|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
OP
|
$214.38
|
|
|
Service Code
|
NDC 00074445604
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$192.94 |
| Rate for Payer: Aetna Commercial |
$182.22
|
| Rate for Payer: Aetna Medicare |
$107.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$139.35
|
| Rate for Payer: BCBS Complete |
$85.75
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$150.07
|
| Rate for Payer: Cofinity Commercial |
$184.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$150.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.50
|
| Rate for Payer: Healthscope Commercial |
$192.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$182.22
|
| Rate for Payer: PHP Commercial |
$182.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.35
|
| Rate for Payer: Priority Health SBD |
$135.06
|
|
|
SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), SUBLINGUAL OR PAROTID, UNCOMPLICATED, INTRAORAL
|
Facility
|
OP
|
$9,986.81
|
|
|
Service Code
|
CPT 42330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$111.46 |
| Max. Negotiated Rate |
$9,986.81 |
| Rate for Payer: Aetna Medicare |
$3,304.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,971.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,971.88
|
| Rate for Payer: BCBS Complete |
$1,788.30
|
| Rate for Payer: BCBS MAPPO |
$3,177.50
|
| Rate for Payer: BCBS Trust/PPO |
$111.46
|
| Rate for Payer: BCN Commercial |
$111.46
|
| Rate for Payer: BCN Medicare Advantage |
$3,177.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,177.50
|
| Rate for Payer: Mclaren Medicaid |
$1,703.14
|
| Rate for Payer: Mclaren Medicare |
$3,177.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,336.38
|
| Rate for Payer: Meridian Medicaid |
$1,788.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,654.12
|
| Rate for Payer: Nomi Health Commercial |
$6,672.75
|
| Rate for Payer: PACE Medicare |
$3,018.62
|
| Rate for Payer: PACE SWMI |
$3,177.50
|
| Rate for Payer: PHP Medicare Advantage |
$3,177.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,986.81
|
| Rate for Payer: Priority Health Medicare |
$3,177.50
|
| Rate for Payer: Priority Health Narrow Network |
$7,989.45
|
| Rate for Payer: Railroad Medicare Medicare |
$3,177.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,944.34
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,177.50
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,177.50
|
| Rate for Payer: UHCCP Medicaid |
$1,788.93
|
| Rate for Payer: VA VA |
$3,177.50
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,807.55
|
|
|
Service Code
|
CPT 45330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$59.28 |
| Max. Negotiated Rate |
$2,807.55 |
| Rate for Payer: Aetna Medicare |
$929.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,116.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,116.60
|
| Rate for Payer: BCBS Complete |
$502.74
|
| Rate for Payer: BCBS MAPPO |
$893.28
|
| Rate for Payer: BCBS Trust/PPO |
$534.94
|
| Rate for Payer: BCN Commercial |
$534.94
|
| Rate for Payer: BCN Medicare Advantage |
$893.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$893.28
|
| Rate for Payer: Mclaren Medicaid |
$478.80
|
| Rate for Payer: Mclaren Medicare |
$893.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$937.94
|
| Rate for Payer: Meridian Medicaid |
$502.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,027.27
|
| Rate for Payer: Nomi Health Commercial |
$1,875.89
|
| Rate for Payer: PACE Medicare |
$848.62
|
| Rate for Payer: PACE SWMI |
$893.28
|
| Rate for Payer: PHP Medicare Advantage |
$893.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$478.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,807.55
|
| Rate for Payer: Priority Health Medicare |
$893.28
|
| Rate for Payer: Priority Health Narrow Network |
$2,246.04
|
| Rate for Payer: Railroad Medicare Medicare |
$893.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.28
|
| Rate for Payer: UHC Core |
$1,463.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$893.28
|
| Rate for Payer: UHC Exchange |
$1,566.00
|
| Rate for Payer: UHC Medicare Advantage |
$893.28
|
| Rate for Payer: UHCCP Medicaid |
$502.92
|
| Rate for Payer: VA VA |
$893.28
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)
|
Facility
|
OP
|
$3,630.90
|
|
|
Service Code
|
CPT 45346
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$167.85 |
| Max. Negotiated Rate |
$3,630.90 |
| Rate for Payer: Aetna Medicare |
$1,201.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,444.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,444.05
|
| Rate for Payer: BCBS Complete |
