|
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP
|
Facility
|
OP
|
$8,943.95
|
|
|
Service Code
|
CPT 46288
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,446.45 |
| Max. Negotiated Rate |
$8,943.95 |
| Rate for Payer: Aetna Medicare |
$2,876.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,457.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,457.10
|
| Rate for Payer: BCBS Complete |
$1,518.91
|
| Rate for Payer: BCBS MAPPO |
$2,765.68
|
| Rate for Payer: BCBS Trust/PPO |
$1,647.57
|
| Rate for Payer: BCN Commercial |
$1,647.57
|
| Rate for Payer: BCN Medicare Advantage |
$2,765.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,765.68
|
| Rate for Payer: Mclaren Medicaid |
$1,446.45
|
| Rate for Payer: Mclaren Medicare |
$2,765.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,903.96
|
| Rate for Payer: Meridian Medicaid |
$2,903.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,180.53
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,042.25
|
| Rate for Payer: Nomi Health Commercial |
$8,297.04
|
| Rate for Payer: PACE Medicare |
$2,627.40
|
| Rate for Payer: PACE SWMI |
$2,765.68
|
| Rate for Payer: PHP Medicare Advantage |
$2,765.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,446.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$8,943.95
|
| Rate for Payer: Priority Health Medicare |
$2,765.68
|
| Rate for Payer: Priority Health Tiered Network |
$7,155.16
|
| Rate for Payer: Railroad Medicare Medicare |
$2,765.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$2,765.68
|
| Rate for Payer: UHC Medicaid |
$1,446.45
|
| Rate for Payer: UHCCP Medicaid |
$1,446.45
|
| Rate for Payer: VA VA |
$2,765.68
|
|
|
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH
|
Facility
|
OP
|
$10,430.93
|
|
|
Service Code
|
CPT 57300
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,576.91 |
| Max. Negotiated Rate |
$10,430.93 |
| Rate for Payer: Aetna Medicare |
$3,354.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,031.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,031.86
|
| Rate for Payer: BCBS Complete |
$1,771.44
|
| Rate for Payer: BCBS MAPPO |
$3,225.49
|
| Rate for Payer: BCBS Trust/PPO |
$1,576.91
|
| Rate for Payer: BCN Commercial |
$1,576.91
|
| Rate for Payer: BCN Medicare Advantage |
$3,225.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,225.49
|
| Rate for Payer: Mclaren Medicaid |
$1,686.93
|
| Rate for Payer: Mclaren Medicare |
$3,225.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,386.76
|
| Rate for Payer: Meridian Medicaid |
$3,386.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,709.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,548.04
|
| Rate for Payer: Nomi Health Commercial |
$9,676.47
|
| Rate for Payer: PACE Medicare |
$3,064.22
|
| Rate for Payer: PACE SWMI |
$3,225.49
|
| Rate for Payer: PHP Medicare Advantage |
$3,225.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,686.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,430.93
|
| Rate for Payer: Priority Health Medicare |
$3,225.49
|
| Rate for Payer: Priority Health Tiered Network |
$8,344.74
|
| Rate for Payer: Railroad Medicare Medicare |
$3,225.49
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,225.49
|
| Rate for Payer: UHC Medicaid |
$1,686.93
|
| Rate for Payer: UHCCP Medicaid |
$1,686.93
|
| Rate for Payer: VA VA |
$3,225.49
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$9.72
|
|
|
Service Code
|
NDC 00536126526
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$8.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.32
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cofinity Advantage |
$6.80
|
| Rate for Payer: Cofinity Commercial |
$8.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.78
|
| Rate for Payer: Healthscope Commercial |
$8.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.29
|
| Rate for Payer: PHP Commercial |
$8.26
|
| Rate for Payer: Priority Health SBD |
$6.12
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$30.40
|
|
|
Service Code
|
NDC 51672127506
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.15 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Aetna Commercial |
$25.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.76
|
| Rate for Payer: Cash Price |
$24.32
|
| Rate for Payer: Cofinity Advantage |
$21.28
|
| Rate for Payer: Cofinity Commercial |
$26.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.32
|
| Rate for Payer: Healthscope Commercial |
$27.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.80
|
| Rate for Payer: PHP Commercial |
$25.84
|
| Rate for Payer: Priority Health SBD |
$19.15
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$9.72
|
|
|
Service Code
|
NDC 00536126526
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$8.26
|
| Rate for Payer: Aetna Medicare |
$4.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.32
|
| Rate for Payer: BCBS Complete |
$3.89
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cofinity Advantage |
$6.80
|
| Rate for Payer: Cofinity Commercial |
$8.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.78
|
| Rate for Payer: Healthscope Commercial |
$8.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.29
|
| Rate for Payer: PHP Commercial |
$8.26
|
| Rate for Payer: Priority Health SBD |
$6.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.32
|
