|
TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE
|
Facility
|
OP
|
$7,322.00
|
|
|
Service Code
|
CPT 27245
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,305.63 |
| Max. Negotiated Rate |
$7,322.00 |
| Rate for Payer: BCBS Trust/PPO |
$2,573.46
|
| Rate for Payer: BCN Commercial |
$2,573.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,305.63
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Exchange |
$7,322.00
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 59820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$415.59 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,338.56
|
| Rate for Payer: BCN Commercial |
$1,338.56
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$415.59
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,753.88
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 59821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$408.39 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,952.70
|
| Rate for Payer: BCN Commercial |
$1,952.70
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$408.39
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,753.88
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE
|
Facility
|
OP
|
$1,885.01
|
|
|
Service Code
|
CPT 12020
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$198.24 |
| Max. Negotiated Rate |
$1,885.01 |
| Rate for Payer: Aetna Medicare |
$623.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$749.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$749.69
|
| Rate for Payer: BCBS Complete |
$337.54
|
| Rate for Payer: BCBS MAPPO |
$599.75
|
| Rate for Payer: BCBS Trust/PPO |
$373.96
|
| Rate for Payer: BCN Commercial |
$373.96
|
| Rate for Payer: BCN Medicare Advantage |
$599.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$599.75
|
| Rate for Payer: Mclaren Medicaid |
$321.47
|
| Rate for Payer: Mclaren Medicare |
$599.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$629.74
|
| Rate for Payer: Meridian Medicaid |
$337.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$689.71
|
| Rate for Payer: Nomi Health Commercial |
$1,259.48
|
| Rate for Payer: PACE Medicare |
$569.76
|
| Rate for Payer: PACE SWMI |
$599.75
|
| Rate for Payer: PHP Medicare Advantage |
$599.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$321.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,885.01
|
| Rate for Payer: Priority Health Medicare |
$599.75
|
| Rate for Payer: Priority Health Narrow Network |
$1,508.01
|
| Rate for Payer: Railroad Medicare Medicare |
$599.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.24
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$599.75
|
| Rate for Payer: UHC Exchange |
$940.00
|
| Rate for Payer: UHC Medicare Advantage |
$599.75
|
| Rate for Payer: UHCCP Medicaid |
$337.66
|
| Rate for Payer: VA VA |
$599.75
|
|
|
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE
|
Facility
|
OP
|
$1,885.01
|
|
|
Service Code
|
CPT 12020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$198.24 |
| Max. Negotiated Rate |
$1,885.01 |
| Rate for Payer: Aetna Medicare |
$623.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$749.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$749.69
|
| Rate for Payer: BCBS Complete |
$337.54
|
| Rate for Payer: BCBS MAPPO |
$599.75
|
| Rate for Payer: BCBS Trust/PPO |
$373.96
|
| Rate for Payer: BCN Commercial |
$373.96
|
| Rate for Payer: BCN Medicare Advantage |
$599.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$599.75
|
| Rate for Payer: Mclaren Medicaid |
$321.47
|
| Rate for Payer: Mclaren Medicare |
$599.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$629.74
|
| Rate for Payer: Meridian Medicaid |
$337.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$689.71
|
| Rate for Payer: Nomi Health Commercial |
$1,259.48
|
| Rate for Payer: PACE Medicare |
$569.76
|
| Rate for Payer: PACE SWMI |
$599.75
|
| Rate for Payer: PHP Medicare Advantage |
$599.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$321.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,885.01
|
| Rate for Payer: Priority Health Medicare |
$599.75
|
| Rate for Payer: Priority Health Narrow Network |
$1,508.01
|
| Rate for Payer: Railroad Medicare Medicare |
$599.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.24
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$599.75
|
| Rate for Payer: UHC Exchange |
$940.00
|
| Rate for Payer: UHC Medicare Advantage |
$599.75
|
| Rate for Payer: UHCCP Medicaid |
$337.66
|
| Rate for Payer: VA VA |
$599.75
|
|
|
TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE
|
Facility
|
OP
|
$39,622.51
|
|
|
Service Code
|
CPT 27759
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,062.72 |
| Max. Negotiated Rate |
$39,622.51 |
| Rate for Payer: Aetna Medicare |
$13,110.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,758.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,758.31
|
| Rate for Payer: BCBS Complete |
$7,095.02
|
| Rate for Payer: BCBS MAPPO |
$12,606.65
