|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 51079030101
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.46
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$1.57
|
| Rate for Payer: Cofinity Commercial |
$1.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.79
|
| Rate for Payer: Healthscope Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.90
|
| Rate for Payer: PHP Commercial |
$1.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.46
|
| Rate for Payer: Priority Health SBD |
$1.41
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$159.60
|
|
|
Service Code
|
NDC 50268019415
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.84 |
| Max. Negotiated Rate |
$143.64 |
| Rate for Payer: Aetna Commercial |
$135.66
|
| Rate for Payer: Aetna Medicare |
$79.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.74
|
| Rate for Payer: BCBS Complete |
$63.84
|
| Rate for Payer: Cash Price |
$127.68
|
| Rate for Payer: Cofinity Commercial |
$111.72
|
| Rate for Payer: Cofinity Commercial |
$137.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.68
|
| Rate for Payer: Healthscope Commercial |
$143.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.66
|
| Rate for Payer: PHP Commercial |
$135.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.74
|
| Rate for Payer: Priority Health SBD |
$100.55
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$223.25
|
|
|
Service Code
|
NDC 51079030120
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.30 |
| Max. Negotiated Rate |
$200.92 |
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna Medicare |
$111.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: BCBS Complete |
$89.30
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: Priority Health SBD |
$140.65
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 51079030120
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.65 |
| Max. Negotiated Rate |
$200.92 |
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: Priority Health SBD |
$140.65
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 52817018210
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.15 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health SBD |
$102.15
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 50268019411
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna Commercial |
$2.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.08
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.56
|
| Rate for Payer: Healthscope Commercial |
$2.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.72
|
| Rate for Payer: PHP Commercial |
$2.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.08
|
| Rate for Payer: Priority Health SBD |
$2.02
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$133.95
|
|
|
Service Code
|
NDC 00228212910
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.39 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Cofinity Commercial |
$93.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.86
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.07
|
| Rate for Payer: Priority Health SBD |
$84.39
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$133.95
|
|
|
Service Code
|
NDC 00228212910
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.58 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna Medicare |
$66.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: BCBS Complete |
$53.58
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Cofinity Commercial |
$93.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.86
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.07
|
| Rate for Payer: Priority Health SBD |
$84.39
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 51079030101
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Medicare |
$1.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.46
|
| Rate for Payer: BCBS Complete |
$0.90
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$1.57
|
| Rate for Payer: Cofinity Commercial |
$1.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.79
|
| Rate for Payer: Healthscope Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.90
|
| Rate for Payer: PHP Commercial |
$1.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.46
|
| Rate for Payer: Priority Health SBD |
$1.41
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
OP
|
$244.40
|
|
|
Service Code
|
NDC 29300013701
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.76 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna Medicare |
$122.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: BCBS Complete |
$97.76
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health SBD |
$153.97
|
|
|
CLONIDINE HCL 0.3 MG TABLET
|
Facility
|
IP
|
$159.60
|
|
|
Service Code
|
NDC 50268019415
|
| Hospital Charge Code |
1757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.55 |
| Max. Negotiated Rate |
$143.64 |
| Rate for Payer: Aetna Commercial |
$135.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.74
|
| Rate for Payer: Cash Price |
$127.68
|
| Rate for Payer: Cofinity Commercial |
$111.72
|
| Rate for Payer: Cofinity Commercial |
$137.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.68
|
| Rate for Payer: Healthscope Commercial |
$143.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.66
|
| Rate for Payer: PHP Commercial |
$135.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.74
|
| Rate for Payer: Priority Health SBD |
$100.55
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$446.50