| Rate for Payer: UHC Core |
$5.06
|
| Rate for Payer: UHC Exchange |
$3.82
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$30.40
|
|
|
Service Code
|
NDC 51672127506
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.95 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Aetna Commercial |
$25.84
|
| Rate for Payer: Aetna Medicare |
$15.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.76
|
| Rate for Payer: BCBS Complete |
$12.16
|
| Rate for Payer: Cash Price |
$24.32
|
| Rate for Payer: Cofinity Advantage |
$21.28
|
| Rate for Payer: Cofinity Commercial |
$26.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.32
|
| Rate for Payer: Healthscope Commercial |
$27.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.80
|
| Rate for Payer: PHP Commercial |
$25.84
|
| Rate for Payer: Priority Health SBD |
$19.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.76
|
| Rate for Payer: UHC Core |
$15.84
|
| Rate for Payer: UHC Exchange |
$11.95
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION
|
Facility
|
IP
|
$194.57
|
|
|
Service Code
|
NDC 51672126003
|
| Hospital Charge Code |
1768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.58 |
| Max. Negotiated Rate |
$175.11 |
| Rate for Payer: Aetna Commercial |
$165.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.47
|
| Rate for Payer: Cash Price |
$155.66
|
| Rate for Payer: Cofinity Advantage |
$136.20
|
| Rate for Payer: Cofinity Commercial |
$167.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.66
|
| Rate for Payer: Healthscope Commercial |
$175.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$145.93
|
| Rate for Payer: PHP Commercial |
$165.38
|
| Rate for Payer: Priority Health SBD |
$122.58
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION
|
Facility
|
OP
|
$194.57
|
|
|
Service Code
|
NDC 51672126003
|
| Hospital Charge Code |
1768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.47 |
| Max. Negotiated Rate |
$175.11 |
| Rate for Payer: Aetna Commercial |
$165.38
|
| Rate for Payer: Aetna Medicare |
$97.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.47
|
| Rate for Payer: BCBS Complete |
$77.83
|
| Rate for Payer: Cash Price |
$155.66
|
| Rate for Payer: Cofinity Advantage |
$136.20
|
| Rate for Payer: Cofinity Commercial |
$167.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.66
|
| Rate for Payer: Healthscope Commercial |
$175.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$155.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$145.93
|
| Rate for Payer: PHP Commercial |
$165.38
|
| Rate for Payer: Priority Health SBD |
$122.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.47
|
| Rate for Payer: UHC Core |
$101.37
|
| Rate for Payer: UHC Exchange |
$76.47
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Advantage |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.87
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Core |
$1.99
|
| Rate for Payer: UHC Exchange |
$1.50
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.97 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna Medicare |
$190.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: BCBS Complete |
$152.64
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Advantage |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$305.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.20
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health SBD |
$240.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.04
|
| Rate for Payer: UHC Core |
$198.81
|
| Rate for Payer: UHC Exchange |
$149.97
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$323.52
|
|
|
Service Code
|
NDC 00904708761
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.14 |
| Max. Negotiated Rate |
$291.17 |
| Rate for Payer: Aetna Commercial |
$274.99
|
| Rate for Payer: Aetna Medicare |
$161.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.29
|
| Rate for Payer: BCBS Complete |
$129.41
|
| Rate for Payer: Cash Price |
$258.82
|
| Rate for Payer: Cofinity Advantage |
$226.46
|
| Rate for Payer: Cofinity Commercial |
$278.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$258.82
|
| Rate for Payer: Healthscope Commercial |
$291.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$258.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.64
|
| Rate for Payer: PHP Commercial |
$274.99
|
| Rate for Payer: Priority Health SBD |
$203.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.29
|
| Rate for Payer: UHC Core |
$168.55
|
| Rate for Payer: UHC Exchange |
$127.14
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.41 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Advantage |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.20
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health SBD |
$240.41
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$334.56
|
|
|
Service Code
|
NDC 65862084601
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.77 |
| Max. Negotiated Rate |
$301.10 |
| Rate for Payer: Aetna Commercial |
$284.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.46
|
| Rate for Payer: Cash Price |
$267.65
|
| Rate for Payer: Cofinity Advantage |
$234.19
|
| Rate for Payer: Cofinity Commercial |
$287.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.65
|
| Rate for Payer: Healthscope Commercial |
$301.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$250.92
