|
CHG X-RAY ABDOMEN 1 VW
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 74000
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: Aetna Medicare |
$18.00
|
| Rate for Payer: BCBS Complete |
$14.40
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
|
|
CHG X-RAY ABDOMEN 2 VW
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS 74020
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$34.45 |
| Rate for Payer: Aetna Medicare |
$26.50
|
| Rate for Payer: BCBS Complete |
$21.20
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.45
|
|
|
CHG X-RAY FEMUR 2 VW
|
Professional
|
Both
|
$94.00
|
|
|
Service Code
|
HCPCS 73550
|
| Min. Negotiated Rate |
$37.60 |
| Max. Negotiated Rate |
$61.10 |
| Rate for Payer: Aetna Medicare |
$47.00
|
| Rate for Payer: Aetna Medicare |
$15.00
|
| Rate for Payer: Aetna Medicare |
$19.00
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: BCBS Complete |
$15.20
|
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: Cash Price |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.70
|
|
|
CHG X-RAY HIPS 4 VW + PELVIS
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
HCPCS 73520
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: Aetna Medicare |
$60.50
|
| Rate for Payer: Aetna Medicare |
$23.50
|
| Rate for Payer: BCBS Complete |
$48.40
|
| Rate for Payer: BCBS Complete |
$21.60
|
| Rate for Payer: BCBS Complete |
$18.80
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$96.80
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.65
|
|
|
CHG X-RAY HIP UNI 2+ VW
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
HCPCS 73510
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$35.10 |
| Rate for Payer: Aetna Medicare |
$27.00
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: Aetna Medicare |
$18.50
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$21.60
|
| Rate for Payer: BCBS Complete |
$14.80
|
| Rate for Payer: Cash Price |
$29.60
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.05
|
|
|
CHG X-RAY HIP UNILAT 1 VW
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 73500
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
|
|
CHG X-RAY PELVIS/HIPS CHILD/INFANT
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 73540
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Medicare |
$17.50
|
| Rate for Payer: Aetna Medicare |
$48.50
|
| Rate for Payer: BCBS Complete |
$38.80
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cash Price |
$77.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.05
|
|
|
CHG X-RAY SPINE SURVEY
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 72010
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna Medicare |
$36.50
|
| Rate for Payer: BCBS Complete |
$29.20
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.45
|
|
|
CHG X-RAY THOR-LUMB SP SCOLIOSIS
|
Professional
|
Both
|
$133.00
|
|
|
Service Code
|
HCPCS 72090
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Aetna Medicare |
$66.50
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: Aetna Medicare |
$35.50
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$53.20
|
| Rate for Payer: BCBS Complete |
$28.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
|
|
CHG X-RAY TRUNK SPINE SCOLIOSIS
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 72069
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna Medicare |
$30.00
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: BCBS Complete |
$24.00
|
| Rate for Payer: BCBS Complete |
$18.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.00
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$286.70
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.09 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna Commercial |
$243.70
|
| Rate for Payer: Aetna Medicare |
$74.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$89.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$89.59
|
| Rate for Payer: BCBS Complete |
$114.68
|
| Rate for Payer: BCBS MAPPO |
$71.68
|
| Rate for Payer: BCBS Trust/PPO |
$235.70
|
| Rate for Payer: BCN Commercial |
$222.91
|
| Rate for Payer: BCN Medicare Advantage |
$71.68
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$71.68
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$75.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.70
|
| Rate for Payer: Nomi Health Commercial |
$235.09
|
| Rate for Payer: PACE Senior Care Partners |
$68.09
|
| Rate for Payer: PACE SWMI |
$71.68
|
| Rate for Payer: PHP Commercial |
$243.70
|
| Rate for Payer: PHP Medicare Advantage |
$71.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.36
|
| Rate for Payer: Priority Health HMO/PPO |
$249.43
|
| Rate for Payer: Priority Health Medicare |
$72.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$192.09
|
| Rate for Payer: Railroad Medicare Medicare |
$71.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.30
|
| Rate for Payer: UHC Core |
$239.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$71.68
|
| Rate for Payer: UHC Exchange |
$71.68
|
| Rate for Payer: UHC Medicare Advantage |
$71.68
|
| Rate for Payer: VA VA |
$71.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.02
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: BCBS Trust/PPO |
$3.56
|
| Rate for Payer: BCN Commercial |
