|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 51079030101
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.46
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cofinity Advantage |
$1.57
|
| Rate for Payer: Cofinity Commercial |
$1.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.79
|
| Rate for Payer: Healthscope Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.68
|
| Rate for Payer: PHP Commercial |
$1.90
|
| Rate for Payer: Priority Health SBD |
$1.41
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$155.10
|
|
|
Service Code
|
NDC 52817018210
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.71 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna Commercial |
$131.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.81
|
| Rate for Payer: Cash Price |
$124.08
|
| Rate for Payer: Cofinity Advantage |
$108.57
|
| Rate for Payer: Cofinity Commercial |
$133.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$139.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.33
|
| Rate for Payer: PHP Commercial |
$131.84
|
| Rate for Payer: Priority Health SBD |
$97.71
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$244.40
|
|
|
Service Code
|
NDC 29300013701
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna Medicare |
$122.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: BCBS Complete |
$97.76
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Advantage |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$195.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.30
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health SBD |
$153.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$158.86
|
| Rate for Payer: UHC Core |
$127.33
|
| Rate for Payer: UHC Exchange |
$96.05
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 00228212910
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.35 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 51079030120
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.65 |
| Max. Negotiated Rate |
$200.93 |
| 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 Advantage |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$167.44
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health SBD |
$140.65
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$223.25
|
|
|
Service Code
|
NDC 51079030120
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.74 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna Medicare |
$111.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: BCBS Complete |
$89.30
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Advantage |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$178.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$167.44
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health SBD |
$140.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$145.11
|
| Rate for Payer: UHC Core |
$116.31
|
| Rate for Payer: UHC Exchange |
$87.74
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$159.60
|
|
|
Service Code
|
NDC 50268019415
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.55 |
| Max. Negotiated Rate |
$143.64 |
| Rate for Payer: Aetna Commercial |
$135.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.74
|
| Rate for Payer: Cash Price |
$127.68
|
| Rate for Payer: Cofinity Advantage |
$111.72
|
| Rate for Payer: Cofinity Commercial |
$137.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.68
|
| Rate for Payer: Healthscope Commercial |
$143.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$119.70
|
| Rate for Payer: PHP Commercial |
$135.66
|
| Rate for Payer: Priority Health SBD |
$100.55
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 00228212910
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.49 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.12
|
| Rate for Payer: UHC Core |
$72.24
|
| Rate for Payer: UHC Exchange |
$54.49
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 50268019411
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna Commercial |
$2.72
|
| Rate for Payer: Aetna Medicare |
$1.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.08
|
| Rate for Payer: BCBS Complete |
$1.28
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cofinity Advantage |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.56
|
| Rate for Payer: Healthscope Commercial |
$2.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.08
|
| Rate for Payer: UHC Core |
$1.67
|
| Rate for Payer: UHC Exchange |
$1.26
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$155.10
|
|
|
Service Code
|
NDC 52817018210
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.95 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna Commercial |
$131.84
|
| Rate for Payer: Aetna Medicare |
$77.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.81
|
| Rate for Payer: BCBS Complete |
$62.04
|
| Rate for Payer: Cash Price |
$124.08
|
| Rate for Payer: Cofinity Advantage |
$108.57
|
| Rate for Payer: Cofinity Commercial |
$133.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$139.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$124.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.33
|
| Rate for Payer: PHP Commercial |
$131.84
|
| Rate for Payer: Priority Health SBD |
$97.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$100.81
|
| Rate for Payer: UHC Core |
$80.81
|
| Rate for Payer: UHC Exchange |
$60.95
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.65 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$202.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$323.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.73
|
| Rate for Payer: UHC Core |
$210.59
|
| Rate for Payer: UHC Exchange |
$158.85
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$97.29
|
|
|
Service Code
|
NDC 16729021815
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.23 |
| Max. Negotiated Rate |
$87.56 |
| Rate for Payer: Aetna Commercial |
$82.70
|
| Rate for Payer: Aetna Medicare |
$48.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.24
|
| Rate for Payer: BCBS Complete |
$38.92
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cofinity Advantage |
$68.10
|
| Rate for Payer: Cofinity Commercial |
$83.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.83
|
| Rate for Payer: Healthscope Commercial |
$87.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$72.97
|
| Rate for Payer: PHP Commercial |
$82.70
|
| Rate for Payer: Priority Health SBD |
$61.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.24
|
| Rate for Payer: UHC Core |
$50.69
|
| Rate for Payer: UHC Exchange |
$38.23
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$97.29
|
|
|
Service Code
|
NDC 16729021815
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.29 |
| Max. Negotiated Rate |
$87.56 |
| Rate for Payer: Aetna Commercial |
$82.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.24
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cofinity Advantage |
$68.10
|
| Rate for Payer: Cofinity Commercial |
