|
ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 29806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$4,253.50
|
| Rate for Payer: BCN Commercial |
$4,253.50
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$3,781.35
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 29823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,705.10 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$2,724.78
|
| Rate for Payer: BCN Commercial |
$2,724.78
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$1,705.10
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 29822
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,705.10 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$2,999.65
|
| Rate for Payer: BCN Commercial |
$2,999.65
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$1,705.10
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$2,348.09
|
|
|
Service Code
|
CPT 29826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,348.09 |
| Max. Negotiated Rate |
$2,348.09 |
| Rate for Payer: BCBS Trust/PPO |
$2,348.09
|
| Rate for Payer: BCN Commercial |
$2,348.09
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 29824
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,705.10 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$2,724.78
|
| Rate for Payer: BCN Commercial |
$2,724.78
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$1,705.10
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 29807
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$4,250.96
|
| Rate for Payer: BCN Commercial |
$4,250.96
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$3,781.35
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 29827
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$4,043.01
|
| Rate for Payer: BCN Commercial |
$4,043.01
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$3,781.35
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE OR FOREIGN BODIES
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 27331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,628.11 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$1,628.11
|
| Rate for Payer: BCN Commercial |
$1,628.11
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$1,705.10
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 27310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,705.10 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$1,744.41
|
| Rate for Payer: BCN Commercial |
$1,744.41
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$1,705.10
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
OP
|
$85.32
|
|
|
Service Code
|
NDC 00536138694
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.53 |
| Max. Negotiated Rate |
$76.79 |
| Rate for Payer: Aetna Commercial |
$72.52
|
| Rate for Payer: Aetna Medicare |
$42.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.46
|
| Rate for Payer: BCBS Complete |
$34.13
|
| Rate for Payer: Cash Price |
$68.26
|
| Rate for Payer: Cofinity Advantage |
$59.72
|
| Rate for Payer: Cofinity Commercial |
$73.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.26
|
| Rate for Payer: Healthscope Commercial |
$76.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$63.99
|
| Rate for Payer: PHP Commercial |
$72.52
|
| Rate for Payer: Priority Health SBD |
$53.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.46
|
| Rate for Payer: UHC Core |
$44.45
|
| Rate for Payer: UHC Exchange |
$33.53
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
IP
|
$58.14
|
|
|
Service Code
|
NDC 00536132594
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.63 |
| Max. Negotiated Rate |
$52.33 |
| Rate for Payer: Aetna Commercial |
$49.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.79
|
| Rate for Payer: Cash Price |
$46.51
|
| Rate for Payer: Cofinity Advantage |
$40.70
|
| Rate for Payer: Cofinity Commercial |
$50.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.51
|
| Rate for Payer: Healthscope Commercial |
$52.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.60
|
| Rate for Payer: PHP Commercial |
$49.42
|
| Rate for Payer: Priority Health SBD |
$36.63
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
IP
|
$85.32
|
|
|
Service Code
|
NDC 00536138694
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.75 |
| Max. Negotiated Rate |
$76.79 |
| Rate for Payer: Aetna Commercial |
$72.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.46
|
| Rate for Payer: Cash Price |
$68.26
|
| Rate for Payer: Cofinity Advantage |
$59.72
|
| Rate for Payer: Cofinity Commercial |
$73.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.26
|
| Rate for Payer: Healthscope Commercial |
$76.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$63.99
|
| Rate for Payer: PHP Commercial |
$72.52
|
| Rate for Payer: Priority Health SBD |
$53.75
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
OP
|
$58.14
|
|
|
Service Code
|
NDC 00536132594
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.85 |
| Max. Negotiated Rate |
$52.33 |
| Rate for Payer: Aetna Commercial |
$49.42
|
| Rate for Payer: Aetna Medicare |
$29.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.79
|
| Rate for Payer: BCBS Complete |
$23.26
|
| Rate for Payer: Cash Price |
$46.51
|
| Rate for Payer: Cofinity Advantage |
$40.70
|
| Rate for Payer: Cofinity Commercial |
$50.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.51
|
| Rate for Payer: Healthscope Commercial |
$52.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$46.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.60
|
| Rate for Payer: PHP Commercial |
$49.42
|
| Rate for Payer: Priority Health SBD |
$36.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.79
|
| Rate for Payer: UHC Core |
$30.29
|
| Rate for Payer: UHC Exchange |
$22.85
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 11845005171
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.71 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna Medicare |
