|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.76 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Advantage |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.15
|
| Rate for Payer: UHC Core |
$12.94
|
| Rate for Payer: UHC Exchange |
$9.76
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$25.94
|
|
|
Service Code
|
NDC 19903001022
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.34 |
| Max. Negotiated Rate |
$23.35 |
| Rate for Payer: Aetna Commercial |
$22.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.86
|
| Rate for Payer: Cash Price |
$20.75
|
| Rate for Payer: Cofinity Advantage |
$18.16
|
| Rate for Payer: Cofinity Commercial |
$22.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.75
|
| Rate for Payer: Healthscope Commercial |
$23.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.45
|
| Rate for Payer: PHP Commercial |
$22.05
|
| Rate for Payer: Priority Health SBD |
$16.34
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$25.94
|
|
|
Service Code
|
NDC 19903001022
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$23.35 |
| Rate for Payer: Aetna Commercial |
$22.05
|
| Rate for Payer: Aetna Medicare |
$12.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.86
|
| Rate for Payer: BCBS Complete |
$10.38
|
| Rate for Payer: Cash Price |
$20.75
|
| Rate for Payer: Cofinity Advantage |
$18.16
|
| Rate for Payer: Cofinity Commercial |
$22.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.75
|
| Rate for Payer: Healthscope Commercial |
$23.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.45
|
| Rate for Payer: PHP Commercial |
$22.05
|
| Rate for Payer: Priority Health SBD |
$16.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.86
|
| Rate for Payer: UHC Core |
$13.51
|
| Rate for Payer: UHC Exchange |
$10.19
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$9.18
|
|
|
Service Code
|
NDC 00536130375
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Aetna Commercial |
$7.80
|
| Rate for Payer: Aetna Medicare |
$4.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.97
|
| Rate for Payer: BCBS Complete |
$3.67
|
| Rate for Payer: Cash Price |
$7.34
|
| Rate for Payer: Cofinity Advantage |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$7.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.34
|
| Rate for Payer: Healthscope Commercial |
$8.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.88
|
| Rate for Payer: PHP Commercial |
$7.80
|
| Rate for Payer: Priority Health SBD |
$5.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.97
|
| Rate for Payer: UHC Core |
$4.78
|
| Rate for Payer: UHC Exchange |
$3.61
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Advantage |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$9.18
|
|
|
Service Code
|
NDC 00536130375
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Aetna Commercial |
$7.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.97
|
| Rate for Payer: Cash Price |
$7.34
|
| Rate for Payer: Cofinity Advantage |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$7.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.34
|
| Rate for Payer: Healthscope Commercial |
$8.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.88
|
| Rate for Payer: PHP Commercial |
$7.80
|
| Rate for Payer: Priority Health SBD |
$5.78
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$411.25
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.62 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: Aetna Medicare |
$205.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.31
|
| Rate for Payer: BCBS Complete |
$164.50
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Advantage |
$287.88
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$370.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$329.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$308.44
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health SBD |
$259.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$267.31
|
| Rate for Payer: UHC Core |
$214.26
|
| Rate for Payer: UHC Exchange |
$161.62
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$411.25
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$259.09 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.31
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Advantage |
$287.88
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$370.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$308.44
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health SBD |
$259.09
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 70000043401
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.86 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Advantage |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$58.16
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health SBD |
$48.86
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$72.85
|
|
|
Service Code
|
NDC 09629513606
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.63 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna Medicare |
$36.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: BCBS Complete |
