|
PRIMIDONE 250 MG TABLET
|
Facility
|
OP
|
$320.15
|
|
|
Service Code
|
NDC 00591532101
|
| Hospital Charge Code |
6544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.46 |
| Max. Negotiated Rate |
$288.13 |
| Rate for Payer: Aetna American Axle |
$208.10
|
| Rate for Payer: Aetna Commercial |
$272.13
|
| Rate for Payer: Aetna Medicare |
$160.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.10
|
| Rate for Payer: BCBS Complete |
$128.06
|
| Rate for Payer: Cash Price |
$256.12
|
| Rate for Payer: Cofinity Commercial |
$224.10
|
| Rate for Payer: Cofinity Commercial |
$275.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$224.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.12
|
| Rate for Payer: Healthscope Commercial |
$288.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$224.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$240.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$272.13
|
| Rate for Payer: PHP Commercial |
$272.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.10
|
| Rate for Payer: Priority Health SBD |
$201.69
|
| Rate for Payer: UMR Bronson Commercial |
$118.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$240.11
|
|
|
PRIMIDONE 250 MG TABLET
|
Facility
|
OP
|
$318.24
|
|
|
Service Code
|
NDC 68084020301
|
| Hospital Charge Code |
6544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.75 |
| Max. Negotiated Rate |
$286.42 |
| Rate for Payer: Aetna American Axle |
$206.86
|
| Rate for Payer: Aetna Commercial |
$270.50
|
| Rate for Payer: Aetna Medicare |
$159.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.86
|
| Rate for Payer: BCBS Complete |
$127.30
|
| Rate for Payer: Cash Price |
$254.59
|
| Rate for Payer: Cofinity Commercial |
$222.77
|
| Rate for Payer: Cofinity Commercial |
$273.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$222.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.59
|
| Rate for Payer: Healthscope Commercial |
$286.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$222.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.50
|
| Rate for Payer: PHP Commercial |
$270.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.86
|
| Rate for Payer: Priority Health SBD |
$200.49
|
| Rate for Payer: UMR Bronson Commercial |
$117.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.68
|
|
|
PRIMIDONE 250 MG TABLET
|
Facility
|
OP
|
$319.20
|
|
|
Service Code
|
NDC 53746054501
|
| Hospital Charge Code |
6544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.10 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna American Axle |
$207.48
|
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: Aetna Medicare |
$159.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.48
|
| Rate for Payer: BCBS Complete |
$127.68
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$274.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.32
|
| Rate for Payer: PHP Commercial |
$271.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.48
|
| Rate for Payer: Priority Health SBD |
$201.10
|
| Rate for Payer: UMR Bronson Commercial |
$118.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
PRIMIDONE 250 MG TABLET
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 68084020311
|
| Hospital Charge Code |
6544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna American Axle |
$2.07
|
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Aetna Medicare |
$1.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.07
|
| Rate for Payer: BCBS Complete |
$1.28
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$2.23
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: PHP Commercial |
$2.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.07
|
| Rate for Payer: Priority Health SBD |
$2.01
|
| Rate for Payer: UMR Bronson Commercial |
$1.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.39
|
|
|
PRIMIDONE 250 MG TABLET
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 68084020311
|
| Hospital Charge Code |
6544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna American Axle |
$2.07
|
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.07
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$2.23
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: PHP Commercial |
$2.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.07
|
| Rate for Payer: Priority Health SBD |
$2.01
|
| Rate for Payer: UMR Bronson Commercial |
$1.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.39
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
OP
|
$356.16
|
|
|
Service Code
|
NDC 68084020201
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.78 |
| Max. Negotiated Rate |
$320.54 |
| Rate for Payer: Aetna American Axle |
$231.50
|
| Rate for Payer: Aetna Commercial |
$302.74
|
| Rate for Payer: Aetna Medicare |
$178.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.50
|
| Rate for Payer: BCBS Complete |
$142.46
|
| Rate for Payer: Cash Price |
$284.93
|
| Rate for Payer: Cofinity Commercial |
$249.31
|
| Rate for Payer: Cofinity Commercial |
$306.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$249.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.93
|
| Rate for Payer: Healthscope Commercial |
$320.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.74
|
| Rate for Payer: PHP Commercial |
$302.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.50
|
| Rate for Payer: Priority Health SBD |
$224.38
|
| Rate for Payer: UMR Bronson Commercial |
$131.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.12
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 68084020211
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna American Axle |
$2.32
|
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$1.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: BCBS Complete |
$1.43
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UMR Bronson Commercial |
$1.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
IP
|
$3.57
|
|
|
Service Code
|
NDC 68084020211
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna American Axle |
$2.32
|
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UMR Bronson Commercial |
$1.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
IP
|
$168.63
|
|
|
Service Code
|
NDC 50268068615
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.20 |
| Max. Negotiated Rate |
$151.77 |
| Rate for Payer: Aetna American Axle |
$109.61
|
| Rate for Payer: Aetna Commercial |
$143.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.61
|
