|
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW
|
Facility
|
OP
|
$5,467.25
|
|
|
Service Code
|
CPT 64718
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$602.82 |
| Max. Negotiated Rate |
$5,467.25 |
| Rate for Payer: Aetna Medicare |
$1,786.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,147.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,147.49
|
| Rate for Payer: BCBS Complete |
$986.81
|
| Rate for Payer: BCBS MAPPO |
$1,717.99
|
| Rate for Payer: BCBS Trust/PPO |
$1,768.29
|
| Rate for Payer: BCN Medicare Advantage |
$1,717.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,717.99
|
| Rate for Payer: Mclaren Medicaid |
$939.74
|
| Rate for Payer: Mclaren Medicare |
$1,717.99
|
| Rate for Payer: Meridian Medicaid |
$986.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,803.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,975.69
|
| Rate for Payer: PACE Medicare |
$1,632.09
|
| Rate for Payer: PACE SWMI |
$1,717.99
|
| Rate for Payer: PHP Medicare Advantage |
$1,717.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$939.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,467.25
|
| Rate for Payer: Priority Health Medicare |
$1,717.99
|
| Rate for Payer: Priority Health Narrow Network |
$4,373.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1,717.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$663.10
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,717.99
|
| Rate for Payer: UHC Exchange |
$602.82
|
| Rate for Payer: UHC Medicare Advantage |
$1,769.53
|
| Rate for Payer: VA VA |
$1,717.99
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST
|
Facility
|
OP
|
$5,467.25
|
|
|
Service Code
|
CPT 64719
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$407.99 |
| Max. Negotiated Rate |
$5,467.25 |
| Rate for Payer: Aetna Medicare |
$1,786.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,147.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,147.49
|
| Rate for Payer: BCBS Complete |
$986.81
|
| Rate for Payer: BCBS MAPPO |
$1,717.99
|
| Rate for Payer: BCBS Trust/PPO |
$798.94
|
| Rate for Payer: BCN Medicare Advantage |
$1,717.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,717.99
|
| Rate for Payer: Mclaren Medicaid |
$939.74
|
| Rate for Payer: Mclaren Medicare |
$1,717.99
|
| Rate for Payer: Meridian Medicaid |
$986.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,803.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,975.69
|
| Rate for Payer: PACE Medicare |
$1,632.09
|
| Rate for Payer: PACE SWMI |
$1,717.99
|
| Rate for Payer: PHP Medicare Advantage |
$1,717.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$939.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,467.25
|
| Rate for Payer: Priority Health Medicare |
$1,717.99
|
| Rate for Payer: Priority Health Narrow Network |
$4,373.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1,717.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$448.79
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,717.99
|
| Rate for Payer: UHC Exchange |
$407.99
|
| Rate for Payer: UHC Medicare Advantage |
$1,769.53
|
| Rate for Payer: VA VA |
$1,717.99
|
|
|
NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED
|
Facility
|
OP
|
$5,467.25
|
|
|
Service Code
|
CPT 64708
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$506.55 |
| Max. Negotiated Rate |
$5,467.25 |
| Rate for Payer: Aetna Medicare |
$1,786.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,147.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,147.49
|
| Rate for Payer: BCBS Complete |
$986.81
|
| Rate for Payer: BCBS MAPPO |
$1,717.99
|
| Rate for Payer: BCBS Trust/PPO |
$827.47
|
| Rate for Payer: BCN Medicare Advantage |
$1,717.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,717.99
|
| Rate for Payer: Mclaren Medicaid |
$939.74
|
| Rate for Payer: Mclaren Medicare |
$1,717.99
|
| Rate for Payer: Meridian Medicaid |
$986.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,803.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,975.69
|
| Rate for Payer: PACE Medicare |
$1,632.09
|
| Rate for Payer: PACE SWMI |
$1,717.99
|
| Rate for Payer: PHP Medicare Advantage |
$1,717.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$939.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,467.25
|
| Rate for Payer: Priority Health Medicare |
$1,717.99
|
| Rate for Payer: Priority Health Narrow Network |
$4,373.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1,717.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$557.20
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,717.99
|
| Rate for Payer: UHC Exchange |
$506.55
|
| Rate for Payer: UHC Medicare Advantage |
$1,769.53
|
| Rate for Payer: VA VA |
$1,717.99
|
|
|
NEUROSES EXCEPT DEPRESSIVE
|
Facility
|
IP
|
$24,515.03
|
|
|
Service Code
|
MS-DRG 882
|
| Min. Negotiated Rate |
$6,894.51 |
| Max. Negotiated Rate |
$24,515.03 |
| Rate for Payer: Aetna Medicare |
$7,547.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,071.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,071.72
|
| Rate for Payer: BCBS MAPPO |
$7,257.38
|
| Rate for Payer: BCBS Trust/PPO |
$24,515.03
|
| Rate for Payer: BCN Medicare Advantage |
