|
CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$273.00
|
|
|
Service Code
|
HCPCS 75831
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$203.35 |
| Rate for Payer: Aetna Commercial |
$147.29
|
| Rate for Payer: Aetna Commercial |
$147.29
|
| Rate for Payer: Aetna Medicare |
$114.32
|
| Rate for Payer: Aetna Medicare |
$114.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.29
|
| Rate for Payer: BCBS Complete |
$44.40
|
| Rate for Payer: BCBS Complete |
$109.20
|
| Rate for Payer: BCBS MAPPO |
$109.92
|
| Rate for Payer: BCBS MAPPO |
$109.92
|
| Rate for Payer: BCN Medicare Advantage |
$109.92
|
| Rate for Payer: BCN Medicare Advantage |
$109.92
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cofinity Commercial |
$147.29
|
| Rate for Payer: Cofinity Commercial |
$147.29
|
| Rate for Payer: Cofinity Commercial |
$158.28
|
| Rate for Payer: Cofinity Commercial |
$158.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$109.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$109.92
|
| Rate for Payer: Healthscope Commercial |
$203.35
|
| Rate for Payer: Healthscope Commercial |
$203.35
|
| Rate for Payer: Healthscope Commercial |
$175.87
|
| Rate for Payer: Healthscope Commercial |
$175.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$115.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$115.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.15
|
| Rate for Payer: Nomi Health Commercial |
$131.90
|
| Rate for Payer: Nomi Health Commercial |
$131.90
|
| Rate for Payer: PACE SWMI |
$109.92
|
| Rate for Payer: PACE SWMI |
$109.92
|
| Rate for Payer: PHP Medicare Advantage |
$109.92
|
| Rate for Payer: PHP Medicare Advantage |
$109.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.15
|
| Rate for Payer: Priority Health Medicare |
$109.92
|
| Rate for Payer: Priority Health Medicare |
$109.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$109.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$109.92
|
| Rate for Payer: UHC Medicare Advantage |
$109.92
|
| Rate for Payer: UHC Medicare Advantage |
$109.92
|
|
|
CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I
|
Professional
|
Both
|
$366.00
|
|
|
Service Code
|
HCPCS 75860
|
| Min. Negotiated Rate |
$115.98 |
| Max. Negotiated Rate |
$237.90 |
| Rate for Payer: Aetna Commercial |
$155.41
|
| Rate for Payer: Aetna Commercial |
$155.41
|
| Rate for Payer: Aetna Medicare |
$120.62
|
| Rate for Payer: Aetna Medicare |
$120.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.01
|
| Rate for Payer: BCBS Complete |
$146.40
|
| Rate for Payer: BCBS Complete |
$112.40
|
| Rate for Payer: BCBS MAPPO |
$115.98
|
| Rate for Payer: BCBS MAPPO |
$115.98
|
| Rate for Payer: BCN Medicare Advantage |
$115.98
|
| Rate for Payer: BCN Medicare Advantage |
$115.98
|
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cofinity Commercial |
$155.41
|
| Rate for Payer: Cofinity Commercial |
$167.01
|
| Rate for Payer: Cofinity Commercial |
$155.41
|
| Rate for Payer: Cofinity Commercial |
$167.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$115.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$115.98
|
| Rate for Payer: Healthscope Commercial |
$214.56
|
| Rate for Payer: Healthscope Commercial |
$214.56
|
| Rate for Payer: Healthscope Commercial |
$185.57
|
| Rate for Payer: Healthscope Commercial |
$185.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$121.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$121.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$182.65
|
| Rate for Payer: Nomi Health Commercial |
$139.18
|
| Rate for Payer: Nomi Health Commercial |
$139.18
|
| Rate for Payer: PACE SWMI |
$115.98
|
| Rate for Payer: PACE SWMI |
$115.98
|
| Rate for Payer: PHP Medicare Advantage |
$115.98
|
| Rate for Payer: PHP Medicare Advantage |
$115.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.90
|
| Rate for Payer: Priority Health Medicare |
$115.98
|
| Rate for Payer: Priority Health Medicare |
$115.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$115.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$115.98
|
| Rate for Payer: UHC Medicare Advantage |
$115.98
|
| Rate for Payer: UHC Medicare Advantage |
$115.98
|
|
|
CHG VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS&
|
Professional
|
Both
|
$334.00
|
|
|
Service Code
|
HCPCS 75893
|
| Min. Negotiated Rate |
$95.18 |
| Max. Negotiated Rate |
$217.10 |
| Rate for Payer: Aetna Commercial |
$127.54
|
| Rate for Payer: Aetna Medicare |
$98.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$127.54
|
| Rate for Payer: BCBS Complete |
$133.60
|
| Rate for Payer: BCBS MAPPO |
$95.18
|
| Rate for Payer: BCN Medicare Advantage |
$95.18
|
| Rate for Payer: Cash Price |
$267.20
|
| Rate for Payer: Cash Price |
$267.20
|
| Rate for Payer: Cofinity Commercial |
$137.06
|
| Rate for Payer: Cofinity Commercial |
$127.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$95.18
|
| Rate for Payer: Healthscope Commercial |
$152.29
|
| Rate for Payer: Healthscope Commercial |
$176.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$99.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.10
|
| Rate for Payer: Nomi Health Commercial |
$114.22
|
| Rate for Payer: PACE SWMI |
$95.18
|
| Rate for Payer: PHP Medicare Advantage |
$95.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.10
|
| Rate for Payer: Priority Health Medicare |
$95.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$95.18
|
| Rate for Payer: UHC Medicare Advantage |
$95.18
|
|
|
CHG VENOUS THROMBOSIS IMAGING VENOGRAM UNILATERAL
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 78457
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: Aetna Commercial |
$189.70
|
| Rate for Payer: Aetna Commercial |
$189.70
|
| Rate for Payer: Aetna Medicare |
$147.23
|
| Rate for Payer: Aetna Medicare |
