|
ARTHROTOMY, ELBOW, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 24000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.37 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$1,271.09
|
| Rate for Payer: BCN Commercial |
$1,271.09
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$512.37
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,789.78
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 23040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$765.30 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$1,361.89
|
| Rate for Payer: BCN Commercial |
$1,361.89
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$765.30
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,789.78
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORATION, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY
|
Facility
|
OP
|
$21,998.64
|
|
|
Service Code
|
CPT 23107
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$710.53 |
| Max. Negotiated Rate |
$21,998.64 |
| Rate for Payer: Aetna Medicare |
$7,279.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,749.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,749.10
|
| Rate for Payer: BCBS Complete |
$3,939.19
|
| Rate for Payer: BCBS MAPPO |
$6,999.28
|
| Rate for Payer: BCBS Trust/PPO |
$2,368.43
|
| Rate for Payer: BCN Commercial |
$2,368.43
|
| Rate for Payer: BCN Medicare Advantage |
$6,999.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,999.28
|
| Rate for Payer: Mclaren Medicaid |
$3,751.61
|
| Rate for Payer: Mclaren Medicare |
$6,999.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,349.24
|
| Rate for Payer: Meridian Medicaid |
$3,939.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,049.17
|
| Rate for Payer: Nomi Health Commercial |
$14,698.49
|
| Rate for Payer: PACE Medicare |
$6,649.32
|
| Rate for Payer: PACE SWMI |
$6,999.28
|
| Rate for Payer: PHP Medicare Advantage |
$6,999.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,751.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,998.64
|
| Rate for Payer: Priority Health Medicare |
$6,999.28
|
| Rate for Payer: Priority Health Narrow Network |
$17,598.91
|
| Rate for Payer: Railroad Medicare Medicare |
$6,999.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$710.53
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,999.28
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$6,999.28
|
| Rate for Payer: UHCCP Medicaid |
$3,940.59
|
| Rate for Payer: VA VA |
$6,999.28
|
|
|
ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 27334
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$733.23 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$1,361.89
|
| Rate for Payer: BCN Commercial |
$1,361.89
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$733.23
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,789.78
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
OP
|
$81.36
|
|
|
Service Code
|
NDC 00536138694
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$73.22 |
| Rate for Payer: Aetna Commercial |
$69.16
|
| Rate for Payer: Aetna Medicare |
$40.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.88
|
| Rate for Payer: BCBS Complete |
$32.54
|
| Rate for Payer: Cash Price |
$65.09
|
| Rate for Payer: Cofinity Commercial |
$56.95
|
| Rate for Payer: Cofinity Commercial |
$69.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.09
|
| Rate for Payer: Healthscope Commercial |
$73.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.16
|
| Rate for Payer: PHP Commercial |
$69.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.88
|
| Rate for Payer: Priority Health SBD |
$51.26
|
|
|
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 Commercial |
$40.70
|
| Rate for Payer: Cofinity Commercial |
$50.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.70
|
| 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: PHP Commercial |
$49.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.79
|
| Rate for Payer: Priority Health SBD |
$36.63
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
OP
|
$58.14
|
|
|
Service Code
|
NDC 00536132594
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.26 |
| 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 Commercial |
$40.70
|
| Rate for Payer: Cofinity Commercial |
$50.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.70
|
| 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: PHP Commercial |
$49.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.79
|
| Rate for Payer: Priority Health SBD |
$36.63
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
IP
|
$81.36
|
|
|
Service Code
|
NDC 00536138694
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.26 |
| Max. Negotiated Rate |
$73.22 |
| Rate for Payer: Aetna Commercial |
$69.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.88
|
| Rate for Payer: Cash Price |
$65.09
|
| Rate for Payer: Cofinity Commercial |
$56.95
|
| Rate for Payer: Cofinity Commercial |
$69.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.09
|
| Rate for Payer: Healthscope Commercial |
$73.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.16
|
| Rate for Payer: PHP Commercial |
$69.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.88
|
| Rate for Payer: Priority Health SBD |
$51.26
|
|
|
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 |
$44.18 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$55.22
|
| 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 Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
|
|
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 |
$99.40 |
| 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 Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
|
|
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 |
$28.20 |
| 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) |
$45.82
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
|
|
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 |
$116.32 |
| 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 Commercial |
$111.16
|
| Rate for Payer: Cofinity Commercial |
$90.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.01
|
| Rate for Payer: Priority Health SBD |
$81.43
|
|
|
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 |
$44.42 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.42 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
|
|
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 |
$51.70 |