|
| Rate for Payer: BCBS Trust/PPO |
$4,514.11
|
| Rate for Payer: BCN Commercial |
$4,514.11
|
| Rate for Payer: BCN Medicare Advantage |
$12,606.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,606.65
|
| Rate for Payer: Mclaren Medicaid |
$6,757.16
|
| Rate for Payer: Mclaren Medicare |
$12,606.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,236.98
|
| Rate for Payer: Meridian Medicaid |
$7,095.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,497.65
|
| Rate for Payer: Nomi Health Commercial |
$26,473.96
|
| Rate for Payer: PACE Medicare |
$11,976.32
|
| Rate for Payer: PACE SWMI |
$12,606.65
|
| Rate for Payer: PHP Medicare Advantage |
$12,606.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,757.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39,622.51
|
| Rate for Payer: Priority Health Medicare |
$12,606.65
|
| Rate for Payer: Priority Health Narrow Network |
$31,698.01
|
| Rate for Payer: Railroad Medicare Medicare |
$12,606.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,062.72
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,606.65
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$12,606.65
|
| Rate for Payer: UHCCP Medicaid |
$7,097.54
|
| Rate for Payer: VA VA |
$12,606.65
|
|
|
TRIAMCINOLONE ACETONIDE 0.147 MG/GRAM TOPICAL AEROSOL
|
Facility
|
IP
|
$1,735.12
|
|
|
Service Code
|
NDC 10631009362
|
| Hospital Charge Code |
19770
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,093.13 |
| Max. Negotiated Rate |
$1,561.61 |
| Rate for Payer: Aetna Commercial |
$1,474.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,127.83
|
| Rate for Payer: Cash Price |
$1,388.10
|
| Rate for Payer: Cofinity Commercial |
$1,214.58
|
| Rate for Payer: Cofinity Commercial |
$1,492.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,214.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,388.10
|
| Rate for Payer: Healthscope Commercial |
$1,561.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,474.85
|
| Rate for Payer: PHP Commercial |
$1,474.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,127.83
|
| Rate for Payer: Priority Health SBD |
$1,093.13
|
|
|
TRIAMCINOLONE ACETONIDE 0.147 MG/GRAM TOPICAL AEROSOL
|
Facility
|
OP
|
$1,735.12
|
|
|
Service Code
|
NDC 10631009362
|
| Hospital Charge Code |
19770
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$694.05 |
| Max. Negotiated Rate |
$1,561.61 |
| Rate for Payer: Aetna Commercial |
$1,474.85
|
| Rate for Payer: Aetna Medicare |
$867.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,127.83
|
| Rate for Payer: BCBS Complete |
$694.05
|
| Rate for Payer: Cash Price |
$1,388.10
|
| Rate for Payer: Cofinity Commercial |
$1,214.58
|
| Rate for Payer: Cofinity Commercial |
$1,492.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,214.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,388.10
|
| Rate for Payer: Healthscope Commercial |
$1,561.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,474.85
|
| Rate for Payer: PHP Commercial |
$1,474.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,127.83
|
| Rate for Payer: Priority Health SBD |
$1,093.13
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$10.33
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$9.30 |
| Rate for Payer: Aetna Commercial |
$8.78
|
| Rate for Payer: Aetna Medicare |
$5.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.71
|
| Rate for Payer: BCBS Complete |
$4.13
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$7.23
|
| Rate for Payer: Cofinity Commercial |
$8.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.26
|
| Rate for Payer: Healthscope Commercial |
$9.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.78
|
| Rate for Payer: PHP Commercial |
$8.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.71
|
| Rate for Payer: Priority Health SBD |
$6.51
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$12.63
|
|
|
Service Code
|
NDC 52565005615
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$11.37 |
| Rate for Payer: Aetna Commercial |
$10.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.21
|
| Rate for Payer: Cash Price |
$10.10
|
| Rate for Payer: Cofinity Commercial |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$8.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.10
|
| Rate for Payer: Healthscope Commercial |
$11.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.74
|
| Rate for Payer: PHP Commercial |
$10.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.21
|
| Rate for Payer: Priority Health SBD |
$7.96
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$12.63
|
|
|
Service Code
|
NDC 52565005615
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$11.37 |
| Rate for Payer: Aetna Commercial |
$10.74
|
| Rate for Payer: Aetna Medicare |
$6.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.21
|
| Rate for Payer: BCBS Complete |
$5.05
|
| Rate for Payer: Cash Price |
$10.10
|
| Rate for Payer: Cofinity Commercial |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$8.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.10