$7,257.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,257.38
|
| Rate for Payer: Mclaren Medicare |
$7,257.38
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,620.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,345.99
|
| Rate for Payer: PACE Medicare |
$6,894.51
|
| Rate for Payer: PACE SWMI |
$7,257.38
|
| Rate for Payer: PHP Medicare Advantage |
$7,257.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,478.88
|
| Rate for Payer: Priority Health Medicare |
$7,257.38
|
| Rate for Payer: Priority Health Narrow Network |
$10,783.10
|
| Rate for Payer: Railroad Medicare Medicare |
$7,257.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,328.08
|
| Rate for Payer: UHC Core |
$8,791.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,257.38
|
| Rate for Payer: UHC Exchange |
$9,416.48
|
| Rate for Payer: UHC Medicare Advantage |
$7,475.10
|
| Rate for Payer: VA VA |
$7,257.38
|
|
|
NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$222.92
|
|
|
Service Code
|
NDC 50268-584-13
|
| Hospital Charge Code |
5545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.44 |
| Max. Negotiated Rate |
$200.63 |
| Rate for Payer: Aetna Commercial |
$189.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.90
|
| Rate for Payer: Cash Price |
$178.34
|
| Rate for Payer: Cofinity Commercial |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$191.71
|
| Rate for Payer: Healthscope Commercial |
$200.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.48
|
| Rate for Payer: PHP Commercial |
$189.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.04
|
| Rate for Payer: Priority Health SBD |
$140.44
|
|
|
NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$7.44
|
|
|
Service Code
|
NDC 50268-584-11
|
| Hospital Charge Code |
5545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.84
|
| Rate for Payer: Cash Price |
$5.95
|
| Rate for Payer: Cofinity Commercial |
$5.21
|
| Rate for Payer: Cofinity Commercial |
$6.40
|
| Rate for Payer: Healthscope Commercial |
$6.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.32
|
| Rate for Payer: PHP Commercial |
$6.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.21
|
| Rate for Payer: Priority Health SBD |
$4.69
|
|
|
NICARDIPINE 20 MG CAPSULE
|
Facility
|
IP
|
$693.64
|
|
|
Service Code
|
NDC 42806-501-09
|
| Hospital Charge Code |
10712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$436.99 |
| Max. Negotiated Rate |
$624.28 |
| Rate for Payer: Aetna Commercial |
$589.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$450.87
|
| Rate for Payer: Cash Price |
$554.91
|
| Rate for Payer: Cofinity Commercial |
$485.55
|
| Rate for Payer: Cofinity Commercial |
$596.53
|
| Rate for Payer: Healthscope Commercial |
$624.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$589.59
|
| Rate for Payer: PHP Commercial |
$589.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$485.55
|
| Rate for Payer: Priority Health SBD |
$436.99
|
|
|
NICARDIPINE 20 MG CAPSULE
|
Facility
|
IP
|
$714.96
|
|
|
Service Code
|
NDC 0378-1020-77
|
| Hospital Charge Code |
10712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$450.42 |
| Max. Negotiated Rate |
$643.46 |
| Rate for Payer: Aetna Commercial |
$607.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.72
|
| Rate for Payer: Cash Price |
$571.97
|
| Rate for Payer: Cofinity Commercial |
$500.47
|
| Rate for Payer: Cofinity Commercial |
$614.87
|
| Rate for Payer: Healthscope Commercial |
$643.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$607.72
|
| Rate for Payer: PHP Commercial |
$607.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$500.47
|
| Rate for Payer: Priority Health SBD |
$450.42
|
|
|
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$50.91
|
|
|
Service Code
|
HCPCS J2404
|
| Hospital Charge Code |
12370
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.07 |
| Max. Negotiated Rate |
$45.82 |
| Rate for Payer: Aetna Commercial |
$43.27
|
| Rate for Payer: Aetna Commercial |
$40.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.09
|
| Rate for Payer: Cash Price |
$38.56
|
| Rate for Payer: Cash Price |
$40.73
|
| Rate for Payer: Cofinity Commercial |
$33.74
|
| Rate for Payer: Cofinity Commercial |
$35.64
|
| Rate for Payer: Cofinity Commercial |
$43.78
|
| Rate for Payer: Cofinity Commercial |
$41.45
|
| Rate for Payer: Healthscope Commercial |
$43.38
|
| Rate for Payer: Healthscope Commercial |
$45.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.27
|
| Rate for Payer: PHP Commercial |
$40.97
|
| Rate for Payer: PHP Commercial |
$43.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.64
|
| Rate for Payer: Priority Health SBD |
$30.37
|
| Rate for Payer: Priority Health SBD |
$32.07
|
|
|
NICARDIPINE 30 MG CAPSULE
|
Facility
|
IP
|
$789.55
|
|
|
Service Code
|
NDC 0378-1430-77
|
| Hospital Charge Code |
10713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$497.42 |
| Max. Negotiated Rate |
$710.60 |
| Rate for Payer: Aetna Commercial |
$671.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$513.21
|
| Rate for Payer: Cash Price |
$631.64
|
| Rate for Payer: Cofinity Commercial |
$552.68
|
| Rate for Payer: Cofinity Commercial |
