|
CLONAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$64.75
|
|
|
Service Code
|
NDC 43547-406-10
|
| Hospital Charge Code |
9637
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.49 |
| Max. Negotiated Rate |
$58.28 |
| Rate for Payer: Aetna Commercial |
$55.04
|
| Rate for Payer: BCBS Trust/PPO |
$50.04
|
| Rate for Payer: BCN Commercial |
$50.04
|
| Rate for Payer: Cash Price |
$51.80
|
| Rate for Payer: Cofinity Commercial |
$55.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.80
|
| Rate for Payer: Healthscope Commercial |
$58.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.04
|
| Rate for Payer: PHP Commercial |
$55.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$56.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.98
|
| Rate for Payer: UHC Core |
$54.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.56
|
|
|
CLONAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 63739-263-10
|
| Hospital Charge Code |
9637
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.16 |
| Max. Negotiated Rate |
$74.02 |
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: BCBS Trust/PPO |
$63.56
|
| Rate for Payer: BCN Commercial |
$63.56
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$50.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$72.38
|
| Rate for Payer: UHC Core |
$68.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.69
|
|
|
CLONAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$7.18
|
|
|
Service Code
|
NDC 60687-544-11
|
| Hospital Charge Code |
9637
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$6.46 |
| Rate for Payer: Aetna Commercial |
$6.10
|
| Rate for Payer: BCBS Trust/PPO |
$5.55
|
| Rate for Payer: BCN Commercial |
$5.55
|
| Rate for Payer: Cash Price |
$5.74
|
| Rate for Payer: Cofinity Commercial |
$6.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.74
|
| Rate for Payer: Healthscope Commercial |
$6.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.10
|
| Rate for Payer: PHP Commercial |
$6.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.32
|
| Rate for Payer: UHC Core |
$6.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.38
|
|
|
CLONAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
NDC 0781-5567-01
|
| Hospital Charge Code |
9638
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.66 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna Commercial |
$124.95
|
| Rate for Payer: BCBS Trust/PPO |
$113.60
|
| Rate for Payer: BCN Commercial |
$113.60
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cofinity Commercial |
$126.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.60
|
| Rate for Payer: Healthscope Commercial |
$132.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.95
|
| Rate for Payer: PHP Commercial |
$124.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$127.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$89.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$129.36
|
| Rate for Payer: UHC Core |
$122.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.25
|
|
|
CLONAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$7.18
|
|
|
Service Code
|
NDC 60687-555-11
|
| Hospital Charge Code |
9638
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$6.46 |
| Rate for Payer: Aetna Commercial |
$6.10
|
| Rate for Payer: BCBS Trust/PPO |
$5.55
|
| Rate for Payer: BCN Commercial |
$5.55
|
| Rate for Payer: Cash Price |
$5.74
|
| Rate for Payer: Cofinity Commercial |
$6.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.74
|
| Rate for Payer: Healthscope Commercial |
$6.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.10
|
| Rate for Payer: PHP Commercial |
$6.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.32
|
| Rate for Payer: UHC Core |
$6.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.38
|
|
|
CLONAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$717.50
|
|
|
Service Code
|
NDC 60687-555-01
|
| Hospital Charge Code |
9638
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$437.60 |
| Max. Negotiated Rate |
$645.75 |
| Rate for Payer: Aetna Commercial |
$609.88
|
| Rate for Payer: BCBS Trust/PPO |
$554.48
|
| Rate for Payer: BCN Commercial |
$554.48
|
| Rate for Payer: Cash Price |
$574.00
|
| Rate for Payer: Cofinity Commercial |
$617.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$574.00
|
| Rate for Payer: Healthscope Commercial |
$645.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$538.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$609.88
|
| Rate for Payer: PHP Commercial |
$609.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$502.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$624.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$437.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$631.40
|
| Rate for Payer: UHC Core |
$599.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$538.12
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$56.76
|
|
|
Service Code
|
NDC 0555-1009-01
|
| Hospital Charge Code |
27505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.62 |
| Max. Negotiated Rate |
$51.08 |
| Rate for Payer: Aetna Commercial |
$48.25
|
| Rate for Payer: BCBS Trust/PPO |
$43.86
|
| Rate for Payer: BCN Commercial |
$43.86
|
| Rate for Payer: Cash Price |
$45.41
|
| Rate for Payer: Cofinity Commercial |
$48.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.41
|
| Rate for Payer: Healthscope Commercial |
$51.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.25
|
| Rate for Payer: PHP Commercial |
$48.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.95
|
| Rate for Payer: UHC Core |
$47.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.57
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$29.67
|
|
|
Service Code
|
NDC 0378-0871-16
|
| Hospital Charge Code |
27505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$26.70 |
| Rate for Payer: Aetna Commercial |
$25.22
|
| Rate for Payer: BCBS Trust/PPO |
$22.93
|
| Rate for Payer: BCN Commercial |
$22.93
|
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Cofinity Commercial |
$25.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$26.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.22
|
| Rate for Payer: PHP Commercial |