|
| Rate for Payer: Healthscope Commercial |
$11.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.74
|
| Rate for Payer: PHP Commercial |
$10.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.21
|
| Rate for Payer: Priority Health SBD |
$7.96
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 67877025115
|
| Hospital Charge Code |
8113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$9.30 |
| Rate for Payer: Aetna Commercial |
$8.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.71
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$7.23
|
| Rate for Payer: Cofinity Commercial |
$8.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.26
|
| Rate for Payer: Healthscope Commercial |
$9.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.78
|
| Rate for Payer: PHP Commercial |
$8.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.71
|
| Rate for Payer: Priority Health SBD |
$6.51
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$17.96
|
|
|
Service Code
|
NDC 51672128401
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: Aetna Medicare |
$8.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.67
|
| Rate for Payer: BCBS Complete |
$7.18
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$12.57
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.37
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.27
|
| Rate for Payer: PHP Commercial |
$15.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.67
|
| Rate for Payer: Priority Health SBD |
$11.31
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$11.28
|
|
|
Service Code
|
NDC 00168000615
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$9.59
|
| Rate for Payer: Aetna Medicare |
$5.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.33
|
| Rate for Payer: BCBS Complete |
$4.51
|
| Rate for Payer: Cash Price |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$7.90
|
| Rate for Payer: Cofinity Commercial |
$9.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.02
|
| Rate for Payer: Healthscope Commercial |
$10.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.59
|
| Rate for Payer: PHP Commercial |
$9.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.33
|
| Rate for Payer: Priority Health SBD |
$7.11
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$19.24
|
|
|
Service Code
|
NDC 45802005535
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.12 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.51
|
| Rate for Payer: Cash Price |
$15.39
|
| Rate for Payer: Cofinity Commercial |
$13.47
|
| Rate for Payer: Cofinity Commercial |
$16.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.39
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.51
|
| Rate for Payer: Priority Health SBD |
$12.12
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$11.28
|
|
|
Service Code
|
NDC 00168000615
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$9.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.33
|
| Rate for Payer: Cash Price |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$7.90
|
| Rate for Payer: Cofinity Commercial |
$9.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.02
|
| Rate for Payer: Healthscope Commercial |
$10.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.59
|
| Rate for Payer: PHP Commercial |
$9.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.33
|
| Rate for Payer: Priority Health SBD |
$7.11
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$19.24
|
|
|
Service Code
|
NDC 45802005535
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna Medicare |
$9.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.51
|
| Rate for Payer: BCBS Complete |
$7.70
|
| Rate for Payer: Cash Price |
$15.39
|
| Rate for Payer: Cofinity Commercial |
$13.47
|
| Rate for Payer: Cofinity Commercial |
$16.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.39
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.51
|
| Rate for Payer: Priority Health SBD |
$12.12
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$17.96
|
|
|
Service Code
|
NDC 51672128401
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.67
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$12.57
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.37
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.27
|
| Rate for Payer: PHP Commercial |
$15.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.67
|
| Rate for Payer: Priority Health SBD |
$11.31
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION
|
Facility
|
OP
|
$38.72
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$34.85 |
| Rate for Payer: Aetna Commercial |
$32.91
|
| Rate for Payer: Aetna Commercial |
$20.20
|
| Rate for Payer: Aetna Commercial |
$249.61
|
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Aetna Medicare |
$146.83
|
| Rate for Payer: Aetna Medicare |
$11.88
|
| Rate for Payer: Aetna Medicare |
$19.36
|
| Rate for Payer: Aetna Medicare |
