|
TORSEMIDE 10 MG TABLET
|
Facility
IP
|
$199.75
|
|
|
Service Code
|
NDC 31722-530-01
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.84 |
| Max. Negotiated Rate |
$179.78 |
| Rate for Payer: Aetna Commercial |
$169.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.84
|
| Rate for Payer: Cash Price |
$159.80
|
| Rate for Payer: Cofinity Commercial |
$139.82
|
| Rate for Payer: Cofinity Commercial |
$171.78
|
| Rate for Payer: Healthscope Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$169.79
|
| Rate for Payer: PHP Commercial |
$169.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.82
|
| Rate for Payer: Priority Health SBD |
$125.84
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
IP
|
$475.00
|
|
|
Service Code
|
NDC 50111-916-01
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.25 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Aetna Commercial |
$403.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.75
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$332.50
|
| Rate for Payer: Cofinity Commercial |
$408.50
|
| Rate for Payer: Healthscope Commercial |
$427.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.75
|
| Rate for Payer: PHP Commercial |
$403.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.50
|
| Rate for Payer: Priority Health SBD |
$299.25
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
IP
|
$103.08
|
|
|
Service Code
|
NDC 50268-755-15
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$92.77 |
| Rate for Payer: Aetna Commercial |
$87.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.00
|
| Rate for Payer: Cash Price |
$82.46
|
| Rate for Payer: Cofinity Commercial |
$72.16
|
| Rate for Payer: Cofinity Commercial |
$88.65
|
| Rate for Payer: Healthscope Commercial |
$92.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.62
|
| Rate for Payer: PHP Commercial |
$87.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.16
|
| Rate for Payer: Priority Health SBD |
$64.94
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
IP
|
$2.07
|
|
|
Service Code
|
NDC 50268-755-11
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.35
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Healthscope Commercial |
$1.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.76
|
| Rate for Payer: PHP Commercial |
$1.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.45
|
| Rate for Payer: Priority Health SBD |
$1.30
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
IP
|
$139.65
|
|
|
Service Code
|
NDC 50268-756-15
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.98 |
| Max. Negotiated Rate |
$125.68 |
| Rate for Payer: Aetna Commercial |
$118.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.77
|
| Rate for Payer: Cash Price |
$111.72
|
| Rate for Payer: Cofinity Commercial |
$120.10
|
| Rate for Payer: Cofinity Commercial |
$97.76
|
| Rate for Payer: Healthscope Commercial |
$125.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$118.70
|
| Rate for Payer: PHP Commercial |
$118.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health SBD |
$87.98
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
IP
|
$280.32
|
|
|
Service Code
|
NDC 50111-917-01
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.60 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.21
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.22
|
| Rate for Payer: Priority Health SBD |
$176.60
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
IP
|
$2.80
|
|
|
Service Code
|
NDC 50268-756-11
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.82
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$1.96
|
| Rate for Payer: Cofinity Commercial |
$2.41
|
| Rate for Payer: Healthscope Commercial |
$2.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.38
|
| Rate for Payer: PHP Commercial |
$2.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.96
|
| Rate for Payer: Priority Health SBD |
$1.76
|
|
|
TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL
|
Facility
OP
|
$50,344.18
|
|
|
Service Code
|
CPT 22856
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,608.40 |
| Max. Negotiated Rate |
$50,344.18 |
| Rate for Payer: Aetna Medicare |
$17,245.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,727.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,727.79
|
| Rate for Payer: BCBS Complete |
$9,524.83
|
| Rate for Payer: BCBS MAPPO |
$16,582.23
|
| Rate for Payer: BCBS Trust/PPO |
$9,643.36
|
| Rate for Payer: BCN Medicare Advantage |
$16,582.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,582.23
|
| Rate for Payer: Mclaren Medicaid |
$9,070.48
|
| Rate for Payer: Mclaren Medicare |
$16,582.23
|
| Rate for Payer: Meridian Medicaid |
$9,524.83
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,411.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,069.56
|
| Rate for Payer: PACE Medicare |
