|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$892.80
|
|
|
Service Code
|
NDC 62135096001
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$357.12 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$758.88
|
| Rate for Payer: Aetna Medicare |
$446.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$580.32
|
| Rate for Payer: BCBS Complete |
$357.12
|
| Rate for Payer: Cash Price |
$714.24
|
| Rate for Payer: Cofinity Commercial |
$624.96
|
| Rate for Payer: Cofinity Commercial |
$767.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$624.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$714.24
|
| Rate for Payer: Healthscope Commercial |
$803.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$758.88
|
| Rate for Payer: PHP Commercial |
$758.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$580.32
|
| Rate for Payer: Priority Health SBD |
$562.46
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$725.76
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$457.23 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$471.74
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$508.03
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$508.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$616.90
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.74
|
| Rate for Payer: Priority Health SBD |
$457.23
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$892.80
|
|
|
Service Code
|
NDC 62135096001
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$562.46 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$758.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$580.32
|
| Rate for Payer: Cash Price |
$714.24
|
| Rate for Payer: Cofinity Commercial |
$624.96
|
| Rate for Payer: Cofinity Commercial |
$767.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$624.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$714.24
|
| Rate for Payer: Healthscope Commercial |
$803.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$758.88
|
| Rate for Payer: PHP Commercial |
$758.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$580.32
|
| Rate for Payer: Priority Health SBD |
$562.46
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$725.76
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$290.30 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna Medicare |
$362.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$471.74
|
| Rate for Payer: BCBS Complete |
$290.30
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$508.03
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$508.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$616.90
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.74
|
| Rate for Payer: Priority Health SBD |
$457.23
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.49 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.95
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$296.10
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$296.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: Priority Health SBD |
$266.49
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$21.99
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.85 |
| Max. Negotiated Rate |
$19.79 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.29
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cofinity Commercial |
$15.39
|
| Rate for Payer: Cofinity Commercial |
$18.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.59
|
| Rate for Payer: Healthscope Commercial |
$19.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.69
|
| Rate for Payer: PHP Commercial |
$18.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: Priority Health SBD |
$13.85
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$21.99
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$19.79 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: Aetna Medicare |
$10.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.29
|
| Rate for Payer: BCBS Complete |
$8.80
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cofinity Commercial |
$15.39
|
| Rate for Payer: Cofinity Commercial |
$18.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.59
|
| Rate for Payer: Healthscope Commercial |
$19.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.69
|
| Rate for Payer: PHP Commercial |
$18.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: Priority Health SBD |
$13.85
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$7.92
|
|
|
Service Code
|
NDC 55111029309
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna Medicare |
$3.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.15
|
| Rate for Payer: BCBS Complete |
$3.17
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$5.54
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.34
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.73
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.15
|
| Rate for Payer: Priority Health SBD |
$4.99
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$7.92
|
|
|
Service Code
|
NDC 55111029309
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.15
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$5.54
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.34
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.73
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.15
|
| Rate for Payer: Priority Health SBD |
$4.99
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 62756052169
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.48 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna Medicare |
$35.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: BCBS Complete |
$28.48
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health SBD |
$44.86
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$7.92
|
|
|
Service Code
|
NDC 55111029209
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna Medicare |
$3.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.15
|
| Rate for Payer: BCBS Complete |
$3.17
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$5.54
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.34
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.73
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.15
|
| Rate for Payer: Priority Health SBD |
$4.99
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756052169
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.86 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health SBD |
$44.86