$35.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.83
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Advantage |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.88
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health SBD |
$44.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.83
|
| Rate for Payer: UHC Core |
$36.73
|
| Rate for Payer: UHC Exchange |
$27.71
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 00904052372
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.66 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Advantage |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$180.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.20
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health SBD |
$142.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$146.64
|
| Rate for Payer: UHC Core |
$117.54
|
| Rate for Payer: UHC Exchange |
$88.66
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 79854030035
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.58 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Advantage |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health SBD |
$69.58
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 11845005171
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.41 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.83
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Advantage |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.88
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health SBD |
$44.41
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 79854030035
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.41 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$55.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Advantage |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$88.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.79
|
| Rate for Payer: UHC Core |
$57.54
|
| Rate for Payer: UHC Exchange |
$43.41
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$129.25
|
|
|
Service Code
|
NDC 79854030105
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.80 |
| Max. Negotiated Rate |
$116.33 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna Medicare |
$64.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.01
|
| Rate for Payer: BCBS Complete |
$51.70
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Advantage |
$90.47
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.94
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health SBD |
$81.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.01
|
| Rate for Payer: UHC Core |
$67.34
|
| Rate for Payer: UHC Exchange |
$50.80
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$72.85
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.63 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna Medicare |
$36.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: BCBS Complete |
$29.14
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Advantage |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$54.64
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.35
|
| Rate for Payer: UHC Core |
$37.95
|
| Rate for Payer: UHC Exchange |
$28.63
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 00904052372
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.13 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Advantage |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.20
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health SBD |
$142.13
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$72.85
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Advantage |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$54.64
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health SBD |
$45.90
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 79854030105
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.43 |
| Max. Negotiated Rate |
$116.33 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.01
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Advantage |
$90.47
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.94
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health SBD |
$81.43
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$1,239.50
|
|
|
Service Code
|
NDC 62332019831
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$780.88 |
| Max. Negotiated Rate |
$1,115.55 |
| Rate for Payer: Aetna Commercial |
$1,053.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.67
|
| Rate for Payer: Cash Price |
$991.60
|
| Rate for Payer: Cofinity Advantage |
$867.65
|
| Rate for Payer: Cofinity Commercial |
$1,065.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$991.60
|
| Rate for Payer: Healthscope Commercial |
$1,115.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,053.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$929.62
|
| Rate for Payer: PHP Commercial |
$1,053.58
|
| Rate for Payer: Priority Health SBD |
$780.88
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$1,052.95
|
|
|
Service Code
|
NDC 51991035860
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$413.81 |
| Max. Negotiated Rate |
$947.65 |
| Rate for Payer: Aetna Commercial |
$895.01
|
| Rate for Payer: Aetna Medicare |
$526.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$684.42
|
| Rate for Payer: BCBS Complete |
$421.18
|
| Rate for Payer: Cash Price |
$842.36
|
| Rate for Payer: Cofinity Advantage |
$737.07
|
| Rate for Payer: Cofinity Commercial |
$905.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$842.36
|
| Rate for Payer: Healthscope Commercial |
$947.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$842.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$895.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$789.71
|
| Rate for Payer: PHP Commercial |
$895.01
|
| Rate for Payer: Priority Health SBD |
$663.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$684.42
|
| Rate for Payer: UHC Core |
$548.59
|
| Rate for Payer: UHC Exchange |
$413.81
|
|
