|
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITHOUT STABILIZATION
|
Facility
|
OP
|
$4,561.52
|
|
|
Service Code
|
CPT 21315
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$63.33 |
| Max. Negotiated Rate |
$4,561.52 |
| Rate for Payer: Aetna Medicare |
$1,509.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,814.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,814.16
|
| Rate for Payer: BCBS Complete |
$816.81
|
| Rate for Payer: BCBS MAPPO |
$1,451.33
|
| Rate for Payer: BCBS Trust/PPO |
$673.13
|
| Rate for Payer: BCN Commercial |
$673.13
|
| Rate for Payer: BCN Medicare Advantage |
$1,451.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,451.33
|
| Rate for Payer: Mclaren Medicaid |
$777.91
|
| Rate for Payer: Mclaren Medicare |
$1,451.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,523.90
|
| Rate for Payer: Meridian Medicaid |
$816.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,669.03
|
| Rate for Payer: Nomi Health Commercial |
$3,047.79
|
| Rate for Payer: PACE Medicare |
$1,378.76
|
| Rate for Payer: PACE SWMI |
$1,451.33
|
| Rate for Payer: PHP Medicare Advantage |
$1,451.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$777.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,561.52
|
| Rate for Payer: Priority Health Medicare |
$1,451.33
|
| Rate for Payer: Priority Health Narrow Network |
$3,649.22
|
| Rate for Payer: Railroad Medicare Medicare |
$1,451.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.33
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,451.33
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,451.33
|
| Rate for Payer: UHCCP Medicaid |
$817.10
|
| Rate for Payer: VA VA |
$1,451.33
|
|
|
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION
|
Facility
|
OP
|
$9,986.81
|
|
|
Service Code
|
CPT 21320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$100.88 |
| Max. Negotiated Rate |
$9,986.81 |
| Rate for Payer: Aetna Medicare |
$3,304.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,971.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,971.88
|
| Rate for Payer: BCBS Complete |
$1,788.30
|
| Rate for Payer: BCBS MAPPO |
$3,177.50
|
| Rate for Payer: BCBS Trust/PPO |
$1,517.91
|
| Rate for Payer: BCN Commercial |
$1,517.91
|
| Rate for Payer: BCN Medicare Advantage |
$3,177.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,177.50
|
| Rate for Payer: Mclaren Medicaid |
$1,703.14
|
| Rate for Payer: Mclaren Medicare |
$3,177.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,336.38
|
| Rate for Payer: Meridian Medicaid |
$1,788.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,654.12
|
| Rate for Payer: Nomi Health Commercial |
$6,672.75
|
| Rate for Payer: PACE Medicare |
$3,018.62
|
| Rate for Payer: PACE SWMI |
$3,177.50
|
| Rate for Payer: PHP Medicare Advantage |
$3,177.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,986.81
|
| Rate for Payer: Priority Health Medicare |
$3,177.50
|
| Rate for Payer: Priority Health Narrow Network |
$7,989.45
|
| Rate for Payer: Railroad Medicare Medicare |
$3,177.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$100.88
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,177.50
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,177.50
|
| Rate for Payer: UHCCP Medicaid |
$1,788.93
|
| Rate for Payer: VA VA |
$3,177.50
|
|
|
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 27266
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$623.69 |
| 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 |
$725.30
|
| Rate for Payer: BCN Commercial |
$725.30
|
| 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) |
$623.69
|
| 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 RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 25565
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$503.01 |
| 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 |
$604.96
|
| Rate for Payer: BCN Commercial |
$604.96
|
| 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) |
$503.01
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,568.05
|
| Rate for Payer: UHC Exchange |
$940.00
|
| 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 SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, WITH MANIPULATION
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 23665
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$432.94 |
| 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 |
$456.46
|
| Rate for Payer: BCN Commercial |
$456.46
|
| 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) |
$432.94
|
| 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 SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 23655
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$437.86 |
| 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 |
$534.87
|
| Rate for Payer: BCN Commercial |
$534.87
|
| 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) |
$437.86
|
| 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 SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 23655
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$437.86 |
| 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 |
$534.87
|
| Rate for Payer: BCN Commercial |
$534.87
|
| 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) |
$437.86
|
| 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
|
|
|
CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP
|
Facility
|
OP
|
$8,445.02
|
|
|
Service Code
|
CPT 46288
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$591.66 |
| Max. Negotiated Rate |
$8,445.02 |
| Rate for Payer: Aetna Medicare |
$2,794.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,358.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,358.68
|
| Rate for Payer: BCBS Complete |
$1,512.21
|
| Rate for Payer: BCBS MAPPO |
$2,686.94
|
| Rate for Payer: BCBS Trust/PPO |
$1,286.29
|
| Rate for Payer: BCN Commercial |
$1,286.29
|
| Rate for Payer: BCN Medicare Advantage |
$2,686.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,686.94
|
| Rate for Payer: Mclaren Medicaid |
$1,440.20
|
| Rate for Payer: Mclaren Medicare |
$2,686.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,821.29
|
| Rate for Payer: Meridian Medicaid |
$1,512.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,089.98