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.60 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Aetna Medicare |
$223.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.22
|
| Rate for Payer: BCBS Complete |
$178.60
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$312.55
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$312.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.22
|
| Rate for Payer: Priority Health SBD |
$281.30
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$97.29
|
|
|
Service Code
|
NDC 16729021815
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.92 |
| Max. Negotiated Rate |
$87.56 |
| Rate for Payer: Aetna Commercial |
$82.70
|
| Rate for Payer: Aetna Medicare |
$48.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.24
|
| Rate for Payer: BCBS Complete |
$38.92
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cofinity Commercial |
$68.10
|
| Rate for Payer: Cofinity Commercial |
$83.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.83
|
| Rate for Payer: Healthscope Commercial |
$87.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.70
|
| Rate for Payer: PHP Commercial |
$82.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.24
|
| Rate for Payer: Priority Health SBD |
$61.29
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.65 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.73
|
| Rate for Payer: Priority Health SBD |
$254.65
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.91
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cofinity Commercial |
$3.13
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.58
|
| Rate for Payer: Healthscope Commercial |
$4.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.80
|
| Rate for Payer: PHP Commercial |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.91
|
| Rate for Payer: Priority Health SBD |
$2.82
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.68 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$202.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.73
|
| Rate for Payer: Priority Health SBD |
$254.65
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Medicare |
$2.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.91
|
| Rate for Payer: BCBS Complete |
$1.79
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cofinity Commercial |
$3.13
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.58
|
| Rate for Payer: Healthscope Commercial |
$4.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.80
|
| Rate for Payer: PHP Commercial |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.91
|
| Rate for Payer: Priority Health SBD |
$2.82
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$97.29
|
|
|
Service Code
|
NDC 16729021815
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.29 |
| Max. Negotiated Rate |
$87.56 |
| Rate for Payer: Aetna Commercial |
$82.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.24
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cofinity Commercial |
$68.10
|
| Rate for Payer: Cofinity Commercial |
$83.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.83
|
| Rate for Payer: Healthscope Commercial |
$87.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.70
|
| Rate for Payer: PHP Commercial |
$82.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.24
|
| Rate for Payer: Priority Health SBD |
$61.29
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$446.50
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.30 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.22
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$312.55
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$312.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.22
|
| Rate for Payer: Priority Health SBD |
$281.30
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
NDC 51672404201
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.60 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna Medicare |
$222.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: BCBS Complete |
$177.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Commercial |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.60
|
| Rate for Payer: Priority Health SBD |
$279.72
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
NDC 51672404201
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$279.72 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Commercial |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.60
|
| Rate for Payer: Priority Health SBD |
$279.72
|
|
|
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 25605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$413.26 |
| Max. Negotiated Rate |
$4,928.37 |
| Rate for Payer: Aetna Medicare |
$1,630.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,960.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,960.06
|
| Rate for Payer: BCBS Complete |
$882.50
|
| Rate for Payer: BCBS MAPPO |
$1,568.05
|
| Rate for Payer: BCBS Trust/PPO |
$413.26
|
| Rate for Payer: BCN Commercial |
$413.26
|
| Rate for Payer: BCN Medicare Advantage |
$1,568.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,568.05
|
| Rate for Payer: Mclaren Medicaid |
$840.47
|
| Rate for Payer: Mclaren Medicare |
$1,568.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,646.45
|
| Rate for Payer: Meridian Medicaid |
$882.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,803.26
|
| Rate for Payer: Nomi Health Commercial |
$3,292.90
|
| Rate for Payer: PACE Medicare |
$1,489.65
|
| Rate for Payer: PACE SWMI |
$1,568.05
|
| Rate for Payer: PHP Medicare Advantage |