$679.01
|
| Rate for Payer: Healthscope Commercial |
$710.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$671.12
|
| Rate for Payer: PHP Commercial |
$671.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$552.68
|
| Rate for Payer: Priority Health SBD |
$497.42
|
|
|
NICARDIPINE 30 MG CAPSULE
|
Facility
|
IP
|
$1,104.57
|
|
|
Service Code
|
NDC 42806-502-09
|
| Hospital Charge Code |
10713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$695.88 |
| Max. Negotiated Rate |
$994.11 |
| Rate for Payer: Aetna Commercial |
$938.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$717.97
|
| Rate for Payer: Cash Price |
$883.66
|
| Rate for Payer: Cofinity Commercial |
$773.20
|
| Rate for Payer: Cofinity Commercial |
$949.93
|
| Rate for Payer: Healthscope Commercial |
$994.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$938.88
|
| Rate for Payer: PHP Commercial |
$938.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$773.20
|
| Rate for Payer: Priority Health SBD |
$695.88
|
|
|
NICARDIPINE 50 MG/250 ML NS (IV PREMIX)
|
Facility
|
IP
|
$193.50
|
|
|
Service Code
|
NDC 9900-0008-64
|
| Hospital Charge Code |
180442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.90 |
| Max. Negotiated Rate |
$174.15 |
| Rate for Payer: Aetna Commercial |
$164.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.78
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Cofinity Commercial |
$135.45
|
| Rate for Payer: Cofinity Commercial |
$166.41
|
| Rate for Payer: Healthscope Commercial |
$174.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.48
|
| Rate for Payer: PHP Commercial |
$164.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.45
|
| Rate for Payer: Priority Health SBD |
$121.90
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.23
|
|
|
Service Code
|
NDC 43598-447-71
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Aetna Commercial |
$7.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.35
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cofinity Commercial |
$5.76
|
| Rate for Payer: Cofinity Commercial |
$7.08
|
| Rate for Payer: Healthscope Commercial |
$7.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.00
|
| Rate for Payer: PHP Commercial |
$7.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.76
|
| Rate for Payer: Priority Health SBD |
$5.18
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$88.31
|
|
|
Service Code
|
NDC 43598-447-74
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.64 |
| Max. Negotiated Rate |
$79.48 |
| Rate for Payer: Aetna Commercial |
$75.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.40
|
| Rate for Payer: Cash Price |
$70.65
|
| Rate for Payer: Cofinity Commercial |
$61.82
|
| Rate for Payer: Cofinity Commercial |
$75.95
|
| Rate for Payer: Healthscope Commercial |
$79.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.06
|
| Rate for Payer: PHP Commercial |
$75.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.82
|
| Rate for Payer: Priority Health SBD |
$55.64
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$57.49
|
|
|
Service Code
|
NDC 0536-5895-53
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.22 |
| Max. Negotiated Rate |
$51.74 |
| Rate for Payer: Aetna Commercial |
$48.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.37
|
| Rate for Payer: Cash Price |
$45.99
|
| Rate for Payer: Cofinity Commercial |
$40.24
|
| Rate for Payer: Cofinity Commercial |
$49.44
|
| Rate for Payer: Healthscope Commercial |
$51.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.87
|
| Rate for Payer: PHP Commercial |
$48.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.24
|
| Rate for Payer: Priority Health SBD |
$36.22
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.12
|
|
|
Service Code
|
NDC 0536-1107-88
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.53 |
| Max. Negotiated Rate |
$103.61 |
| Rate for Payer: Aetna Commercial |
$97.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.83
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cofinity Commercial |
$80.58
|
| Rate for Payer: Cofinity Commercial |
$99.00
|
| Rate for Payer: Healthscope Commercial |
$103.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97.85
|
| Rate for Payer: PHP Commercial |
$97.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.58
|
| Rate for Payer: Priority Health SBD |
$72.53
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$107.05
|
|
|
Service Code
|
NDC 0536-5895-88
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.44 |
| Max. Negotiated Rate |
$96.34 |
| Rate for Payer: Aetna Commercial |
$90.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.58
|
| Rate for Payer: Cash Price |
$85.64
|
| Rate for Payer: Cofinity Commercial |
$74.94
|
| Rate for Payer: Cofinity Commercial |
$92.06
|
| Rate for Payer: Healthscope Commercial |
$96.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.99
|
| Rate for Payer: PHP Commercial |
$90.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.94
|
| Rate for Payer: Priority Health SBD |
$67.44
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$107.93
|
|
|
Service Code
|
NDC 4898500150
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$97.14 |