$650.17
|
| Rate for Payer: BCBS MAPPO |
$1,155.24
|
| Rate for Payer: BCBS Trust/PPO |
$494.57
|
| Rate for Payer: BCN Commercial |
$494.57
|
| Rate for Payer: BCN Medicare Advantage |
$1,155.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,155.24
|
| Rate for Payer: Mclaren Medicaid |
$619.21
|
| Rate for Payer: Mclaren Medicare |
$1,155.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,213.00
|
| Rate for Payer: Meridian Medicaid |
$650.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,328.53
|
| Rate for Payer: Nomi Health Commercial |
$2,426.00
|
| Rate for Payer: PACE Medicare |
$1,097.48
|
| Rate for Payer: PACE SWMI |
$1,155.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,155.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$619.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,630.90
|
| Rate for Payer: Priority Health Medicare |
$1,155.24
|
| Rate for Payer: Priority Health Narrow Network |
$2,904.72
|
| Rate for Payer: Railroad Medicare Medicare |
$1,155.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.85
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,155.24
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,155.24
|
| Rate for Payer: UHCCP Medicaid |
$650.40
|
| Rate for Payer: VA VA |
$1,155.24
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE
|
Facility
|
OP
|
$2,807.55
|
|
|
Service Code
|
CPT 45331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$75.61 |
| Max. Negotiated Rate |
$2,807.55 |
| Rate for Payer: Aetna Medicare |
$929.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,116.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,116.60
|
| Rate for Payer: BCBS Complete |
$502.74
|
| Rate for Payer: BCBS MAPPO |
$893.28
|
| Rate for Payer: BCBS Trust/PPO |
$668.07
|
| Rate for Payer: BCN Commercial |
$668.07
|
| Rate for Payer: BCN Medicare Advantage |
$893.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$893.28
|
| Rate for Payer: Mclaren Medicaid |
$478.80
|
| Rate for Payer: Mclaren Medicare |
$893.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$937.94
|
| Rate for Payer: Meridian Medicaid |
$502.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,027.27
|
| Rate for Payer: Nomi Health Commercial |
$1,875.89
|
| Rate for Payer: PACE Medicare |
$848.62
|
| Rate for Payer: PACE SWMI |
$893.28
|
| Rate for Payer: PHP Medicare Advantage |
$893.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$478.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,807.55
|
| Rate for Payer: Priority Health Medicare |
$893.28
|
| Rate for Payer: Priority Health Narrow Network |
$2,246.04
|
| Rate for Payer: Railroad Medicare Medicare |
$893.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.61
|
| Rate for Payer: UHC Core |
$1,463.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$893.28
|
| Rate for Payer: UHC Exchange |
$1,566.00
|
| Rate for Payer: UHC Medicare Advantage |
$893.28
|
| Rate for Payer: UHCCP Medicaid |
$502.92
|
| Rate for Payer: VA VA |
$893.28
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD
|
Facility
|
OP
|
$3,630.90
|
|
|
Service Code
|
CPT 45334
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$122.87 |
| Max. Negotiated Rate |
$3,630.90 |
| Rate for Payer: Aetna Medicare |
$1,201.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,444.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,444.05
|
| Rate for Payer: BCBS Complete |
$650.17
|
| Rate for Payer: BCBS MAPPO |
$1,155.24
|
| Rate for Payer: BCBS Trust/PPO |
$423.92
|
| Rate for Payer: BCN Commercial |
$423.92
|
| Rate for Payer: BCN Medicare Advantage |
$1,155.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,155.24
|
| Rate for Payer: Mclaren Medicaid |
$619.21
|
| Rate for Payer: Mclaren Medicare |
$1,155.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,213.00
|
| Rate for Payer: Meridian Medicaid |
$650.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,328.53
|
| Rate for Payer: Nomi Health Commercial |
$2,426.00
|
| Rate for Payer: PACE Medicare |
$1,097.48
|
| Rate for Payer: PACE SWMI |
$1,155.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,155.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$619.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,630.90
|
| Rate for Payer: Priority Health Medicare |
$1,155.24
|
| Rate for Payer: Priority Health Narrow Network |
$2,904.72
|
| Rate for Payer: Railroad Medicare Medicare |
$1,155.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.87
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,155.24
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,155.24
|
| Rate for Payer: UHCCP Medicaid |