$1,568.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$840.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,928.37
|
| Rate for Payer: Priority Health Medicare |
$1,568.05
|
| Rate for Payer: Priority Health Narrow Network |
$3,942.70
|
| Rate for Payer: Railroad Medicare Medicare |
$1,568.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$551.22
|
| Rate for Payer: UHC Core |
$1,463.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,568.05
|
| Rate for Payer: UHC Exchange |
$1,566.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,568.05
|
| Rate for Payer: UHCCP Medicaid |
$882.81
|
| Rate for Payer: VA VA |
$1,568.05
|
|
|
CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 27502
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$621.68 |
| Max. Negotiated Rate |
$4,928.37 |
| Rate for Payer: Aetna Medicare |
$1,630.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,960.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,960.06
|
| Rate for Payer: BCBS Complete |
$882.50
|
| Rate for Payer: BCBS MAPPO |
$1,568.05
|
| Rate for Payer: BCBS Trust/PPO |
$621.68
|
| Rate for Payer: BCN Commercial |
$621.68
|
| Rate for Payer: BCN Medicare Advantage |
$1,568.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,568.05
|
| Rate for Payer: Mclaren Medicaid |
$840.47
|
| Rate for Payer: Mclaren Medicare |
$1,568.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,646.45
|
| Rate for Payer: Meridian Medicaid |
$882.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,803.26
|
| Rate for Payer: Nomi Health Commercial |
$3,292.90
|
| Rate for Payer: PACE Medicare |
$1,489.65
|
| Rate for Payer: PACE SWMI |
$1,568.05
|
| Rate for Payer: PHP Medicare Advantage |
$1,568.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$840.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,928.37
|
| Rate for Payer: Priority Health Medicare |
$1,568.05
|
| Rate for Payer: Priority Health Narrow Network |
$3,942.70
|
| Rate for Payer: Railroad Medicare Medicare |
$1,568.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$808.28
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,568.05
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,568.05
|
| Rate for Payer: UHCCP Medicaid |
$882.81
|
| Rate for Payer: VA VA |
$1,568.05
|
|
|
CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
CPT 26775
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$90.63 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Aetna Medicare |
$270.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$325.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$325.26
|
| Rate for Payer: BCBS Complete |
$146.45
|
| Rate for Payer: BCBS MAPPO |
$260.21
|
| Rate for Payer: BCBS Trust/PPO |
$90.63
|
| Rate for Payer: BCN Commercial |
$90.63
|
| Rate for Payer: BCN Medicare Advantage |
$260.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$260.21
|
| Rate for Payer: Mclaren Medicaid |
$139.47
|
| Rate for Payer: Mclaren Medicare |
$260.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$273.22
|
| Rate for Payer: Meridian Medicaid |
$146.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$299.24
|
| Rate for Payer: Nomi Health Commercial |
$546.44
|
| Rate for Payer: PACE Medicare |
$247.20
|
| Rate for Payer: PACE SWMI |
$260.21
|
| Rate for Payer: PHP Medicare Advantage |
$260.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$139.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$817.84
|
| Rate for Payer: Priority Health Medicare |
$260.21
|
| Rate for Payer: Priority Health Narrow Network |
$654.27
|
| Rate for Payer: Railroad Medicare Medicare |
$260.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$383.38
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$260.21
|
| Rate for Payer: UHC Exchange |
$940.00
|
| Rate for Payer: UHC Medicare Advantage |
$260.21
|
| Rate for Payer: UHCCP Medicaid |
$146.50
|
| Rate for Payer: VA VA |
$260.21
|
|
|
CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 27552
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$678.88 |
| Max. Negotiated Rate |
$4,928.37 |
| Rate for Payer: Aetna Medicare |
$1,630.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,960.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,960.06
|
| Rate for Payer: BCBS Complete |
$882.50
|
| Rate for Payer: BCBS MAPPO |
$1,568.05
|
| Rate for Payer: BCBS Trust/PPO |
$781.07
|
| Rate for Payer: BCN Commercial |
$781.07
|
| Rate for Payer: BCN Medicare Advantage |
$1,568.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,568.05
|
| Rate for Payer: Mclaren Medicaid |
$840.47
|
| Rate for Payer: Mclaren Medicare |
$1,568.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,646.45
|
| Rate for Payer: Meridian Medicaid |
$882.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,803.26
|
| Rate for Payer: Nomi Health Commercial |
$3,292.90
|
| Rate for Payer: PACE Medicare |
$1,489.65
|
| Rate for Payer: PACE SWMI |
$1,568.05
|
| Rate for Payer: PHP Medicare Advantage |
$1,568.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$840.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,928.37
|
| Rate for Payer: Priority Health Medicare |
$1,568.05
|
| Rate for Payer: Priority Health Narrow Network |
$3,942.70
|
| Rate for Payer: Railroad Medicare Medicare |
$1,568.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$678.88
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,568.05
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,568.05
|
| Rate for Payer: UHCCP Medicaid |
$882.81
|
| Rate for Payer: VA VA |
$1,568.05
|
|