$147.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: BCBS Complete |
$132.80
|
| Rate for Payer: BCBS Complete |
$32.80
|
| Rate for Payer: BCBS MAPPO |
$141.57
|
| Rate for Payer: BCBS MAPPO |
$141.57
|
| Rate for Payer: BCN Medicare Advantage |
$141.57
|
| Rate for Payer: BCN Medicare Advantage |
$141.57
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cash Price |
$265.60
|
| Rate for Payer: Cash Price |
$265.60
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cofinity Commercial |
$189.70
|
| Rate for Payer: Cofinity Commercial |
$189.70
|
| Rate for Payer: Cofinity Commercial |
$203.86
|
| Rate for Payer: Cofinity Commercial |
$203.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$141.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$141.57
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Commercial |
$226.51
|
| Rate for Payer: Healthscope Commercial |
$226.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$148.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$148.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.80
|
| Rate for Payer: Nomi Health Commercial |
$169.88
|
| Rate for Payer: Nomi Health Commercial |
$169.88
|
| Rate for Payer: PACE SWMI |
$141.57
|
| Rate for Payer: PACE SWMI |
$141.57
|
| Rate for Payer: PHP Medicare Advantage |
$141.57
|
| Rate for Payer: PHP Medicare Advantage |
$141.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.80
|
| Rate for Payer: Priority Health Medicare |
$141.57
|
| Rate for Payer: Priority Health Medicare |
$141.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$141.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$141.57
|
| Rate for Payer: UHC Medicare Advantage |
$141.57
|
| Rate for Payer: UHC Medicare Advantage |
$141.57
|
|
|
CHG X-RAY ABDOMEN 1 VW
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 74000
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: BCBS Complete |
$14.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.40
|
|
|
CHG X-RAY ABDOMEN 2 VW
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS 74020
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$34.45 |
| Rate for Payer: Aetna Medicare |
$26.50
|
| Rate for Payer: BCBS Complete |
$21.20
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.45
|
|
|
CHG X-RAY FEMUR 2 VW
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
HCPCS 73550
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Medicare |
$19.00
|
| Rate for Payer: Aetna Medicare |
$47.00
|
| Rate for Payer: Aetna Medicare |
$15.00
|
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: BCBS Complete |
$15.20
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$30.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
|
|
CHG X-RAY HIPS 4 VW + PELVIS
|
Professional
|
Both
|
$47.00
|
|
|
Service Code
|
HCPCS 73520
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$30.55 |
| Rate for Payer: Aetna Medicare |
$23.50
|
| Rate for Payer: Aetna Medicare |
$60.50
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: BCBS Complete |
$18.80
|
| Rate for Payer: BCBS Complete |
$48.40
|
| Rate for Payer: BCBS Complete |
$21.60
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$96.80
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.55
|
|
|
CHG X-RAY HIP UNI 2+ VW
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 73510
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: Aetna Medicare |
$18.50
|
| Rate for Payer: BCBS Complete |
$14.80
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$21.60
|
| Rate for Payer: Cash Price |
$29.60
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.10
|
|
|
CHG X-RAY HIP UNILAT 1 VW
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 73500
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
|
|
CHG X-RAY PELVIS/HIPS CHILD/INFANT
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 73540
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Medicare |
$17.50
|
| Rate for Payer: Aetna Medicare |
$48.50
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: BCBS Complete |
$38.80
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cash Price |
$77.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.05
|
|
|
CHG X-RAY SPINE SURVEY
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 72010
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna Medicare |
$36.50
|
| Rate for Payer: BCBS Complete |
$29.20
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.45
|
|
|
CHG X-RAY THOR-LUMB SP SCOLIOSIS
|
Professional
|
Both
|
$71.00
|
|
|
Service Code
|
HCPCS 72090
|
| Min. Negotiated Rate |
$28.40 |
| Max. Negotiated Rate |
$46.15 |
| Rate for Payer: Aetna Medicare |
$35.50
|
| Rate for Payer: Aetna Medicare |
$66.50
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$53.20
|
| Rate for Payer: BCBS Complete |
$28.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
|
|
CHG X-RAY TRUNK SPINE SCOLIOSIS
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 72069
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Medicare |
$30.00
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS Complete |
$24.00
|
| Rate for Payer: BCBS Complete |
$18.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.00
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$286.70
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.68 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna Commercial |
$243.69
|
| Rate for Payer: Aetna Medicare |
$143.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.35
|
| Rate for Payer: BCBS Complete |
$114.68
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.69
|
| Rate for Payer: PHP Commercial |
$243.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.35
|
| Rate for Payer: Priority Health SBD |
$180.62
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Aetna Medicare |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.83