|
| Rate for Payer: Nomi Health Commercial |
$5,642.57
|
| Rate for Payer: PACE Medicare |
$2,552.59
|
| Rate for Payer: PACE SWMI |
$2,686.94
|
| Rate for Payer: PHP Medicare Advantage |
$2,686.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,440.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,445.02
|
| Rate for Payer: Priority Health Medicare |
$2,686.94
|
| Rate for Payer: Priority Health Narrow Network |
$6,756.02
|
| Rate for Payer: Railroad Medicare Medicare |
$2,686.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$591.66
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,686.94
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$2,686.94
|
| Rate for Payer: UHCCP Medicaid |
$1,512.75
|
| Rate for Payer: VA VA |
$2,686.94
|
|
|
CLOSURE OF GASTROSTOMY, SURGICAL
|
Facility
|
OP
|
$11,715.79
|
|
|
Service Code
|
CPT 43870
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$762.66 |
| Max. Negotiated Rate |
$11,715.79 |
| Rate for Payer: Aetna Medicare |
$3,876.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,659.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,659.50
|
| Rate for Payer: BCBS Complete |
$2,097.89
|
| Rate for Payer: BCBS MAPPO |
$3,727.60
|
| Rate for Payer: BCBS Trust/PPO |
$1,183.68
|
| Rate for Payer: BCN Commercial |
$1,183.68
|
| Rate for Payer: BCN Medicare Advantage |
$3,727.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,727.60
|
| Rate for Payer: Mclaren Medicaid |
$1,997.99
|
| Rate for Payer: Mclaren Medicare |
$3,727.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,913.98
|
| Rate for Payer: Meridian Medicaid |
$2,097.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,286.74
|
| Rate for Payer: Nomi Health Commercial |
$7,827.96
|
| Rate for Payer: PACE Medicare |
$3,541.22
|
| Rate for Payer: PACE SWMI |
$3,727.60
|
| Rate for Payer: PHP Medicare Advantage |
$3,727.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,997.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,715.79
|
| Rate for Payer: Priority Health Medicare |
$3,727.60
|
| Rate for Payer: Priority Health Narrow Network |
$9,372.63
|
| Rate for Payer: Railroad Medicare Medicare |
$3,727.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$762.66
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,727.60
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,727.60
|
| Rate for Payer: UHCCP Medicaid |
$2,098.64
|
| Rate for Payer: VA VA |
$3,727.60
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$32.92
|
|
|
Service Code
|
NDC 51672127506
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.17 |
| Max. Negotiated Rate |
$29.63 |
| Rate for Payer: Aetna Commercial |
$27.98
|
| Rate for Payer: Aetna Medicare |
$16.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.40
|
| Rate for Payer: BCBS Complete |
$13.17
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cofinity Commercial |
$23.04
|
| Rate for Payer: Cofinity Commercial |
$28.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Healthscope Commercial |
$29.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.98
|
| Rate for Payer: PHP Commercial |
$27.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.40
|
| Rate for Payer: Priority Health SBD |
$20.74
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$9.52
|
|
|
Service Code
|
NDC 00536126526
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Aetna Medicare |
$4.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: BCBS Complete |
$3.81
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Cofinity Commercial |
$8.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$8.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.09
|
| Rate for Payer: PHP Commercial |
$8.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health SBD |
$6.00
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$32.92
|
|
|
Service Code
|
NDC 51672127506
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.74 |
| Max. Negotiated Rate |
$29.63 |
| Rate for Payer: Aetna Commercial |
$27.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.40
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cofinity Commercial |
$23.04
|
| Rate for Payer: Cofinity Commercial |
$28.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Healthscope Commercial |
$29.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.98
|
| Rate for Payer: PHP Commercial |
$27.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.40
|
| Rate for Payer: Priority Health SBD |
$20.74
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$9.52
|
|
|
Service Code
|
NDC 00536126526
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna Commercial |
$8.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Cofinity Commercial |
$8.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$8.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.09
|
| Rate for Payer: PHP Commercial |
$8.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health SBD |
$6.00
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION
|
Facility
|
OP
|
$194.57
|
|
|
Service Code
|
NDC 51672126003
|
| Hospital Charge Code |
1768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.83 |
| Max. Negotiated Rate |
$175.11 |
| Rate for Payer: Aetna Commercial |
$165.38
|
| Rate for Payer: Aetna Medicare |
$97.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.47
|
| Rate for Payer: BCBS Complete |
$77.83
|
| Rate for Payer: Cash Price |
$155.66
|
| Rate for Payer: Cofinity Commercial |
$136.20
|
| Rate for Payer: Cofinity Commercial |
$167.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.66
|
| Rate for Payer: Healthscope Commercial |
$175.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.38
|
| Rate for Payer: PHP Commercial |
$165.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.47
|
| Rate for Payer: Priority Health SBD |
$122.58
|
|
|
CLOTRIMAZOLE 1 % TOPICAL SOLUTION
|
Facility
|
IP
|
$194.57
|
|
|
Service Code
|
NDC 51672126003
|
| Hospital Charge Code |
1768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.58 |
| Max. Negotiated Rate |
$175.11 |
| Rate for Payer: Aetna Commercial |
$165.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.47
|
| Rate for Payer: Cash Price |
$155.66
|