$11.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.59
|
| Rate for Payer: BCBS Complete |
$117.46
|
| Rate for Payer: BCBS Complete |
$15.49
|
| Rate for Payer: BCBS Complete |
$9.59
|
| Rate for Payer: BCBS Complete |
$9.51
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.52
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$30.98
|
| Rate for Payer: Cash Price |
$30.98
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Cofinity Commercial |
$16.64
|
| Rate for Payer: Cofinity Commercial |
$20.44
|
| Rate for Payer: Cofinity Commercial |
$20.62
|
| Rate for Payer: Cofinity Commercial |
$205.56
|
| Rate for Payer: Cofinity Commercial |
$252.55
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$33.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$205.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Healthscope Commercial |
$21.58
|
| Rate for Payer: Healthscope Commercial |
$34.85
|
| Rate for Payer: Healthscope Commercial |
$264.29
|
| Rate for Payer: Healthscope Commercial |
$21.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.91
|
| Rate for Payer: PHP Commercial |
$32.91
|
| Rate for Payer: PHP Commercial |
$20.38
|
| Rate for Payer: PHP Commercial |
$249.61
|
| Rate for Payer: PHP Commercial |
$20.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.59
|
| Rate for Payer: Priority Health SBD |
$24.39
|
| Rate for Payer: Priority Health SBD |
$15.11
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: Priority Health SBD |
$185.01
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION
|
Facility
|
IP
|
$293.66
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.01 |
| Max. Negotiated Rate |
$264.29 |
| Rate for Payer: Aetna Commercial |
$249.61
|
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Aetna Commercial |
$32.91
|
| Rate for Payer: Aetna Commercial |
$20.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.17
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cash Price |
$30.98
|
| Rate for Payer: Cofinity Commercial |
$16.64
|
| Rate for Payer: Cofinity Commercial |
$33.30
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Cofinity Commercial |
$20.62
|
| Rate for Payer: Cofinity Commercial |
$252.55
|
| Rate for Payer: Cofinity Commercial |
$205.56
|
| Rate for Payer: Cofinity Commercial |
$20.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$205.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.98
|
| Rate for Payer: Healthscope Commercial |
$21.58
|
| Rate for Payer: Healthscope Commercial |
$21.39
|
| Rate for Payer: Healthscope Commercial |
$34.85
|
| Rate for Payer: Healthscope Commercial |
$264.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.20
|
| Rate for Payer: PHP Commercial |
$20.20
|
| Rate for Payer: PHP Commercial |
$249.61
|
| Rate for Payer: PHP Commercial |
$20.38
|
| Rate for Payer: PHP Commercial |
$32.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.17
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: Priority Health SBD |
$185.01
|
| Rate for Payer: Priority Health SBD |
$15.11
|
| Rate for Payer: Priority Health SBD |
$24.39
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
|
OP
|
$200.45
|
|
|
Service Code
|
NDC 00378253701
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.18 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna Medicare |
$100.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.29
|
| Rate for Payer: BCBS Complete |
$80.18
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$140.32
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health SBD |
$126.28
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 00527163201
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.83 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
|
IP
|
$200.45
|
|
|
Service Code
|
NDC 00378253701
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.29
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$140.32
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health SBD |
$126.28
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 00527163201
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna Medicare |
$160.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
OP
|
$637.98
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$255.19 |
| Max. Negotiated Rate |
$574.18 |
| Rate for Payer: Aetna Commercial |
$542.28
|
| Rate for Payer: Aetna Medicare |
$318.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$414.69
|
| Rate for Payer: BCBS Complete |
$255.19
|
| Rate for Payer: Cash Price |
$510.38
|
| Rate for Payer: Cofinity Commercial |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$548.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$446.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$510.38
|
| Rate for Payer: Healthscope Commercial |
$574.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$542.28
|
| Rate for Payer: PHP Commercial |
$542.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.69
|
| Rate for Payer: Priority Health SBD |
$401.93
|
|
