|
|
Service Code
|
NDC 0172-5729-60
|
Hospital Charge Code |
10012
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$96.23 |
Max. Negotiated Rate |
$137.48 |
Rate for Payer: Aetna Commercial |
$129.84
|
Rate for Payer: Aetna New Business (MI Preferred) |
$99.29
|
Rate for Payer: Cash Price |
$122.20
|
Rate for Payer: Cofinity Commercial |
$106.92
|
Rate for Payer: Cofinity Commercial |
$131.36
|
Rate for Payer: Healthscope Commercial |
$137.48
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.84
|
Rate for Payer: PHP Commercial |
$129.84
|
Rate for Payer: Priority Health Cigna Priority Health |
$106.92
|
Rate for Payer: Priority Health SBD |
$96.23
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$223.25
|
|
Service Code
|
NDC 50268-304-15
|
Hospital Charge Code |
10012
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$140.65 |
Max. Negotiated Rate |
$200.92 |
Rate for Payer: Aetna Commercial |
$189.76
|
Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
Rate for Payer: Cash Price |
$178.60
|
Rate for Payer: Cofinity Commercial |
$156.28
|
Rate for Payer: Cofinity Commercial |
$192.00
|
Rate for Payer: Healthscope Commercial |
$200.92
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.76
|
Rate for Payer: PHP Commercial |
$189.76
|
Rate for Payer: Priority Health Cigna Priority Health |
$156.28
|
Rate for Payer: Priority Health SBD |
$140.65
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
Service Code
|
NDC 0172-5729-70
|
Hospital Charge Code |
10012
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$518.18 |
Max. Negotiated Rate |
$740.25 |
Rate for Payer: Aetna Commercial |
$699.12
|
Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
Rate for Payer: Cash Price |
$658.00
|
Rate for Payer: Cofinity Commercial |
$575.75
|
Rate for Payer: Cofinity Commercial |
$707.35
|
Rate for Payer: Healthscope Commercial |
$740.25
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$699.12
|
Rate for Payer: PHP Commercial |
$699.12
|
Rate for Payer: Priority Health Cigna Priority Health |
$575.75
|
Rate for Payer: Priority Health SBD |
$518.18
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$272.60
|
|
Service Code
|
NDC 61442-122-01
|
Hospital Charge Code |
10012
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$171.74 |
Max. Negotiated Rate |
$245.34 |
Rate for Payer: Aetna Commercial |
$231.71
|
Rate for Payer: Aetna New Business (MI Preferred) |
$177.19
|
Rate for Payer: Cash Price |
$218.08
|
Rate for Payer: Cofinity Commercial |
$190.82
|
Rate for Payer: Cofinity Commercial |
$234.44
|
Rate for Payer: Healthscope Commercial |
$245.34
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$231.71
|
Rate for Payer: PHP Commercial |
$231.71
|
Rate for Payer: Priority Health Cigna Priority Health |
$190.82
|
Rate for Payer: Priority Health SBD |
$171.74
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.21
|
|
Service Code
|
NDC 0641-6022-01
|
Hospital Charge Code |
117801
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$4.88 |
Max. Negotiated Rate |
$10.99 |
Rate for Payer: Aetna Commercial |
$10.38
|
Rate for Payer: Aetna New Business (MI Preferred) |
$7.94
|
Rate for Payer: BCBS Complete |
$4.88
|
Rate for Payer: Cash Price |
$9.77
|
Rate for Payer: Cofinity Commercial |
$10.50
|
Rate for Payer: Cofinity Commercial |
$8.55
|
Rate for Payer: Healthscope Commercial |
$10.99
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
Rate for Payer: PHP Commercial |
$10.38
|
Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
Rate for Payer: Priority Health SBD |
$7.69
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
Service Code
|
NDC 63323-739-12
|
Hospital Charge Code |
117801
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$6.42 |
Max. Negotiated Rate |
$14.44 |
Rate for Payer: Aetna Commercial |
$13.64
|
Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
Rate for Payer: BCBS Complete |
$6.42
|
Rate for Payer: Cash Price |
$12.84
|
Rate for Payer: Cofinity Commercial |
$11.24
|
Rate for Payer: Cofinity Commercial |
$13.80
|
Rate for Payer: Healthscope Commercial |
$14.44
|
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
Rate for Payer: PHP Commercial |
$13.64
|
Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
Rate for Payer: Priority Health SBD |
$10.11
|
|