$650.40
|
| Rate for Payer: VA VA |
$1,155.24
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
|
Facility
|
OP
|
$2,807.55
|
|
|
Service Code
|
CPT 45335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$69.95 |
| Max. Negotiated Rate |
$2,807.55 |
| Rate for Payer: Aetna Medicare |
$929.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,116.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,116.60
|
| Rate for Payer: BCBS Complete |
$502.74
|
| Rate for Payer: BCBS MAPPO |
$893.28
|
| Rate for Payer: BCBS Trust/PPO |
$322.51
|
| Rate for Payer: BCN Commercial |
$322.51
|
| Rate for Payer: BCN Medicare Advantage |
$893.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$893.28
|
| Rate for Payer: Mclaren Medicaid |
$478.80
|
| Rate for Payer: Mclaren Medicare |
$893.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$937.94
|
| Rate for Payer: Meridian Medicaid |
$502.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,027.27
|
| Rate for Payer: Nomi Health Commercial |
$1,875.89
|
| Rate for Payer: PACE Medicare |
$848.62
|
| Rate for Payer: PACE SWMI |
$893.28
|
| Rate for Payer: PHP Medicare Advantage |
$893.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$478.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,807.55
|
| Rate for Payer: Priority Health Medicare |
$893.28
|
| Rate for Payer: Priority Health Narrow Network |
$2,246.04
|
| Rate for Payer: Railroad Medicare Medicare |
$893.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.95
|
| Rate for Payer: UHC Core |
$1,463.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$893.28
|
| Rate for Payer: UHC Exchange |
$1,566.00
|
| Rate for Payer: UHC Medicare Advantage |
$893.28
|
| Rate for Payer: UHCCP Medicaid |
$502.92
|
| Rate for Payer: VA VA |
$893.28
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)
|
Facility
|
OP
|
$3,630.90
|
|
|
Service Code
|
CPT 45332
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$110.62 |
| Max. Negotiated Rate |
$3,630.90 |
| Rate for Payer: Aetna Medicare |
$1,201.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,444.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,444.05
|
| Rate for Payer: BCBS Complete |
$650.17
|
| Rate for Payer: BCBS MAPPO |
$1,155.24
|
| Rate for Payer: BCBS Trust/PPO |
$423.92
|
| Rate for Payer: BCN Commercial |
$423.92
|
| Rate for Payer: BCN Medicare Advantage |
$1,155.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,155.24
|
| Rate for Payer: Mclaren Medicaid |
$619.21
|
| Rate for Payer: Mclaren Medicare |
$1,155.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,213.00
|
| Rate for Payer: Meridian Medicaid |
$650.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,328.53
|
| Rate for Payer: Nomi Health Commercial |
$2,426.00
|
| Rate for Payer: PACE Medicare |
$1,097.48
|
| Rate for Payer: PACE SWMI |
$1,155.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,155.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$619.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,630.90
|
| Rate for Payer: Priority Health Medicare |
$1,155.24
|
| Rate for Payer: Priority Health Narrow Network |
$2,904.72
|
| Rate for Payer: Railroad Medicare Medicare |
$1,155.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$110.62
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,155.24
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,155.24
|
| Rate for Payer: UHCCP Medicaid |
$650.40
|
| Rate for Payer: VA VA |
$1,155.24
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
|
Facility
|
OP
|
$3,630.90
|
|
|
Service Code
|
CPT 45338
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$125.84 |
| Max. Negotiated Rate |
$3,630.90 |
| Rate for Payer: Aetna Medicare |
$1,201.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,444.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,444.05
|
| Rate for Payer: BCBS Complete |
$650.17
|
| Rate for Payer: BCBS MAPPO |
$1,155.24
|
| Rate for Payer: BCBS Trust/PPO |
$851.45
|
| Rate for Payer: BCN Commercial |
$851.45
|
| Rate for Payer: BCN Medicare Advantage |
$1,155.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,155.24
|
| Rate for Payer: Mclaren Medicaid |
$619.21
|
| Rate for Payer: Mclaren Medicare |
$1,155.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,213.00
|
| Rate for Payer: Meridian Medicaid |
$650.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,328.53
|
| Rate for Payer: Nomi Health Commercial |
$2,426.00
|
| Rate for Payer: PACE Medicare |
$1,097.48
|
| Rate for Payer: PACE SWMI |
$1,155.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,155.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$619.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,630.90