|
| Rate for Payer: BCBS Complete |
$1.74
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.05
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health SBD |
$2.75
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$435.10
|
|
|
Service Code
|
NDC 51079037520
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$274.11 |
| Max. Negotiated Rate |
$391.59 |
| Rate for Payer: Aetna Commercial |
$369.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.81
|
| Rate for Payer: Cash Price |
$348.08
|
| Rate for Payer: Cofinity Commercial |
$304.57
|
| Rate for Payer: Cofinity Commercial |
$374.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.08
|
| Rate for Payer: Healthscope Commercial |
$391.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.83
|
| Rate for Payer: PHP Commercial |
$369.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.81
|
| Rate for Payer: Priority Health SBD |
$274.11
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$435.10
|
|
|
Service Code
|
NDC 51079037520
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.04 |
| Max. Negotiated Rate |
$391.59 |
| Rate for Payer: Aetna Commercial |
$369.83
|
| Rate for Payer: Aetna Medicare |
$217.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.81
|
| Rate for Payer: BCBS Complete |
$174.04
|
| Rate for Payer: Cash Price |
$348.08
|
| Rate for Payer: Cofinity Commercial |
$304.57
|
| Rate for Payer: Cofinity Commercial |
$374.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.08
|
| Rate for Payer: Healthscope Commercial |
$391.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.83
|
| Rate for Payer: PHP Commercial |
$369.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.81
|
| Rate for Payer: Priority Health SBD |
$274.11
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.83
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.05
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health SBD |
$2.75
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$286.70
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.62 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna Commercial |
$243.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.35
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.69
|
| Rate for Payer: PHP Commercial |
$243.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.35
|
| Rate for Payer: Priority Health SBD |
$180.62
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$354.85
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$223.56 |
| Max. Negotiated Rate |
$319.37 |
| Rate for Payer: Aetna Commercial |
$301.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.65
|
| Rate for Payer: Cash Price |
$283.88
|
| Rate for Payer: Cofinity Commercial |
$248.40
|
| Rate for Payer: Cofinity Commercial |
$305.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.88
|
| Rate for Payer: Healthscope Commercial |
$319.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.62
|
| Rate for Payer: PHP Commercial |
$301.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.65
|
| Rate for Payer: Priority Health SBD |
$223.56
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$1,527.50
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$962.33 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$992.88
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,069.25
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,069.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,298.38
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$992.88
|
| Rate for Payer: Priority Health SBD |
$962.33
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$354.85
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.94 |
| Max. Negotiated Rate |
$319.37 |
| Rate for Payer: Aetna Commercial |
$301.62
|
| Rate for Payer: Aetna Medicare |
$177.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.65
|
| Rate for Payer: BCBS Complete |
$141.94
|
| Rate for Payer: Cash Price |
$283.88
|
| Rate for Payer: Cofinity Commercial |
$248.40
|
| Rate for Payer: Cofinity Commercial |
$305.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.88
|
| Rate for Payer: Healthscope Commercial |
$319.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.62
|
| Rate for Payer: PHP Commercial |
$301.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.65
|
| Rate for Payer: Priority Health SBD |
$223.56
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$1,527.50
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$611.00 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: Aetna Medicare |
$763.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$992.88
|
| Rate for Payer: BCBS Complete |
$611.00
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,069.25
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,069.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,298.38
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$992.88
|
| Rate for Payer: Priority Health SBD |
$962.33
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
OP
|
$406.55
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.62 |
| Max. Negotiated Rate |
$365.89 |
| Rate for Payer: Aetna Commercial |
$345.57
|
| Rate for Payer: Aetna Medicare |
$203.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.26
|
| Rate for Payer: BCBS Complete |
$162.62
|
| Rate for Payer: Cash Price |
$325.24
|
| Rate for Payer: Cofinity Commercial |
$284.58
|
| Rate for Payer: Cofinity Commercial |
$349.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.24
|
| Rate for Payer: Healthscope Commercial |
$365.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.57
|
| Rate for Payer: PHP Commercial |
$345.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.26
|
| Rate for Payer: Priority Health SBD |
$256.13
|
|