$15,753.12
|
| Rate for Payer: PACE SWMI |
$16,582.23
|
| Rate for Payer: PHP Medicare Advantage |
$16,582.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,070.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$50,344.18
|
| Rate for Payer: Priority Health Medicare |
$16,582.23
|
| Rate for Payer: Priority Health Narrow Network |
$40,275.34
|
| Rate for Payer: Railroad Medicare Medicare |
$16,582.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,769.24
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,582.23
|
| Rate for Payer: UHC Exchange |
$1,608.40
|
| Rate for Payer: UHC Medicare Advantage |
$17,079.70
|
| Rate for Payer: VA VA |
$16,582.23
|
|
|
TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY
|
Facility
OP
|
$15,628.84
|
|
|
Service Code
|
CPT 60220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$697.78 |
| Max. Negotiated Rate |
$15,628.84 |
| Rate for Payer: Aetna Medicare |
$5,339.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,417.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,417.61
|
| Rate for Payer: BCBS Complete |
$2,949.02
|
| Rate for Payer: BCBS MAPPO |
$5,134.09
|
| Rate for Payer: BCBS Trust/PPO |
$3,378.70
|
| Rate for Payer: BCN Medicare Advantage |
$5,134.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,134.09
|
| Rate for Payer: Mclaren Medicaid |
$2,808.35
|
| Rate for Payer: Mclaren Medicare |
$5,134.09
|
| Rate for Payer: Meridian Medicaid |
$2,949.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,390.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,904.20
|
| Rate for Payer: PACE Medicare |
$4,877.39
|
| Rate for Payer: PACE SWMI |
$5,134.09
|
| Rate for Payer: PHP Medicare Advantage |
$5,134.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,808.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,628.84
|
| Rate for Payer: Priority Health Medicare |
$5,134.09
|
| Rate for Payer: Priority Health Narrow Network |
$12,503.07
|
| Rate for Payer: Railroad Medicare Medicare |
$5,134.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$767.56
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,134.09
|
| Rate for Payer: UHC Exchange |
$697.78
|
| Rate for Payer: UHC Medicare Advantage |
$5,288.11
|
| Rate for Payer: VA VA |
$5,134.09
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$14,468.63
|
|
|
Service Code
|
HCPCS J9352
|
| Hospital Charge Code |
175966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,115.24 |
| Max. Negotiated Rate |
$13,021.77 |
| Rate for Payer: Aetna Commercial |
$12,298.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,404.61
|
| Rate for Payer: Cash Price |
$11,574.90
|
| Rate for Payer: Cofinity Commercial |
$10,128.04
|
| Rate for Payer: Cofinity Commercial |
$12,443.02
|
| Rate for Payer: Healthscope Commercial |
$13,021.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,298.34
|
| Rate for Payer: PHP Commercial |
$12,298.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,128.04
|
| Rate for Payer: Priority Health SBD |
$9,115.24
|
|
|
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION
|
Facility
IP
|
$87.93
|
|
|
Service Code
|
NDC 0517-9305-01
|
| Hospital Charge Code |
194947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.40 |
| Max. Negotiated Rate |
$79.14 |
| Rate for Payer: Aetna Commercial |
$74.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.15
|
| Rate for Payer: Cash Price |
$70.34
|
| Rate for Payer: Cofinity Commercial |
$61.55
|
| Rate for Payer: Cofinity Commercial |
$75.62
|
| Rate for Payer: Healthscope Commercial |
$79.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.74
|
| Rate for Payer: PHP Commercial |
$74.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.55
|
| Rate for Payer: Priority Health SBD |
$55.40
|
|
|
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION
|
Facility
IP
|
$87.93
|
|
|
Service Code
|
NDC 0517-9305-25
|
| Hospital Charge Code |
194947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.40 |
| Max. Negotiated Rate |
$79.14 |
| Rate for Payer: Aetna Commercial |
$74.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.15
|
| Rate for Payer: Cash Price |
$70.34
|
| Rate for Payer: Cofinity Commercial |
$61.55
|
| Rate for Payer: Cofinity Commercial |
$75.62
|
| Rate for Payer: Healthscope Commercial |
$79.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.74
|
| Rate for Payer: PHP Commercial |
$74.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.55
|
| Rate for Payer: Priority Health SBD |
$55.40
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC
|
Facility
IP
|
$90,771.92
|
|
|
Service Code
|
MS-DRG 012
|
| Min. Negotiated Rate |
$27,868.43 |
| Max. Negotiated Rate |
$90,771.92 |
| Rate for Payer: Aetna Medicare |
$30,508.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36,668.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36,668.99
|
| Rate for Payer: BCBS MAPPO |