$3.37
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: Nomi Health Commercial |
$3.58
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health HMO/PPO |
$3.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.84
|
| Rate for Payer: UHC Core |
$3.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.27
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Aetna Medicare |
$1.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.36
|
| Rate for Payer: BCBS Complete |
$1.74
|
| Rate for Payer: BCBS MAPPO |
$1.09
|
| Rate for Payer: BCBS Trust/PPO |
$3.58
|
| Rate for Payer: BCN Commercial |
$3.39
|
| Rate for Payer: BCN Medicare Advantage |
$1.09
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.09
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: Nomi Health Commercial |
$3.58
|
| Rate for Payer: PACE Senior Care Partners |
$1.04
|
| Rate for Payer: PACE SWMI |
$1.09
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: PHP Medicare Advantage |
$1.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health HMO/PPO |
$3.79
|
| Rate for Payer: Priority Health Medicare |
$1.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.92
|
| Rate for Payer: Railroad Medicare Medicare |
$1.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.84
|
| Rate for Payer: UHC Core |
$3.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.09
|
| Rate for Payer: UHC Exchange |
$1.09
|
| Rate for Payer: UHC Medicare Advantage |
$1.09
|
| Rate for Payer: VA VA |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.27
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$286.70
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.36 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna Commercial |
$243.70
|
| Rate for Payer: BCBS Trust/PPO |
$234.03
|
| Rate for Payer: BCN Commercial |
$221.56
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.70
|
| Rate for Payer: Nomi Health Commercial |
$235.09
|
| Rate for Payer: PHP Commercial |
$243.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.36
|
| Rate for Payer: Priority Health HMO/PPO |
$249.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$192.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.30
|
| Rate for Payer: UHC Core |
$239.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.02
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$1,527.50
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$362.78 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: Aetna Medicare |
$397.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$477.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$477.34
|
| Rate for Payer: BCBS Complete |
$611.00
|
| Rate for Payer: BCBS MAPPO |
$381.88
|
| Rate for Payer: BCBS Trust/PPO |
$1,255.76
|
| Rate for Payer: BCN Commercial |
$1,187.63
|
| Rate for Payer: BCN Medicare Advantage |
$381.88
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$381.88
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,145.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$400.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$439.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,298.38
|
| Rate for Payer: Nomi Health Commercial |
$1,252.55
|
| Rate for Payer: PACE Senior Care Partners |
$362.78
|
| Rate for Payer: PACE SWMI |
$381.88
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: PHP Medicare Advantage |
$381.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$992.88
|
| Rate for Payer: Priority Health HMO/PPO |
$1,328.92
|
| Rate for Payer: Priority Health Medicare |
$385.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,023.42
|
| Rate for Payer: Railroad Medicare Medicare |
$381.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,344.20
|
| Rate for Payer: UHC Core |
$1,275.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$381.88
|
| Rate for Payer: UHC Exchange |
$381.88
|
| Rate for Payer: UHC Medicare Advantage |
$381.88
|
| Rate for Payer: VA VA |
$381.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,145.62
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$354.85
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.65 |
| Max. Negotiated Rate |
$319.36 |
| Rate for Payer: Aetna Commercial |
$301.62
|
| Rate for Payer: BCBS Trust/PPO |
$289.66
|
| Rate for Payer: BCN Commercial |
$274.23
|
| Rate for Payer: Cash Price |
$283.88
|
| Rate for Payer: Cofinity Commercial |
$305.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.88
|
| Rate for Payer: Healthscope Commercial |
$319.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.62
|
| Rate for Payer: Nomi Health Commercial |
$290.98
|
| Rate for Payer: PHP Commercial |
$301.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.65
|
| Rate for Payer: Priority Health HMO/PPO |
$308.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$237.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$312.27
|
| Rate for Payer: UHC Core |
$296.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.14
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$354.85
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$319.36 |
| Rate for Payer: Aetna Commercial |
$301.62
|
| Rate for Payer: Aetna Medicare |
$92.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$110.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$110.89