$83.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.83
|
| Rate for Payer: Healthscope Commercial |
$87.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$72.97
|
| Rate for Payer: PHP Commercial |
$82.70
|
| Rate for Payer: Priority Health SBD |
$61.29
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$260.30
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.30 |
| Max. Negotiated Rate |
$234.27 |
| Rate for Payer: Aetna Commercial |
$221.25
|
| Rate for Payer: Aetna Medicare |
$130.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.19
|
| Rate for Payer: BCBS Complete |
$104.12
|
| Rate for Payer: Cash Price |
$208.24
|
| Rate for Payer: Cofinity Advantage |
$182.21
|
| Rate for Payer: Cofinity Commercial |
$223.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.24
|
| Rate for Payer: Healthscope Commercial |
$234.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.22
|
| Rate for Payer: PHP Commercial |
$221.25
|
| Rate for Payer: Priority Health SBD |
$163.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.19
|
| Rate for Payer: UHC Core |
$135.62
|
| Rate for Payer: UHC Exchange |
$102.30
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$116.33
|
|
|
Service Code
|
NDC 67877027690
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Aetna Commercial |
$98.88
|
| Rate for Payer: Aetna Medicare |
$58.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.61
|
| Rate for Payer: BCBS Complete |
$46.53
|
| Rate for Payer: Cash Price |
$93.06
|
| Rate for Payer: Cofinity Advantage |
$81.43
|
| Rate for Payer: Cofinity Commercial |
$100.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.06
|
| Rate for Payer: Healthscope Commercial |
$104.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.25
|
| Rate for Payer: PHP Commercial |
$98.88
|
| Rate for Payer: Priority Health SBD |
$73.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.61
|
| Rate for Payer: UHC Core |
$60.61
|
| Rate for Payer: UHC Exchange |
$45.72
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$109.98
|
|
|
Service Code
|
NDC 50228012490
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.29 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Advantage |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health SBD |
$69.29
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$109.98
|
|
|
Service Code
|
NDC 50228012490
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna Medicare |
$54.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: BCBS Complete |
$43.99
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Advantage |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$87.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.49
|
| Rate for Payer: UHC Core |
$57.30
|
| Rate for Payer: UHC Exchange |
$43.22
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health SBD |
$1.64
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$116.33
|
|
|
Service Code
|
NDC 67877027690
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.29 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Aetna Commercial |
$98.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.61
|
| Rate for Payer: Cash Price |
$93.06
|
| Rate for Payer: Cofinity Advantage |
$81.43
|
| Rate for Payer: Cofinity Commercial |
$100.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.06
|
| Rate for Payer: Healthscope Commercial |
$104.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.25
|
| Rate for Payer: PHP Commercial |
$98.88
|
| Rate for Payer: Priority Health SBD |
$73.29
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$260.30
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.99 |
| Max. Negotiated Rate |
$234.27 |
| Rate for Payer: Aetna Commercial |
$221.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.19
|
| Rate for Payer: Cash Price |
$208.24
|
| Rate for Payer: Cofinity Advantage |
$182.21
|
| Rate for Payer: Cofinity Commercial |
$223.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.24
|
| Rate for Payer: Healthscope Commercial |
$234.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.22
|
| Rate for Payer: PHP Commercial |
$221.25
|
| Rate for Payer: Priority Health SBD |
$163.99
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$2.61
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.70
|
| Rate for Payer: UHC Core |
$1.36
|
| Rate for Payer: UHC Exchange |
$1.03
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
NDC 51672404201
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.49 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna Medicare |
$222.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: BCBS Complete |
$177.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Advantage |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$355.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.00
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.60
|
| Rate for Payer: UHC Core |
$231.32
|
| Rate for Payer: UHC Exchange |
$174.49
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
NDC 51672404201
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$279.72 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Advantage |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.00
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health SBD |
$279.72
|
|
|
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION
|
Facility
|
OP
|
$10,683.35
|
|
|
Service Code
|
CPT 21320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,727.75 |
| Max. Negotiated Rate |
$10,683.35 |
| Rate for Payer: Aetna Medicare |
$3,435.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,129.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,129.43
|
| Rate for Payer: BCBS Complete |
$1,814.30
|
| Rate for Payer: BCBS MAPPO |
$3,303.54
|
| Rate for Payer: BCBS Trust/PPO |
$1,944.25
|
| Rate for Payer: BCN Commercial |
$1,944.25
|
| Rate for Payer: BCN Medicare Advantage |
$3,303.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,303.54
|
| Rate for Payer: Mclaren Medicaid |
$1,727.75
|
| Rate for Payer: Mclaren Medicare |
$3,303.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,468.72
|
| Rate for Payer: Meridian Medicaid |
$3,468.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,799.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,633.89
|
| Rate for Payer: Nomi Health Commercial |
$9,910.62
|
| Rate for Payer: PACE Medicare |
$3,138.36
|
| Rate for Payer: PACE SWMI |
$3,303.54
|
| Rate for Payer: PHP Medicare Advantage |
$3,303.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,727.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,683.35
|
| Rate for Payer: Priority Health Medicare |
$3,303.54
|
| Rate for Payer: Priority Health Tiered Network |
$8,546.68
|
| Rate for Payer: Railroad Medicare Medicare |
$3,303.54
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,303.54
|
| Rate for Payer: UHC Medicaid |
$1,727.75
|
| Rate for Payer: UHCCP Medicaid |
$1,727.75
|
| Rate for Payer: VA VA |
$3,303.54
|
|