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$29.33
|
|
|
Service Code
|
NDC 65862014736
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.73 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: Aetna Commercial |
$24.93
|
| Rate for Payer: Aetna Medicare |
$14.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.06
|
| Rate for Payer: BCBS Complete |
$11.73
|
| Rate for Payer: Cash Price |
$23.46
|
| Rate for Payer: Cofinity Commercial |
$20.53
|
| Rate for Payer: Cofinity Commercial |
$25.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.46
|
| Rate for Payer: Healthscope Commercial |
$26.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.93
|
| Rate for Payer: PHP Commercial |
$24.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.06
|
| Rate for Payer: Priority Health SBD |
$18.48
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$29.33
|
|
|
Service Code
|
NDC 65862014736
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: Aetna Commercial |
$24.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.06
|
| Rate for Payer: Cash Price |
$23.46
|
| Rate for Payer: Cofinity Commercial |
$20.53
|
| Rate for Payer: Cofinity Commercial |
$25.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.46
|
| Rate for Payer: Healthscope Commercial |
$26.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.93
|
| Rate for Payer: PHP Commercial |
$24.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.06
|
| Rate for Payer: Priority Health SBD |
$18.48
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$7.92
|
|
|
Service Code
|
NDC 55111029209
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.15
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$5.54
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.34
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.73
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.15
|
| Rate for Payer: Priority Health SBD |
$4.99
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$26.38
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.62 |
| Max. Negotiated Rate |
$23.74 |
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Commercial |
$88.46
|
| Rate for Payer: Aetna Commercial |
$21.15
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$83.26
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Commercial |
$72.85
|
| Rate for Payer: Cofinity Commercial |
$89.50
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$21.40
|
| Rate for Payer: Cofinity Commercial |
$18.47
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$93.66
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$88.46
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.15
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$65.56
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$16.62
|
| Rate for Payer: Priority Health SBD |
$15.67
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$20.70
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna Commercial |
$88.46
|
| Rate for Payer: Aetna Commercial |
$21.15
|
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna Medicare |
$13.19
|
| Rate for Payer: Aetna Medicare |
$12.44
|
| Rate for Payer: Aetna Medicare |
$10.35
|
| Rate for Payer: Aetna Medicare |
$52.03
|
| Rate for Payer: Aetna Medicare |
$13.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: BCBS Complete |
$41.63
|
| Rate for Payer: BCBS Complete |
$10.55
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: BCBS Complete |
$9.95
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$83.26
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$18.47
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$89.50
|
| Rate for Payer: Cofinity Commercial |
$72.85
|
| Rate for Payer: Cofinity Commercial |
$21.40
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$93.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: PHP Commercial |
$21.15
|
| Rate for Payer: PHP Commercial |
$88.46
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.15
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$65.56
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$16.62
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$1,680.50
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$319.99 |
| Max. Negotiated Rate |
$1,680.50 |
| Rate for Payer: Aetna Medicare |
$620.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$746.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$746.25
|
| Rate for Payer: BCBS Complete |
$335.99
|
| Rate for Payer: BCBS MAPPO |
$597.00
|
| Rate for Payer: BCN Medicare Advantage |
$597.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$597.00
|
| Rate for Payer: Mclaren Medicaid |
$319.99
|
| Rate for Payer: Mclaren Medicare |
$597.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$626.85
|
| Rate for Payer: Meridian Medicaid |
$335.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$686.55
|
| Rate for Payer: PACE Medicare |
$567.15
|
| Rate for Payer: PACE SWMI |
$597.00
|
| Rate for Payer: PHP Medicare Advantage |
$597.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$319.99
|
| Rate for Payer: Priority Health Medicare |
$597.00
|
| Rate for Payer: Railroad Medicare Medicare |
$597.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,680.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$597.00
|
| Rate for Payer: UHC Medicare Advantage |
$597.00
|
| Rate for Payer: UHCCP Medicaid |
$336.11
|
| Rate for Payer: VA VA |
$597.00
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT 15002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$1,004.40
|
| Rate for Payer: VA VA |
$1,784.01
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC
|
Facility
|
OP
|
$7,528.73
|
|
|
Service Code
|
CPT 46275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,433.59 |
| Max. Negotiated Rate |
$7,528.73 |
| Rate for Payer: Aetna Medicare |
$2,781.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,343.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,343.25
|
| Rate for Payer: BCBS Complete |
$1,505.26
|
| Rate for Payer: BCBS MAPPO |
$2,674.60
|
| Rate for Payer: BCN Medicare Advantage |
$2,674.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,674.60
|
| Rate for Payer: Mclaren Medicaid |
$1,433.59
|
| Rate for Payer: Mclaren Medicare |
$2,674.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,808.33
|
| Rate for Payer: Meridian Medicaid |
$1,505.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,075.79
|
| Rate for Payer: PACE Medicare |
$2,540.87
|
| Rate for Payer: PACE SWMI |