| Rate for Payer: Aetna Commercial |
$91.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.15
|
| Rate for Payer: Cash Price |
$86.34
|
| Rate for Payer: Cofinity Commercial |
$75.55
|
| Rate for Payer: Cofinity Commercial |
$92.82
|
| Rate for Payer: Healthscope Commercial |
$97.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.74
|
| Rate for Payer: PHP Commercial |
$91.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.55
|
| Rate for Payer: Priority Health SBD |
$68.00
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$88.31
|
|
|
Service Code
|
NDC 43598-448-74
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.64 |
| Max. Negotiated Rate |
$79.48 |
| Rate for Payer: Aetna Commercial |
$75.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.40
|
| Rate for Payer: Cash Price |
$70.65
|
| Rate for Payer: Cofinity Commercial |
$61.82
|
| Rate for Payer: Cofinity Commercial |
$75.95
|
| Rate for Payer: Healthscope Commercial |
$79.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.06
|
| Rate for Payer: PHP Commercial |
$75.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.82
|
| Rate for Payer: Priority Health SBD |
$55.64
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$170.53
|
|
|
Service Code
|
NDC 766142020
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.43 |
| Max. Negotiated Rate |
$153.48 |
| Rate for Payer: Aetna Commercial |
$144.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.84
|
| Rate for Payer: Cash Price |
$136.42
|
| Rate for Payer: Cofinity Commercial |
$119.37
|
| Rate for Payer: Cofinity Commercial |
$146.66
|
| Rate for Payer: Healthscope Commercial |
$153.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$144.95
|
| Rate for Payer: PHP Commercial |
$144.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.37
|
| Rate for Payer: Priority Health SBD |
$107.43
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$92.14
|
|
|
Service Code
|
NDC 0536-5896-88
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$82.93 |
| Rate for Payer: Aetna Commercial |
$78.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.89
|
| Rate for Payer: Cash Price |
$73.71
|
| Rate for Payer: Cofinity Commercial |
$64.50
|
| Rate for Payer: Cofinity Commercial |
$79.24
|
| Rate for Payer: Healthscope Commercial |
$82.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$78.32
|
| Rate for Payer: PHP Commercial |
$78.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.50
|
| Rate for Payer: Priority Health SBD |
$58.05
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.12
|
|
|
Service Code
|
NDC 0536-1108-88
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.53 |
| Max. Negotiated Rate |
$103.61 |
| Rate for Payer: Aetna Commercial |
$97.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.83
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cofinity Commercial |
$80.58
|
| Rate for Payer: Cofinity Commercial |
$99.00
|
| Rate for Payer: Healthscope Commercial |
$103.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97.85
|
| Rate for Payer: PHP Commercial |
$97.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.58
|
| Rate for Payer: Priority Health SBD |
$72.53
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$121.91
|
|
|
Service Code
|
NDC 4898500152
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.80 |
| Max. Negotiated Rate |
$109.72 |
| Rate for Payer: Aetna Commercial |
$103.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.24
|
| Rate for Payer: Cash Price |
$97.53
|
| Rate for Payer: Cofinity Commercial |
$104.84
|
| Rate for Payer: Cofinity Commercial |
$85.34
|
| Rate for Payer: Healthscope Commercial |
$109.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.62
|
| Rate for Payer: PHP Commercial |
$103.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.34
|
| Rate for Payer: Priority Health SBD |
$76.80
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$62.30
|
|
|
Service Code
|
NDC 43598-446-70
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.25 |
| Max. Negotiated Rate |
$56.07 |
| Rate for Payer: Aetna Commercial |
$52.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.50
|
| Rate for Payer: Cash Price |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$43.61
|
| Rate for Payer: Cofinity Commercial |
$53.58
|
| Rate for Payer: Healthscope Commercial |
$56.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.96
|
| Rate for Payer: PHP Commercial |
$52.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.61
|
| Rate for Payer: Priority Health SBD |
$39.25
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.04
|
|
|
Service Code
|
NDC 43598-446-71
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$7.24 |
| Rate for Payer: Aetna Commercial |
$6.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.23
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$5.63
|
| Rate for Payer: Cofinity Commercial |
$6.91
|
| Rate for Payer: Healthscope Commercial |
$7.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.83
|
| Rate for Payer: PHP Commercial |
$6.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.63
|
| Rate for Payer: Priority Health SBD |
$5.07
|
|