| Max. Negotiated Rate |
$116.32 |
| 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 Commercial |
$111.16
|
| Rate for Payer: Cofinity Commercial |
$90.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.01
|
| Rate for Payer: Priority Health SBD |
$81.43
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.20 |
| 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) |
$45.82
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 00904052372
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.32 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna Medicare |
$91.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: BCBS Complete |
$73.32
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health SBD |
$115.48
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 00904052372
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.48 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health SBD |
$115.48
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$207.02
|
|
|
Service Code
|
NDC 59762201201
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.81 |
| Max. Negotiated Rate |
$186.32 |
| Rate for Payer: Aetna Commercial |
$175.97
|
| Rate for Payer: Aetna Medicare |
$103.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.56
|
| Rate for Payer: BCBS Complete |
$82.81
|
| Rate for Payer: Cash Price |
$165.62
|
| Rate for Payer: Cofinity Commercial |
$144.91
|
| Rate for Payer: Cofinity Commercial |
$178.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.62
|
| Rate for Payer: Healthscope Commercial |
$186.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.97
|
| Rate for Payer: PHP Commercial |
$175.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.56
|
| Rate for Payer: Priority Health SBD |
$130.42
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$123.95
|
|
|
Service Code
|
NDC 62332019810
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.58 |
| Max. Negotiated Rate |
$111.56 |
| Rate for Payer: Aetna Commercial |
$105.36
|
| Rate for Payer: Aetna Medicare |
$61.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.57
|
| Rate for Payer: BCBS Complete |
$49.58
|
| Rate for Payer: Cash Price |
$99.16
|
| Rate for Payer: Cofinity Commercial |
$106.60
|
| Rate for Payer: Cofinity Commercial |
$86.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.16
|
| Rate for Payer: Healthscope Commercial |
$111.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.36
|
| Rate for Payer: PHP Commercial |
$105.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.57
|
| Rate for Payer: Priority Health SBD |
$78.09
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$123.95
|
|
|
Service Code
|
NDC 62332019810
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.09 |
| Max. Negotiated Rate |
$111.56 |
| Rate for Payer: Aetna Commercial |
$105.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.57
|
| Rate for Payer: Cash Price |
$99.16
|
| Rate for Payer: Cofinity Commercial |
$106.60
|
| Rate for Payer: Cofinity Commercial |
$86.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.16
|
| Rate for Payer: Healthscope Commercial |
$111.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.36
|
| Rate for Payer: PHP Commercial |
$105.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.57
|
| Rate for Payer: Priority Health SBD |
$78.09
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$1,239.50
|
|
|
Service Code
|
NDC 62332019831
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$495.80 |
| Max. Negotiated Rate |
$1,115.55 |
| Rate for Payer: Aetna Commercial |
$1,053.58
|
| Rate for Payer: Aetna Medicare |
$619.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.68
|
| Rate for Payer: BCBS Complete |
$495.80
|
| Rate for Payer: Cash Price |
$991.60
|
| Rate for Payer: Cofinity Commercial |
$1,065.97
|
| Rate for Payer: Cofinity Commercial |
$867.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$867.65
|
| 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: PHP Commercial |
$1,053.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$805.68
|
| 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 |
$421.18 |
| Max. Negotiated Rate |
$947.66 |
| 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 Commercial |
$737.06
|
| Rate for Payer: Cofinity Commercial |
$905.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$737.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$842.36
|
| Rate for Payer: Healthscope Commercial |
$947.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$895.01
|
| Rate for Payer: PHP Commercial |
$895.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$684.42
|
| Rate for Payer: Priority Health SBD |
$663.36
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$1,242.09
|
|
|
Service Code
|
NDC 59762201206
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$782.52 |
| Max. Negotiated Rate |
$1,117.88 |
| Rate for Payer: Aetna Commercial |
$1,055.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$807.36
|
| Rate for Payer: Cash Price |
$993.67
|
| Rate for Payer: Cofinity Commercial |
$1,068.20
|
| Rate for Payer: Cofinity Commercial |
$869.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$869.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$993.67
|
| Rate for Payer: Healthscope Commercial |
$1,117.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,055.78
|
| Rate for Payer: PHP Commercial |
$1,055.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$807.36
|
| Rate for Payer: Priority Health SBD |
$782.52
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$1,242.09
|
|
|
Service Code
|
NDC 59762201206
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$496.84 |
| Max. Negotiated Rate |
$1,117.88 |
| Rate for Payer: Aetna Commercial |
$1,055.78
|
| Rate for Payer: Aetna Medicare |
$621.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$807.36
|
| Rate for Payer: BCBS Complete |
$496.84
|
| Rate for Payer: Cash Price |
$993.67
|
| Rate for Payer: Cofinity Commercial |
$1,068.20
|
| Rate for Payer: Cofinity Commercial |
$869.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$869.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$993.67
|
| Rate for Payer: Healthscope Commercial |
$1,117.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,055.78
|
| Rate for Payer: PHP Commercial |
$1,055.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$807.36
|
| Rate for Payer: Priority Health SBD |
$782.52
|
|