|
| Rate for Payer: BCBS Complete |
$141.94
|
| Rate for Payer: BCBS MAPPO |
$88.71
|
| Rate for Payer: BCBS Trust/PPO |
$291.72
|
| Rate for Payer: BCN Commercial |
$275.90
|
| Rate for Payer: BCN Medicare Advantage |
$88.71
|
| Rate for Payer: Cash Price |
$283.88
|
| Rate for Payer: Cofinity Commercial |
$305.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$88.71
|
| Rate for Payer: Healthscope Commercial |
$319.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$93.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.62
|
| Rate for Payer: Nomi Health Commercial |
$290.98
|
| Rate for Payer: PACE Senior Care Partners |
$84.28
|
| Rate for Payer: PACE SWMI |
$88.71
|
| Rate for Payer: PHP Commercial |
$301.62
|
| Rate for Payer: PHP Medicare Advantage |
$88.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.65
|
| Rate for Payer: Priority Health HMO/PPO |
$308.72
|
| Rate for Payer: Priority Health Medicare |
$89.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$237.75
|
| Rate for Payer: Railroad Medicare Medicare |
$88.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$312.27
|
| Rate for Payer: UHC Core |
$296.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$88.71
|
| Rate for Payer: UHC Exchange |
$88.71
|
| Rate for Payer: UHC Medicare Advantage |
$88.71
|
| Rate for Payer: VA VA |
$88.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.14
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$1,527.50
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$992.88 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,246.90
|
| Rate for Payer: BCN Commercial |
$1,180.45
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,145.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,298.38
|
| Rate for Payer: Nomi Health Commercial |
$1,252.55
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$992.88
|
| Rate for Payer: Priority Health HMO/PPO |
$1,328.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,023.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,344.20
|
| Rate for Payer: UHC Core |
$1,275.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,145.62
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$32.08
|
|
|
Service Code
|
NDC 66689010601
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$28.87 |
| Rate for Payer: Aetna Commercial |
$27.27
|
| Rate for Payer: Aetna Medicare |
$8.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.02
|
| Rate for Payer: BCBS Complete |
$12.83
|
| Rate for Payer: BCBS MAPPO |
$8.02
|
| Rate for Payer: BCBS Trust/PPO |
$26.37
|
| Rate for Payer: BCN Commercial |
$24.94
|
| Rate for Payer: BCN Medicare Advantage |
$8.02
|
| Rate for Payer: Cash Price |
$25.66
|
| Rate for Payer: Cofinity Commercial |
$27.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.02
|
| Rate for Payer: Healthscope Commercial |
$28.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.27
|
| Rate for Payer: Nomi Health Commercial |
$26.31
|
| Rate for Payer: PACE Senior Care Partners |
$7.62
|
| Rate for Payer: PACE SWMI |
$8.02
|
| Rate for Payer: PHP Commercial |
$27.27
|
| Rate for Payer: PHP Medicare Advantage |
$8.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.85
|
| Rate for Payer: Priority Health HMO/PPO |
$27.91
|
| Rate for Payer: Priority Health Medicare |
$8.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.49
|
| Rate for Payer: Railroad Medicare Medicare |
$8.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.23
|
| Rate for Payer: UHC Core |
$26.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.02
|
| Rate for Payer: UHC Exchange |
$8.02
|
| Rate for Payer: UHC Medicare Advantage |
$8.02
|
| Rate for Payer: VA VA |
$8.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.06
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$3.88
|
|
|
Service Code
|
NDC 09900000023
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna Medicare |
$1.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.21
|
| Rate for Payer: BCBS Complete |
$1.55
|
| Rate for Payer: BCBS MAPPO |
$0.97
|
| Rate for Payer: BCBS Trust/PPO |
$3.19
|
| Rate for Payer: BCN Commercial |
$3.02
|
| Rate for Payer: BCN Medicare Advantage |
$0.97
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.97
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: Nomi Health Commercial |
$3.18
|
| Rate for Payer: PACE Senior Care Partners |
$0.92
|
| Rate for Payer: PACE SWMI |
$0.97
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: PHP Medicare Advantage |
$0.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health HMO/PPO |
$3.38
|
| Rate for Payer: Priority Health Medicare |
$0.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.60
|
| Rate for Payer: Railroad Medicare Medicare |
$0.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.41
|
| Rate for Payer: UHC Core |
$3.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.97
|
| Rate for Payer: UHC Exchange |
$0.97
|
| Rate for Payer: UHC Medicare Advantage |
$0.97
|
| Rate for Payer: VA VA |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$32.08
|
|
|
Service Code
|
NDC 66689010650
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.85 |
| Max. Negotiated Rate |
$28.87 |
| Rate for Payer: Aetna Commercial |
$27.27
|