$25.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.11
|
| Rate for Payer: UHC Core |
$24.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.25
|
|
|
CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$118.67
|
|
|
Service Code
|
NDC 0378-0871-99
|
| Hospital Charge Code |
27505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.38 |
| Max. Negotiated Rate |
$106.80 |
| Rate for Payer: Aetna Commercial |
$100.87
|
| Rate for Payer: BCBS Trust/PPO |
$91.71
|
| Rate for Payer: BCN Commercial |
$91.71
|
| Rate for Payer: Cash Price |
$94.94
|
| Rate for Payer: Cofinity Commercial |
$102.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.94
|
| Rate for Payer: Healthscope Commercial |
$106.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.87
|
| Rate for Payer: PHP Commercial |
$100.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$103.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$72.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.43
|
| Rate for Payer: UHC Core |
$99.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.00
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$49.61
|
|
|
Service Code
|
NDC 0378-0872-16
|
| Hospital Charge Code |
27506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.26 |
| Max. Negotiated Rate |
$44.65 |
| Rate for Payer: Aetna Commercial |
$42.17
|
| Rate for Payer: BCBS Trust/PPO |
$38.34
|
| Rate for Payer: BCN Commercial |
$38.34
|
| Rate for Payer: Cash Price |
$39.69
|
| Rate for Payer: Cofinity Commercial |
$42.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.69
|
| Rate for Payer: Healthscope Commercial |
$44.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$42.17
|
| Rate for Payer: PHP Commercial |
$42.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$43.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$30.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.66
|
| Rate for Payer: UHC Core |
$41.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.21
|
|
|
CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$198.44
|
|
|
Service Code
|
NDC 0378-0872-99
|
| Hospital Charge Code |
27506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.03 |
| Max. Negotiated Rate |
$178.60 |
| Rate for Payer: Aetna Commercial |
$168.67
|
| Rate for Payer: BCBS Trust/PPO |
$153.35
|
| Rate for Payer: BCN Commercial |
$153.35
|
| Rate for Payer: Cash Price |
$158.75
|
| Rate for Payer: Cofinity Commercial |
$170.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.75
|
| Rate for Payer: Healthscope Commercial |
$178.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.67
|
| Rate for Payer: PHP Commercial |
$168.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$172.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$121.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$174.63
|
| Rate for Payer: UHC Core |
$165.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.83
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$254.64
|
|
|
Service Code
|
NDC 0378-0873-99
|
| Hospital Charge Code |
27507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.30 |
| Max. Negotiated Rate |
$229.18 |
| Rate for Payer: Aetna Commercial |
$216.44
|
| Rate for Payer: BCBS Trust/PPO |
$196.79
|
| Rate for Payer: BCN Commercial |
$196.79
|
| Rate for Payer: Cash Price |
$203.71
|
| Rate for Payer: Cofinity Commercial |
$218.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.71
|
| Rate for Payer: Healthscope Commercial |
$229.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.44
|
| Rate for Payer: PHP Commercial |
$216.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$221.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.08
|
| Rate for Payer: UHC Core |
$212.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.98
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH
|
Facility
|
IP
|
$63.66
|
|
|
Service Code
|
NDC 0378-0873-16
|
| Hospital Charge Code |
27507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.83 |
| Max. Negotiated Rate |
$57.29 |
| Rate for Payer: Aetna Commercial |
$54.11
|
| Rate for Payer: BCBS Trust/PPO |
$49.20
|
| Rate for Payer: BCN Commercial |
$49.20
|
| Rate for Payer: Cash Price |
$50.93
|
| Rate for Payer: Cofinity Commercial |
$54.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.93
|
| Rate for Payer: Healthscope Commercial |
$57.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.11
|
| Rate for Payer: PHP Commercial |
$54.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.02
|
| Rate for Payer: UHC Core |
$53.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.74
|
|
|
CLONIDINE HCL 0.1 MG TABLET
|
Facility
|
IP
|
$254.60
|
|
|
Service Code
|
NDC 60687-113-01
|
| Hospital Charge Code |
1755
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.28 |
| Max. Negotiated Rate |
$229.14 |
| Rate for Payer: Aetna Commercial |
$216.41
|
| Rate for Payer: BCBS Trust/PPO |
$196.75
|
| Rate for Payer: BCN Commercial |
$196.75
|
| Rate for Payer: Cash Price |
$203.68
|
| Rate for Payer: Cofinity Commercial |
$218.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.68
|
| Rate for Payer: Healthscope Commercial |
$229.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.41
|
| Rate for Payer: PHP Commercial |
$216.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$221.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.05
|
| Rate for Payer: UHC Core |
$212.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.95
|
|
|
CLONIDINE HCL 0.1 MG TABLET
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 60687-113-11
|
| Hospital Charge Code |
1755
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: BCBS Trust/PPO |
$1.97
|
| Rate for Payer: BCN Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.24
|
| Rate for Payer: UHC Core |
$2.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
CLONIDINE HCL 0.1 MG TABLET
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 0228-2127-10
|
| Hospital Charge Code |
1755
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$75.90
|
| Rate for Payer: BCBS Trust/PPO |
$69.01
|
| Rate for Payer: BCN Commercial |
$69.01
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.90
|
| Rate for Payer: PHP Commercial |