$29,335.19
|
| Rate for Payer: BCBS Trust/PPO |
$90,771.92
|
| Rate for Payer: BCN Medicare Advantage |
$29,335.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29,335.19
|
| Rate for Payer: Mclaren Medicare |
$29,335.19
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$30,801.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33,735.47
|
| Rate for Payer: PACE Medicare |
$27,868.43
|
| Rate for Payer: PACE SWMI |
$29,335.19
|
| Rate for Payer: PHP Medicare Advantage |
$29,335.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$57,469.99
|
| Rate for Payer: Priority Health Medicare |
$29,335.19
|
| Rate for Payer: Priority Health Narrow Network |
$45,975.99
|
| Rate for Payer: Railroad Medicare Medicare |
$29,335.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61,090.74
|
| Rate for Payer: UHC Core |
$37,485.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$29,335.19
|
| Rate for Payer: UHC Exchange |
$40,149.12
|
| Rate for Payer: UHC Medicare Advantage |
$30,215.25
|
| Rate for Payer: VA VA |
$29,335.19
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC
|
Facility
IP
|
$90,859.75
|
|
|
Service Code
|
MS-DRG 011
|
| Min. Negotiated Rate |
$35,745.96 |
| Max. Negotiated Rate |
$90,859.75 |
| Rate for Payer: Aetna Medicare |
$39,132.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47,034.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47,034.16
|
| Rate for Payer: BCBS MAPPO |
$37,627.33
|
| Rate for Payer: BCBS Trust/PPO |
$90,859.75
|
| Rate for Payer: BCN Medicare Advantage |
$37,627.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37,627.33
|
| Rate for Payer: Mclaren Medicare |
$37,627.33
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$39,508.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43,271.43
|
| Rate for Payer: PACE Medicare |
$35,745.96
|
| Rate for Payer: PACE SWMI |
$37,627.33
|
| Rate for Payer: PHP Medicare Advantage |
$37,627.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$73,992.49
|
| Rate for Payer: Priority Health Medicare |
$37,627.33
|
| Rate for Payer: Priority Health Narrow Network |
$59,193.99
|
| Rate for Payer: Railroad Medicare Medicare |
$37,627.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$78,654.20
|
| Rate for Payer: UHC Core |
$48,262.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$37,627.33
|
| Rate for Payer: UHC Exchange |
$51,691.91
|
| Rate for Payer: UHC Medicare Advantage |
$38,756.15
|
| Rate for Payer: VA VA |
$37,627.33
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC
|
Facility
IP
|
$63,604.24
|
|
|
Service Code
|
MS-DRG 013
|
| Min. Negotiated Rate |
$18,842.86 |
| Max. Negotiated Rate |
$63,604.24 |
| Rate for Payer: Aetna Medicare |
$20,627.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,793.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,793.24
|
| Rate for Payer: BCBS MAPPO |
$19,834.59
|
| Rate for Payer: BCBS Trust/PPO |
$63,604.24
|
| Rate for Payer: BCN Medicare Advantage |
$19,834.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,834.59
|
| Rate for Payer: Mclaren Medicare |
$19,834.59
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,826.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,809.78
|
| Rate for Payer: PACE Medicare |
$18,842.86
|
| Rate for Payer: PACE SWMI |
$19,834.59
|
| Rate for Payer: PHP Medicare Advantage |
$19,834.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38,539.58
|
| Rate for Payer: Priority Health Medicare |
$19,834.59
|
| Rate for Payer: Priority Health Narrow Network |
$30,831.66
|
| Rate for Payer: Railroad Medicare Medicare |
$19,834.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40,967.67
|
| Rate for Payer: UHC Core |
$25,138.15
|
| Rate for Payer: UHC Dual Complete DSNP |
$19,834.59
|
| Rate for Payer: UHC Exchange |
$26,924.14
|
| Rate for Payer: UHC Medicare Advantage |
$20,429.63
|
| Rate for Payer: VA VA |
$19,834.59
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES
|
Facility
IP
|
$224,233.80
|
|
|
Service Code
|
MS-DRG 004
|
| Min. Negotiated Rate |
$101,041.13 |
| Max. Negotiated Rate |
$224,233.80 |
| Rate for Payer: Aetna Medicare |
$110,613.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$132,948.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$132,948.85
|
| Rate for Payer: BCBS MAPPO |
$106,359.08
|
| Rate for Payer: BCBS Trust/PPO |
$199,264.75
|
| Rate for Payer: BCN Medicare Advantage |
$106,359.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$106,359.08
|
| Rate for Payer: Mclaren Medicare |
$106,359.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$111,677.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122,312.94
|
| Rate for Payer: PACE Medicare |
$101,041.13
|
| Rate for Payer: PACE SWMI |
$106,359.08
|
| Rate for Payer: PHP Medicare Advantage |
$106,359.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$210,943.82
|