| Rate for Payer: Cofinity Commercial |
$136.20
|
| Rate for Payer: Cofinity Commercial |
$167.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.66
|
| Rate for Payer: Healthscope Commercial |
$175.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.38
|
| Rate for Payer: PHP Commercial |
$165.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.47
|
| Rate for Payer: Priority Health SBD |
$122.58
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$794.76
|
|
|
Service Code
|
NDC 00093777201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$500.70 |
| Max. Negotiated Rate |
$715.28 |
| Rate for Payer: Aetna Commercial |
$675.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.59
|
| Rate for Payer: Cash Price |
$635.81
|
| Rate for Payer: Cofinity Commercial |
$556.33
|
| Rate for Payer: Cofinity Commercial |
$683.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$556.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.81
|
| Rate for Payer: Healthscope Commercial |
$715.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.55
|
| Rate for Payer: PHP Commercial |
$675.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$516.59
|
| Rate for Payer: Priority Health SBD |
$500.70
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$325.44
|
|
|
Service Code
|
NDC 00904708761
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.18 |
| Max. Negotiated Rate |
$292.90 |
| Rate for Payer: Aetna Commercial |
$276.62
|
| Rate for Payer: Aetna Medicare |
$162.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.54
|
| Rate for Payer: BCBS Complete |
$130.18
|
| Rate for Payer: Cash Price |
$260.35
|
| Rate for Payer: Cofinity Commercial |
$227.81
|
| Rate for Payer: Cofinity Commercial |
$279.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.35
|
| Rate for Payer: Healthscope Commercial |
$292.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.62
|
| Rate for Payer: PHP Commercial |
$276.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.54
|
| Rate for Payer: Priority Health SBD |
$205.03
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.41 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Commercial |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$267.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.04
|
| Rate for Payer: Priority Health SBD |
$240.41
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$325.44
|
|
|
Service Code
|
NDC 00904708761
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.03 |
| Max. Negotiated Rate |
$292.90 |
| Rate for Payer: Aetna Commercial |
$276.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.54
|
| Rate for Payer: Cash Price |
$260.35
|
| Rate for Payer: Cofinity Commercial |
$227.81
|
| Rate for Payer: Cofinity Commercial |
$279.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.35
|
| Rate for Payer: Healthscope Commercial |
$292.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.62
|
| Rate for Payer: PHP Commercial |
$276.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.54
|
| Rate for Payer: Priority Health SBD |
$205.03
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$794.76
|
|
|
Service Code
|
NDC 00093777201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$317.90 |
| Max. Negotiated Rate |
$715.28 |
| Rate for Payer: Aetna Commercial |
$675.55
|
| Rate for Payer: Aetna Medicare |
$397.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.59
|
| Rate for Payer: BCBS Complete |
$317.90
|
| Rate for Payer: Cash Price |
$635.81
|
| Rate for Payer: Cofinity Commercial |
$556.33
|
| Rate for Payer: Cofinity Commercial |
$683.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$556.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.81
|
| Rate for Payer: Healthscope Commercial |
$715.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.55
|
| Rate for Payer: PHP Commercial |
$675.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$516.59
|
| Rate for Payer: Priority Health SBD |
$500.70
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$303.84
|
|
|
Service Code
|
NDC 65862084601
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.54 |
| Max. Negotiated Rate |
$273.46 |
| Rate for Payer: Aetna Commercial |
$258.26
|
| Rate for Payer: Aetna Medicare |
$151.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.50
|
| Rate for Payer: BCBS Complete |
$121.54
|
| Rate for Payer: Cash Price |
$243.07
|
| Rate for Payer: Cofinity Commercial |
$212.69
|
| Rate for Payer: Cofinity Commercial |
$261.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$212.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.07
|
| Rate for Payer: Healthscope Commercial |
$273.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.26
|
| Rate for Payer: PHP Commercial |
$258.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.50
|
| Rate for Payer: Priority Health SBD |
$191.42
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health SBD |
$2.41
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$303.84
|
|
|
Service Code
|
NDC 65862084601
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.42 |
| Max. Negotiated Rate |
$273.46 |
| Rate for Payer: Aetna Commercial |
$258.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.50
|
| Rate for Payer: Cash Price |
$243.07
|
| Rate for Payer: Cofinity Commercial |
$212.69
|
| Rate for Payer: Cofinity Commercial |
$261.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$212.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.07
|
| Rate for Payer: Healthscope Commercial |
$273.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.26
|
| Rate for Payer: PHP Commercial |
$258.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.50
|
| Rate for Payer: Priority Health SBD |
$191.42
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.64 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna Medicare |
$190.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: BCBS Complete |
$152.64
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Commercial |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$267.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.04
|
| Rate for Payer: Priority Health SBD |
$240.41
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health SBD |
$2.41
|
|