| Rate for Payer: BCBS Trust/PPO |
$26.19
|
| Rate for Payer: BCN Commercial |
$24.79
|
| Rate for Payer: Cash Price |
$25.66
|
| Rate for Payer: Cofinity Commercial |
$27.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.66
|
| Rate for Payer: Healthscope Commercial |
$28.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.27
|
| Rate for Payer: Nomi Health Commercial |
$26.31
|
| Rate for Payer: PHP Commercial |
$27.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.85
|
| Rate for Payer: Priority Health HMO/PPO |
$27.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.23
|
| Rate for Payer: UHC Core |
$26.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.06
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$66.70
|
|
|
Service Code
|
NDC 00116200116
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.36 |
| Max. Negotiated Rate |
$60.03 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: BCBS Trust/PPO |
$54.45
|
| Rate for Payer: BCN Commercial |
$51.55
|
| Rate for Payer: Cash Price |
$53.36
|
| Rate for Payer: Cofinity Commercial |
$57.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.36
|
| Rate for Payer: Healthscope Commercial |
$60.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.70
|
| Rate for Payer: Nomi Health Commercial |
$54.69
|
| Rate for Payer: PHP Commercial |
$56.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.36
|
| Rate for Payer: Priority Health HMO/PPO |
$58.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.70
|
| Rate for Payer: UHC Core |
$55.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.02
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$66.70
|
|
|
Service Code
|
NDC 00116200116
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$60.03 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Medicare |
$17.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20.84
|
| Rate for Payer: BCBS Complete |
$26.68
|
| Rate for Payer: BCBS MAPPO |
$16.68
|
| Rate for Payer: BCBS Trust/PPO |
$54.83
|
| Rate for Payer: BCN Commercial |
$51.86
|
| Rate for Payer: BCN Medicare Advantage |
$16.68
|
| Rate for Payer: Cash Price |
$53.36
|
| Rate for Payer: Cofinity Commercial |
$57.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.68
|
| Rate for Payer: Healthscope Commercial |
$60.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.70
|
| Rate for Payer: Nomi Health Commercial |
$54.69
|
| Rate for Payer: PACE Senior Care Partners |
$15.84
|
| Rate for Payer: PACE SWMI |
$16.68
|
| Rate for Payer: PHP Commercial |
$56.70
|
| Rate for Payer: PHP Medicare Advantage |
$16.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.36
|
| Rate for Payer: Priority Health HMO/PPO |
$58.03
|
| Rate for Payer: Priority Health Medicare |
$16.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.69
|
| Rate for Payer: Railroad Medicare Medicare |
$16.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.70
|
| Rate for Payer: UHC Core |
$55.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.68
|
| Rate for Payer: UHC Exchange |
$16.68
|
| Rate for Payer: UHC Medicare Advantage |
$16.68
|
| Rate for Payer: VA VA |
$16.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.02
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$32.08
|
|
|
Service Code
|
NDC 66689010650
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$28.87 |
| Rate for Payer: Aetna Commercial |
$27.27
|
| Rate for Payer: Aetna Medicare |
$8.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.02
|
| Rate for Payer: BCBS Complete |
$12.83
|
| Rate for Payer: BCBS MAPPO |
$8.02
|
| Rate for Payer: BCBS Trust/PPO |
$26.37
|
| Rate for Payer: BCN Commercial |
$24.94
|
| Rate for Payer: BCN Medicare Advantage |
$8.02
|
| Rate for Payer: Cash Price |
$25.66
|
| Rate for Payer: Cofinity Commercial |
$27.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.02
|
| Rate for Payer: Healthscope Commercial |
$28.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.27
|
| Rate for Payer: Nomi Health Commercial |
$26.31
|
| Rate for Payer: PACE Senior Care Partners |
$7.62
|
| Rate for Payer: PACE SWMI |
$8.02
|
| Rate for Payer: PHP Commercial |
$27.27
|
| Rate for Payer: PHP Medicare Advantage |
$8.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.85
|
| Rate for Payer: Priority Health HMO/PPO |
$27.91
|
| Rate for Payer: Priority Health Medicare |
$8.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.49
|
| Rate for Payer: Railroad Medicare Medicare |
$8.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.23
|
| Rate for Payer: UHC Core |
$26.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.02
|
| Rate for Payer: UHC Exchange |
$8.02
|
| Rate for Payer: UHC Medicare Advantage |
$8.02
|
| Rate for Payer: VA VA |
$8.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.06
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 09900000023
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: BCBS Trust/PPO |
$3.17
|
| Rate for Payer: BCN Commercial |
$3.00
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: Nomi Health Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health HMO/PPO |
$3.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.41
|
| Rate for Payer: UHC Core |
$3.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