|
| Rate for Payer: PHP Commercial |
$284.38
|
| Rate for Payer: Priority Health SBD |
$210.77
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$323.52
|
|
|
Service Code
|
NDC 00904708761
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.82 |
| Max. Negotiated Rate |
$291.17 |
| Rate for Payer: Aetna Commercial |
$274.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.29
|
| Rate for Payer: Cash Price |
$258.82
|
| Rate for Payer: Cofinity Advantage |
$226.46
|
| Rate for Payer: Cofinity Commercial |
$278.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$258.82
|
| Rate for Payer: Healthscope Commercial |
$291.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.64
|
| Rate for Payer: PHP Commercial |
$274.99
|
| Rate for Payer: Priority Health SBD |
$203.82
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Advantage |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.87
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health SBD |
$2.41
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$334.56
|
|
|
Service Code
|
NDC 65862084601
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.48 |
| Max. Negotiated Rate |
$301.10 |
| Rate for Payer: Aetna Commercial |
$284.38
|
| Rate for Payer: Aetna Medicare |
$167.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.46
|
| Rate for Payer: BCBS Complete |
$133.82
|
| Rate for Payer: Cash Price |
$267.65
|
| Rate for Payer: Cofinity Advantage |
$234.19
|
| Rate for Payer: Cofinity Commercial |
$287.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.65
|
| Rate for Payer: Healthscope Commercial |
$301.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$267.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$250.92
|
| Rate for Payer: PHP Commercial |
$284.38
|
| Rate for Payer: Priority Health SBD |
$210.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.46
|
| Rate for Payer: UHC Core |
$174.31
|
| Rate for Payer: UHC Exchange |
$131.48
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
OP
|
$271.70
|
|
|
Service Code
|
NDC 51079092120
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.78 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna Medicare |
$135.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: BCBS Complete |
$108.68
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$217.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.60
|
| Rate for Payer: UHC Core |
$141.56
|
| Rate for Payer: UHC Exchange |
$106.78
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$271.70
|
|
|
Service Code
|
NDC 51079092120
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.17 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$2.72
|
|
|
Service Code
|
NDC 51079092101
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
OP
|
$2.72
|
|
|
Service Code
|
NDC 51079092101
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna Medicare |
$1.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: BCBS Complete |
$1.09
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.77
|
| Rate for Payer: UHC Core |
$1.42
|
| Rate for Payer: UHC Exchange |
$1.07
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$277.40
|
|
|
Service Code
|
NDC 65862084401
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.76 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Advantage |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.05
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health SBD |
$174.76
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 65862084401
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.02 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Advantage |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$221.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.05
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$180.31
|
| Rate for Payer: UHC Core |
$144.53
|
| Rate for Payer: UHC Exchange |
$109.02
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
|
IP
|
$26,513.41
|
|
|
Service Code
|
APR-DRG 6614
|
| Min. Negotiated Rate |
$25,250.86 |
| Max. Negotiated Rate |
$26,513.41 |
| Rate for Payer: BCBS Complete |
$26,513.41
|
| Rate for Payer: Mclaren Medicaid |
$25,250.86
|
| Rate for Payer: Meridian Medicaid |
$26,513.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$25,250.86
|
| Rate for Payer: UHC Medicaid |
$25,250.86
|
| Rate for Payer: UHCCP Medicaid |
$25,250.86
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
|
IP
|
$4,435.62
|
|
|
Service Code
|
APR-DRG 6611
|
| Min. Negotiated Rate |
$4,224.40 |
| Max. Negotiated Rate |
$4,435.62 |
| Rate for Payer: BCBS Complete |
$4,435.62
|
| Rate for Payer: Mclaren Medicaid |
$4,224.40
|
| Rate for Payer: Meridian Medicaid |
$4,435.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,224.40
|
| Rate for Payer: UHC Medicaid |
$4,224.40
|
| Rate for Payer: UHCCP Medicaid |
$4,224.40
|
|
|
COAGULATION AND PLATELET DISORDERS
|
Facility
|
IP
|
$7,377.22
|
|
|
Service Code
|
APR-DRG 6612
|
| Min. Negotiated Rate |
$7,025.93 |
| Max. Negotiated Rate |
$7,377.22 |
| Rate for Payer: BCBS Complete |
$7,377.22
|
| Rate for Payer: Mclaren Medicaid |
$7,025.93
|
| Rate for Payer: Meridian Medicaid |
$7,377.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$7,025.93
|
| Rate for Payer: UHC Medicaid |
$7,025.93
|
| Rate for Payer: UHCCP Medicaid |
$7,025.93
|
|