|
| Rate for Payer: Priority Health Medicare |
$1,155.24
|
| Rate for Payer: Priority Health Narrow Network |
$2,904.72
|
| Rate for Payer: Railroad Medicare Medicare |
$1,155.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.84
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,155.24
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,155.24
|
| Rate for Payer: UHCCP Medicaid |
$650.40
|
| Rate for Payer: VA VA |
$1,155.24
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 50268071711
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.05
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$130.80
|
|
|
Service Code
|
NDC 50268071715
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.32 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$111.18
|
| Rate for Payer: Aetna Medicare |
$65.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.02
|
| Rate for Payer: BCBS Complete |
$52.32
|
| Rate for Payer: Cash Price |
$104.64
|
| Rate for Payer: Cofinity Commercial |
$112.49
|
| Rate for Payer: Cofinity Commercial |
$91.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.64
|
| Rate for Payer: Healthscope Commercial |
$117.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.18
|
| Rate for Payer: PHP Commercial |
$111.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.02
|
| Rate for Payer: Priority Health SBD |
$82.40
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$19,155.83
|
|
|
Service Code
|
NDC 00069419068
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12,068.17 |
| Max. Negotiated Rate |
$17,240.25 |
| Rate for Payer: Aetna Commercial |
$16,282.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,451.29
|
| Rate for Payer: Cash Price |
$15,324.66
|
| Rate for Payer: Cofinity Commercial |
$13,409.08
|
| Rate for Payer: Cofinity Commercial |
$16,474.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,409.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,324.66
|
| Rate for Payer: Healthscope Commercial |
$17,240.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,282.46
|
| Rate for Payer: PHP Commercial |
$16,282.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,451.29
|
| Rate for Payer: Priority Health SBD |
$12,068.17
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$19,155.83
|
|
|
Service Code
|
NDC 00069419068
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,662.33 |
| Max. Negotiated Rate |
$17,240.25 |
| Rate for Payer: Aetna Commercial |
$16,282.46
|
| Rate for Payer: Aetna Medicare |
$9,577.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,451.29
|
| Rate for Payer: BCBS Complete |
$7,662.33
|
| Rate for Payer: Cash Price |
$15,324.66
|
| Rate for Payer: Cofinity Commercial |
$13,409.08
|
| Rate for Payer: Cofinity Commercial |
$16,474.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,409.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,324.66
|
| Rate for Payer: Healthscope Commercial |
$17,240.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,282.46
|
| Rate for Payer: PHP Commercial |
$16,282.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,451.29
|
| Rate for Payer: Priority Health SBD |
$12,068.17
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$235.60
|
|
|
Service Code
|
NDC 00904667106
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.43 |
| Max. Negotiated Rate |
$212.04 |
| Rate for Payer: Aetna Commercial |
$200.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.14
|
| Rate for Payer: Cash Price |
$188.48
|
| Rate for Payer: Cofinity Commercial |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$202.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.48
|
| Rate for Payer: Healthscope Commercial |
$212.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$200.26
|
| Rate for Payer: PHP Commercial |
$200.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.14
|
| Rate for Payer: Priority Health SBD |
$148.43
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$235.60
|
|
|
Service Code
|
NDC 00904667106
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.24 |
| Max. Negotiated Rate |
$212.04 |
| Rate for Payer: Aetna Commercial |
$200.26
|
| Rate for Payer: Aetna Medicare |
$117.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.14
|
| Rate for Payer: BCBS Complete |
$94.24
|
| Rate for Payer: Cash Price |
$188.48
|
| Rate for Payer: Cofinity Commercial |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$202.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.48
|
| Rate for Payer: Healthscope Commercial |
$212.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$200.26