$75.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$54.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$78.58
|
| Rate for Payer: UHC Core |
$74.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.98
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 0904-6294-61
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.22 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: BCBS Trust/PPO |
$252.44
|
| Rate for Payer: BCN Commercial |
$252.44
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$284.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.45
|
| Rate for Payer: UHC Core |
$272.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION
|
Facility
|
OP
|
$1,107.03
|
|
|
Service Code
|
CPT 25605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,054.31 |
| Max. Negotiated Rate |
$1,107.03 |
| Rate for Payer: BCBS Complete |
$1,107.03
|
| Rate for Payer: Mclaren Medicaid |
$1,054.31
|
| Rate for Payer: Meridian Medicaid |
$1,107.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,054.31
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$19.44
|
|
|
Service Code
|
NDC 45802-434-11
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Aetna Commercial |
$16.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.02
|
| Rate for Payer: BCN Commercial |
$15.02
|
| Rate for Payer: Cash Price |
$15.55
|
| Rate for Payer: Cofinity Commercial |
$16.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.55
|
| Rate for Payer: Healthscope Commercial |
$17.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.52
|
| Rate for Payer: PHP Commercial |
$16.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.11
|
| Rate for Payer: UHC Core |
$16.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.58
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$9.36
|
|
|
Service Code
|
NDC 0904-7822-31
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.71 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Aetna Commercial |
$7.96
|
| Rate for Payer: BCBS Trust/PPO |
$7.23
|
| Rate for Payer: BCN Commercial |
$7.23
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Cofinity Commercial |
$8.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.49
|
| Rate for Payer: Healthscope Commercial |
$8.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.96
|
| Rate for Payer: PHP Commercial |
$7.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.24
|
| Rate for Payer: UHC Core |
$7.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.02
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$12.15
|
|
|
Service Code
|
NDC 51672-1275-2
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna Commercial |
$10.33
|
| Rate for Payer: BCBS Trust/PPO |
$9.39
|
| Rate for Payer: BCN Commercial |
$9.39
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cofinity Commercial |
$10.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.72
|
| Rate for Payer: Healthscope Commercial |
$10.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.33
|
| Rate for Payer: PHP Commercial |
$10.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.69
|
| Rate for Payer: UHC Core |
$10.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.11
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$19.51
|
|
|
Service Code
|
NDC 68462-298-17
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: BCBS Trust/PPO |
$15.08
|
| Rate for Payer: BCN Commercial |
$15.08
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cofinity Commercial |
$16.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.61
|
| Rate for Payer: Healthscope Commercial |
$17.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.58
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.17
|
| Rate for Payer: UHC Core |
$16.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.63
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$19.92
|
|
|
Service Code
|
NDC 0168-0258-15
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$17.93 |
| Rate for Payer: Aetna Commercial |
$16.93
|
| Rate for Payer: BCBS Trust/PPO |
$15.39
|
| Rate for Payer: BCN Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$15.94
|
| Rate for Payer: Cofinity Commercial |
$17.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.94
|
| Rate for Payer: Healthscope Commercial |
$17.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.93
|
| Rate for Payer: PHP Commercial |
$16.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.53
|
| Rate for Payer: UHC Core |
$16.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.94
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$32.92
|
|
|
Service Code
|
NDC 0472-0379-15
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.08 |
| Max. Negotiated Rate |
$29.63 |
| Rate for Payer: Aetna Commercial |
$27.98
|
| Rate for Payer: BCBS Trust/PPO |
$25.44
|
| Rate for Payer: BCN Commercial |
$25.44
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cofinity Commercial |
$28.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Healthscope Commercial |
$29.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.98
|
| Rate for Payer: PHP Commercial |
$27.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.97
|
| Rate for Payer: UHC Core |
$27.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.69
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$794.76
|
|
|
Service Code
|
NDC 0093-7772-01
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$484.72 |
| Max. Negotiated Rate |
$715.28 |
| Rate for Payer: Aetna Commercial |
$675.55
|
| Rate for Payer: BCBS Trust/PPO |
$614.19
|
| Rate for Payer: BCN Commercial |
$614.19
|
| Rate for Payer: Cash Price |
$635.81
|
| Rate for Payer: Cofinity Commercial |
$683.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.81
|
| Rate for Payer: Healthscope Commercial |
$715.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$596.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$675.55
|
| Rate for Payer: PHP Commercial |
$675.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$556.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$691.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$484.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$699.39
|
| Rate for Payer: UHC Core |
$663.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$596.07
|
|