$29.14
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Advantage |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$54.64
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.35
|
| Rate for Payer: UHC Core |
$37.95
|
| Rate for Payer: UHC Exchange |
$28.63
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 70000043401
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.48 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna Medicare |
$38.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Advantage |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$58.16
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.41
|
| Rate for Payer: UHC Core |
$40.40
|
| Rate for Payer: UHC Exchange |
$30.48
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.68
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Advantage |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health SBD |
$2.60
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$4.12
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna Medicare |
$2.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.68
|
| Rate for Payer: BCBS Complete |
$1.65
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Advantage |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health SBD |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.68
|
| Rate for Payer: UHC Core |
$2.15
|
| Rate for Payer: UHC Exchange |
$1.62
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$72.85
|
|
|
Service Code
|
NDC 09629513606
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Advantage |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$54.64
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health SBD |
$45.90
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$13,136.17
|
|
|
Service Code
|
MSDRG 194
|
| Min. Negotiated Rate |
$6,466.82 |
| Max. Negotiated Rate |
$13,136.17 |
| Rate for Payer: Aetna Medicare |
$7,079.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,508.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,508.98
|
| Rate for Payer: BCBS MAPPO |
$6,807.18
|
| Rate for Payer: BCBS Trust/PPO |
$11,458.22
|
| Rate for Payer: BCN Commercial |
$11,458.22
|
| Rate for Payer: BCN Medicare Advantage |
$6,807.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,807.18
|
| Rate for Payer: Mclaren Medicare |
$6,807.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,147.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,828.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,487.90
|
| Rate for Payer: Nomi Health Commercial |
$10,396.11
|
| Rate for Payer: PACE Medicare |
$6,466.82
|
| Rate for Payer: PACE SWMI |
$6,807.18
|
| Rate for Payer: PHP Medicare Advantage |
$6,807.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,992.83
|
| Rate for Payer: Priority Health Medicare |
$6,807.18
|
| Rate for Payer: Priority Health Tiered Network |
$10,394.26
|
| Rate for Payer: Railroad Medicare Medicare |
$6,807.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,136.17
|
| Rate for Payer: UHC Core |
$10,990.06
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,807.18
|
| Rate for Payer: UHC Exchange |
$8,975.31
|
| Rate for Payer: VA VA |
$6,807.18
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$21,424.72
|
|
|
Service Code
|
MSDRG 193
|
| Min. Negotiated Rate |
$10,200.13 |
| Max. Negotiated Rate |
$21,424.72 |
| Rate for Payer: Aetna Medicare |
$11,166.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,421.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,421.23
|
| Rate for Payer: BCBS MAPPO |
$10,736.98
|
| Rate for Payer: BCBS Trust/PPO |
$17,979.68
|
| Rate for Payer: BCN Commercial |
$17,979.68
|
| Rate for Payer: BCN Medicare Advantage |
$10,736.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,736.98
|
| Rate for Payer: Mclaren Medicare |
$10,736.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11,273.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,347.53
|
| Rate for Payer: Molina Medicare/Medicaid |
$11,810.68
|
| Rate for Payer: Nomi Health Commercial |
$16,955.76
|
| Rate for Payer: PACE Medicare |
$10,200.13
|
| Rate for Payer: PACE SWMI |
$10,736.98
|
| Rate for Payer: PHP Medicare Advantage |
$10,736.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$21,190.94
|
| Rate for Payer: Priority Health Medicare |
$10,736.98
|
| Rate for Payer: Priority Health Tiered Network |
$16,952.75
|
| Rate for Payer: Railroad Medicare Medicare |
$10,736.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21,424.72
|
| Rate for Payer: UHC Core |
$17,924.47
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$10,736.98
|
| Rate for Payer: UHC Exchange |
$14,638.47
|
| Rate for Payer: VA VA |
$10,736.98
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$10,244.55
|
|
|
Service Code
|
MSDRG 195
|
| Min. Negotiated Rate |
$5,164.37 |
| Max. Negotiated Rate |
$10,244.55 |
| Rate for Payer: Aetna Medicare |
$5,653.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,795.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,795.23
|
| Rate for Payer: BCBS MAPPO |
$5,436.18
|
| Rate for Payer: BCBS Trust/PPO |