|
| Rate for Payer: PHP Commercial |
$200.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.14
|
| Rate for Payer: Priority Health SBD |
$148.43
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$130.80
|
|
|
Service Code
|
NDC 50268071715
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.40 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$111.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.02
|
| Rate for Payer: Cash Price |
$104.64
|
| Rate for Payer: Cofinity Commercial |
$112.49
|
| Rate for Payer: Cofinity Commercial |
$91.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.64
|
| Rate for Payer: Healthscope Commercial |
$117.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.18
|
| Rate for Payer: PHP Commercial |
$111.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.02
|
| Rate for Payer: Priority Health SBD |
$82.40
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 50268071711
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE
|
Facility
|
IP
|
$70.71
|
|
|
Service Code
|
NDC 08327030909
|
| Hospital Charge Code |
115249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$63.64 |
| Rate for Payer: Aetna Commercial |
$60.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.96
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cofinity Commercial |
$49.50
|
| Rate for Payer: Cofinity Commercial |
$60.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.57
|
| Rate for Payer: Healthscope Commercial |
$63.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.10
|
| Rate for Payer: PHP Commercial |
$60.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.96
|
| Rate for Payer: Priority Health SBD |
$44.55
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE
|
Facility
|
OP
|
$70.71
|
|
|
Service Code
|
NDC 08327030909
|
| Hospital Charge Code |
115249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.28 |
| Max. Negotiated Rate |
$63.64 |
| Rate for Payer: Aetna Commercial |
$60.10
|
| Rate for Payer: Aetna Medicare |
$35.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.96
|
| Rate for Payer: BCBS Complete |
$28.28
|
| Rate for Payer: Cash Price |
$56.57
|
| Rate for Payer: Cofinity Commercial |
$49.50
|
| Rate for Payer: Cofinity Commercial |
$60.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.57
|
| Rate for Payer: Healthscope Commercial |
$63.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.10
|
| Rate for Payer: PHP Commercial |
$60.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.96
|
| Rate for Payer: Priority Health SBD |
$44.55
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE
|
Facility
|
OP
|
$72.54
|
|
|
Service Code
|
NDC 80196029660
|
| Hospital Charge Code |
115249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.02 |
| Max. Negotiated Rate |
$65.29 |
| Rate for Payer: Aetna Commercial |
$61.66
|
| Rate for Payer: Aetna Medicare |
$36.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.15
|
| Rate for Payer: BCBS Complete |
$29.02
|
| Rate for Payer: Cash Price |
$58.03
|
| Rate for Payer: Cofinity Commercial |
$50.78
|
| Rate for Payer: Cofinity Commercial |
$62.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.03
|
| Rate for Payer: Healthscope Commercial |
$65.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.66
|
| Rate for Payer: PHP Commercial |
$61.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.15
|
| Rate for Payer: Priority Health SBD |
$45.70
|
|
|
SILVER ER TOPICAL GEL,EXTENDED RELEASE
|
Facility
|
IP
|
$72.54
|
|
|
Service Code
|
NDC 80196029660
|
| Hospital Charge Code |
115249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.70 |
| Max. Negotiated Rate |
$65.29 |
| Rate for Payer: Aetna Commercial |
$61.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.15
|
| Rate for Payer: Cash Price |
$58.03
|
| Rate for Payer: Cofinity Commercial |
$50.78
|
| Rate for Payer: Cofinity Commercial |
$62.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.03
|
| Rate for Payer: Healthscope Commercial |
$65.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.66
|
| Rate for Payer: PHP Commercial |
$61.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.15
|
| Rate for Payer: Priority Health SBD |
$45.70
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.35
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: Priority Health SBD |
$3.25
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$81.90
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna Medicare |
$40.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: BCBS Complete |
$32.76
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
|