| Rate for Payer: Cash Price |
$134.90
|
| Rate for Payer: Cofinity Commercial |
$118.04
|
| Rate for Payer: Cofinity Commercial |
$145.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.90
|
| Rate for Payer: Healthscope Commercial |
$151.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.34
|
| Rate for Payer: PHP Commercial |
$143.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.61
|
| Rate for Payer: Priority Health SBD |
$106.24
|
| Rate for Payer: UMR Bronson Commercial |
$74.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.47
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
OP
|
$168.63
|
|
|
Service Code
|
NDC 50268068615
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.39 |
| Max. Negotiated Rate |
$151.77 |
| Rate for Payer: Aetna American Axle |
$109.61
|
| Rate for Payer: Aetna Commercial |
$143.34
|
| Rate for Payer: Aetna Medicare |
$84.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.61
|
| Rate for Payer: BCBS Complete |
$67.45
|
| Rate for Payer: Cash Price |
$134.90
|
| Rate for Payer: Cofinity Commercial |
$118.04
|
| Rate for Payer: Cofinity Commercial |
$145.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.90
|
| Rate for Payer: Healthscope Commercial |
$151.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.34
|
| Rate for Payer: PHP Commercial |
$143.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.61
|
| Rate for Payer: Priority Health SBD |
$106.24
|
| Rate for Payer: UMR Bronson Commercial |
$62.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.47
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
IP
|
$347.80
|
|
|
Service Code
|
NDC 00527130101
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.03 |
| Max. Negotiated Rate |
$313.02 |
| Rate for Payer: Aetna American Axle |
$226.07
|
| Rate for Payer: Aetna Commercial |
$295.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.07
|
| Rate for Payer: Cash Price |
$278.24
|
| Rate for Payer: Cofinity Commercial |
$243.46
|
| Rate for Payer: Cofinity Commercial |
$299.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$243.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$278.24
|
| Rate for Payer: Healthscope Commercial |
$313.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$243.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$260.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$295.63
|
| Rate for Payer: PHP Commercial |
$295.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.07
|
| Rate for Payer: Priority Health SBD |
$219.11
|
| Rate for Payer: UMR Bronson Commercial |
$153.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$260.85
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
OP
|
$347.80
|
|
|
Service Code
|
NDC 00527130101
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.69 |
| Max. Negotiated Rate |
$313.02 |
| Rate for Payer: Aetna American Axle |
$226.07
|
| Rate for Payer: Aetna Commercial |
$295.63
|
| Rate for Payer: Aetna Medicare |
$173.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.07
|
| Rate for Payer: BCBS Complete |
$139.12
|
| Rate for Payer: Cash Price |
$278.24
|
| Rate for Payer: Cofinity Commercial |
$243.46
|
| Rate for Payer: Cofinity Commercial |
$299.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$243.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$278.24
|
| Rate for Payer: Healthscope Commercial |
$313.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$243.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$260.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$295.63
|
| Rate for Payer: PHP Commercial |
$295.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.07
|
| Rate for Payer: Priority Health SBD |
$219.11
|
| Rate for Payer: UMR Bronson Commercial |
$128.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$260.85
|
|
|
PRIMIDONE 50 MG TABLET
|
Facility
|
IP
|
$356.16
|
|
|
Service Code
|
NDC 68084020201
|
| Hospital Charge Code |
11129
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.71 |
| Max. Negotiated Rate |
$320.54 |
| Rate for Payer: Aetna American Axle |
$231.50
|
| Rate for Payer: Aetna Commercial |
$302.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.50
|
| Rate for Payer: Cash Price |
$284.93
|
| Rate for Payer: Cofinity Commercial |
$249.31
|
| Rate for Payer: Cofinity Commercial |
$306.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$249.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.93
|
| Rate for Payer: Healthscope Commercial |
$320.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.74
|
| Rate for Payer: PHP Commercial |
$302.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.50
|
| Rate for Payer: Priority Health SBD |
$224.38
|
| Rate for Payer: UMR Bronson Commercial |
$156.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.12
|
|
|
PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 1ST DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0011A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 2ND DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0012A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 3RD DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0013A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 1ST
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0071A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 2ND
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0072A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 3RD
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0073A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE BST
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0074A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 1ST DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0111A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 2ND DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0112A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 1ST DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0001A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 2ND DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0002A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
|
PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 3RD DOSE
|
Professional
|
Both
|
$41.00
|
|
|
Service Code
|
HCPCS 0003A
|
| Min. Negotiated Rate |
$16.40 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Medicare |
$20.50
|
| Rate for Payer: BCBS Complete |
$16.40
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.86
|
|