$7,773.80
|
| Rate for Payer: BCN Commercial |
$7,773.80
|
| Rate for Payer: BCN Medicare Advantage |
$5,436.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,436.18
|
| Rate for Payer: Mclaren Medicare |
$5,436.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,707.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,251.61
|
| Rate for Payer: Molina Medicare/Medicaid |
$5,979.80
|
| Rate for Payer: Nomi Health Commercial |
$8,107.65
|
| Rate for Payer: PACE Medicare |
$5,164.37
|
| Rate for Payer: PACE SWMI |
$5,436.18
|
| Rate for Payer: PHP Medicare Advantage |
$5,436.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,132.76
|
| Rate for Payer: Priority Health Medicare |
$5,436.18
|
| Rate for Payer: Priority Health Tiered Network |
$8,106.21
|
| Rate for Payer: Railroad Medicare Medicare |
$5,436.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,244.55
|
| Rate for Payer: UHC Core |
$8,570.85
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,436.18
|
| Rate for Payer: UHC Exchange |
$6,999.60
|
| Rate for Payer: VA VA |
$5,436.18
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 12011
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$105.41
|
| Rate for Payer: BCN Commercial |
$105.41
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 12013
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$142.79
|
| Rate for Payer: BCN Commercial |
$142.79
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 12001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$102.76 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$102.76
|
| Rate for Payer: BCN Commercial |
$102.76
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 12002
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$123.90
|
| Rate for Payer: BCN Commercial |
$123.90
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 12004
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$161.49
|
| Rate for Payer: BCN Commercial |
$161.49
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM
|
Facility
|
OP
|
$646.50
|
|
|
Service Code
|
CPT 12004
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$646.50 |
| Rate for Payer: Aetna Medicare |
$207.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$249.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$249.89
|
| Rate for Payer: BCBS Complete |
$109.79
|
| Rate for Payer: BCBS MAPPO |
$199.91
|
| Rate for Payer: BCBS Trust/PPO |
$161.49
|
| Rate for Payer: BCN Commercial |
$161.49
|
| Rate for Payer: BCN Medicare Advantage |
$199.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$199.91
|
| Rate for Payer: Mclaren Medicaid |
$104.55
|
| Rate for Payer: Mclaren Medicare |
$199.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$209.91
|
| Rate for Payer: Meridian Medicaid |
$209.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$219.90
|
| Rate for Payer: Nomi Health Commercial |
$599.73
|
| Rate for Payer: PACE Medicare |
$189.91
|
| Rate for Payer: PACE SWMI |
$199.91
|
| Rate for Payer: PHP Medicare Advantage |
$199.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$646.50
|
| Rate for Payer: Priority Health Medicare |
$199.91
|
| Rate for Payer: Priority Health Tiered Network |
$517.20
|
| Rate for Payer: Railroad Medicare Medicare |
$199.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$199.91
|
| Rate for Payer: UHC Medicaid |
$104.55
|
| Rate for Payer: UHCCP Medicaid |
$104.55
|
| Rate for Payer: VA VA |
$199.91
|
|
|
SIMPLE SYRUP
|
Facility
|
OP
|
$190.08
|
|
|
Service Code
|
NDC 00395266116
|
| Hospital Charge Code |
7242
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.70 |
| Max. Negotiated Rate |
$171.07 |
| Rate for Payer: Aetna Commercial |
$161.57
|
| Rate for Payer: Aetna Medicare |
$95.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.55
|
| Rate for Payer: BCBS Complete |
$76.03
|
| Rate for Payer: Cash Price |
$152.06
|
| Rate for Payer: Cofinity Advantage |
$133.06
|
| Rate for Payer: Cofinity Commercial |
$163.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.06
|
| Rate for Payer: Healthscope Commercial |
$171.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$152.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$142.56
|
| Rate for Payer: PHP Commercial |
$161.57
|
| Rate for Payer: Priority Health SBD |
$119.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.55
|
| Rate for Payer: UHC Core |
$99.03
|
| Rate for Payer: UHC Exchange |
$74.70
|
|
|
SIMPLE SYRUP
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
NDC 38779177908
|
| Hospital Charge Code |
7242
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.74 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.70
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cofinity Advantage |
$138.60
|
| Rate for Payer: Cofinity Commercial |
$170.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.40
|
| Rate for Payer: Healthscope Commercial |
$178.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$168.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.50
|
| Rate for Payer: PHP Commercial |
$168.30
|
| Rate for Payer: Priority Health SBD |
$124.74
|
|