$2,674.60
|
| Rate for Payer: PHP Medicare Advantage |
$2,674.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,433.59
|
| Rate for Payer: Priority Health Medicare |
$2,674.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,674.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7,528.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,674.60
|
| Rate for Payer: UHC Medicare Advantage |
$2,674.60
|
| Rate for Payer: UHCCP Medicaid |
$1,505.80
|
| Rate for Payer: VA VA |
$2,674.60
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE
|
Facility
|
OP
|
$7,528.73
|
|
|
Service Code
|
CPT 46285
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,433.59 |
| Max. Negotiated Rate |
$7,528.73 |
| Rate for Payer: Aetna Medicare |
$2,781.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,343.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,343.25
|
| Rate for Payer: BCBS Complete |
$1,505.26
|
| Rate for Payer: BCBS MAPPO |
$2,674.60
|
| Rate for Payer: BCN Medicare Advantage |
$2,674.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,674.60
|
| Rate for Payer: Mclaren Medicaid |
$1,433.59
|
| Rate for Payer: Mclaren Medicare |
$2,674.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,808.33
|
| Rate for Payer: Meridian Medicaid |
$1,505.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,075.79
|
| Rate for Payer: PACE Medicare |
$2,540.87
|
| Rate for Payer: PACE SWMI |
$2,674.60
|
| Rate for Payer: PHP Medicare Advantage |
$2,674.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,433.59
|
| Rate for Payer: Priority Health Medicare |
$2,674.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,674.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7,528.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,674.60
|
| Rate for Payer: UHC Medicare Advantage |
$2,674.60
|
| Rate for Payer: UHCCP Medicaid |
$1,505.80
|
| Rate for Payer: VA VA |
$2,674.60
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS
|
Facility
|
OP
|
$7,528.73
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,433.59 |
| Max. Negotiated Rate |
$7,528.73 |
| Rate for Payer: Aetna Medicare |
$2,781.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,343.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,343.25
|
| Rate for Payer: BCBS Complete |
$1,505.26
|
| Rate for Payer: BCBS MAPPO |
$2,674.60
|
| Rate for Payer: BCN Medicare Advantage |
$2,674.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,674.60
|
| Rate for Payer: Mclaren Medicaid |
$1,433.59
|
| Rate for Payer: Mclaren Medicare |
$2,674.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,808.33
|
| Rate for Payer: Meridian Medicaid |
$1,505.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,075.79
|
| Rate for Payer: PACE Medicare |
$2,540.87
|
| Rate for Payer: PACE SWMI |
$2,674.60
|
| Rate for Payer: PHP Medicare Advantage |
$2,674.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,433.59
|
| Rate for Payer: Priority Health Medicare |
$2,674.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,674.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7,528.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,674.60
|
| Rate for Payer: UHC Medicare Advantage |
$2,674.60
|
| Rate for Payer: UHCCP Medicaid |
$1,505.80
|
| Rate for Payer: VA VA |
$2,674.60
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED
|
Facility
|
OP
|
$7,528.73
|
|
|
Service Code
|
CPT 46280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,433.59 |
| Max. Negotiated Rate |
$7,528.73 |
| Rate for Payer: Aetna Medicare |
$2,781.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,343.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,343.25
|
| Rate for Payer: BCBS Complete |
$1,505.26
|
| Rate for Payer: BCBS MAPPO |
$2,674.60
|
| Rate for Payer: BCN Medicare Advantage |
$2,674.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,674.60
|
| Rate for Payer: Mclaren Medicaid |
$1,433.59
|
| Rate for Payer: Mclaren Medicare |
$2,674.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,808.33
|
| Rate for Payer: Meridian Medicaid |
$1,505.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,075.79
|
| Rate for Payer: PACE Medicare |
$2,540.87
|
| Rate for Payer: PACE SWMI |
$2,674.60
|
| Rate for Payer: PHP Medicare Advantage |
$2,674.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,433.59
|
| Rate for Payer: Priority Health Medicare |
$2,674.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,674.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7,528.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,674.60
|
| Rate for Payer: UHC Medicare Advantage |
$2,674.60
|
| Rate for Payer: UHCCP Medicaid |
$1,505.80
|
| Rate for Payer: VA VA |
$2,674.60
|
|
|
SURGICEL, OXIDIZED 2" X 1" MISC
|
Facility
|
OP
|
$310.06
|
|
|
Service Code
|
NDC 63713001961
|
| Hospital Charge Code |
200200150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.02 |
| Max. Negotiated Rate |
$279.05 |
| Rate for Payer: Aetna Commercial |
$263.55
|
| Rate for Payer: Aetna Medicare |
$155.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.54
|
| Rate for Payer: BCBS Complete |
$124.02
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cofinity Commercial |
$217.04
|
| Rate for Payer: Cofinity Commercial |
$266.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$217.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.05
|
| Rate for Payer: Healthscope Commercial |
$279.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.55
|
| Rate for Payer: PHP Commercial |
$263.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.54
|
| Rate for Payer: Priority Health SBD |
$195.34
|
|
|
SURGICEL, OXIDIZED 2" X 1" MISC
|
Facility
|
IP
|
$310.06
|
|
|
Service Code
|
NDC 63713001961
|
| Hospital Charge Code |
200200150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$195.34 |
| Max. Negotiated Rate |
$279.05 |
| Rate for Payer: Aetna Commercial |
$263.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.54
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cofinity Commercial |
$217.04
|
| Rate for Payer: Cofinity Commercial |
$266.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$217.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.05
|
| Rate for Payer: Healthscope Commercial |
$279.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.55
|
| Rate for Payer: PHP Commercial |
$263.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.54
|
| Rate for Payer: Priority Health SBD |
$195.34
|
|