| Rate for Payer: Priority Health Medicare |
$106,359.08
|
| Rate for Payer: Priority Health Narrow Network |
$168,755.06
|
| Rate for Payer: Railroad Medicare Medicare |
$106,359.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224,233.80
|
| Rate for Payer: UHC Core |
$137,592.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$106,359.08
|
| Rate for Payer: UHC Exchange |
$147,367.50
|
| Rate for Payer: UHC Medicare Advantage |
$109,549.85
|
| Rate for Payer: VA VA |
$106,359.08
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$105.75
|
|
|
Service Code
|
NDC 0093-0058-01
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.62 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$1.37
|
|
|
Service Code
|
NDC 55154-2541-7
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.89
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$0.96
|
| Rate for Payer: Cofinity Commercial |
$1.18
|
| Rate for Payer: Healthscope Commercial |
$1.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.16
|
| Rate for Payer: PHP Commercial |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.96
|
| Rate for Payer: Priority Health SBD |
$0.86
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$101.05
|
|
|
Service Code
|
NDC 51079-991-20
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.66 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.74
|
| Rate for Payer: Priority Health SBD |
$63.66
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$1.02
|
|
|
Service Code
|
NDC 51079-991-01
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.66
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cofinity Commercial |
$0.71
|
| Rate for Payer: Cofinity Commercial |
$0.88
|
| Rate for Payer: Healthscope Commercial |
$0.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.87
|
| Rate for Payer: PHP Commercial |
$0.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.71
|
| Rate for Payer: Priority Health SBD |
$0.64
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$505.25
|
|
|
Service Code
|
NDC 57664-377-13
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$318.31 |
| Max. Negotiated Rate |
$454.72 |
| Rate for Payer: Aetna Commercial |
$429.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$328.41
|
| Rate for Payer: Cash Price |
$404.20
|
| Rate for Payer: Cofinity Commercial |
$434.52
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Healthscope Commercial |
$454.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$429.46
|
| Rate for Payer: PHP Commercial |
$429.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$353.68
|
| Rate for Payer: Priority Health SBD |
$318.31
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$136.30
|
|
|
Service Code
|
NDC 55154-2541-4
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.87 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health SBD |
$85.87
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$987.00
|
|
|
Service Code
|
NDC 57664-377-18
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$621.81 |
| Max. Negotiated Rate |
$888.30 |
| Rate for Payer: Aetna Commercial |
$838.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$641.55
|
| Rate for Payer: Cash Price |
$789.60
|
| Rate for Payer: Cofinity Commercial |
$690.90
|
| Rate for Payer: Cofinity Commercial |
$848.82
|
| Rate for Payer: Healthscope Commercial |
$888.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$838.95
|
| Rate for Payer: PHP Commercial |
$838.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$690.90
|
| Rate for Payer: Priority Health SBD |
$621.81
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$284.35
|
|
|
Service Code
|
NDC 68084-808-01
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.14 |
| Max. Negotiated Rate |
$255.92 |
| Rate for Payer: Aetna Commercial |
$241.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.83
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Commercial |
$244.54
|
| Rate for Payer: Cofinity Commercial |
$199.04
|
| Rate for Payer: Healthscope Commercial |
$255.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.70
|
| Rate for Payer: PHP Commercial |
$241.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.04
|
| Rate for Payer: Priority Health SBD |
$179.14
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$270.25
|
|
|
Service Code
|
NDC 0904-7179-61
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.26 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna Commercial |
$229.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.66
|
| Rate for Payer: Cash Price |
$216.20
|
| Rate for Payer: Cofinity Commercial |
$189.18
|
| Rate for Payer: Cofinity Commercial |
$232.42
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.71
|
| Rate for Payer: PHP Commercial |
$229.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.18
|
| Rate for Payer: Priority Health SBD |
$170.26
|
|
