|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$199.97
|
|
|
Service Code
|
NDC 386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.96 |
| Max. Negotiated Rate |
$179.97 |
| Rate for Payer: Aetna Commercial |
$169.97
|
| Rate for Payer: BCBS Trust/PPO |
$154.54
|
| Rate for Payer: BCN Commercial |
$154.54
|
| Rate for Payer: Cash Price |
$159.98
|
| Rate for Payer: Cofinity Commercial |
$171.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.98
|
| Rate for Payer: Healthscope Commercial |
$179.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$169.97
|
| Rate for Payer: PHP Commercial |
$169.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$173.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$121.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.97
|
| Rate for Payer: UHC Core |
$166.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.98
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$112.06
|
|
|
Service Code
|
NDC 386000103
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$100.85 |
| Rate for Payer: Aetna Commercial |
$95.25
|
| Rate for Payer: BCBS Trust/PPO |
$86.60
|
| Rate for Payer: BCN Commercial |
$86.60
|
| Rate for Payer: Cash Price |
$89.65
|
| Rate for Payer: Cofinity Commercial |
$96.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.65
|
| Rate for Payer: Healthscope Commercial |
$100.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$95.25
|
| Rate for Payer: PHP Commercial |
$95.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$97.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$68.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.61
|
| Rate for Payer: UHC Core |
$93.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.04
|
|
|
ETODOLAC 400 MG TABLET
|
Facility
|
IP
|
$284.55
|
|
|
Service Code
|
NDC 63629-1377-5
|
| Hospital Charge Code |
9999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.55 |
| Max. Negotiated Rate |
$256.10 |
| Rate for Payer: Aetna Commercial |
$241.87
|
| Rate for Payer: BCBS Trust/PPO |
$219.90
|
| Rate for Payer: BCN Commercial |
$219.90
|
| Rate for Payer: Cash Price |
$227.64
|
| Rate for Payer: Cofinity Commercial |
$244.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.64
|
| Rate for Payer: Healthscope Commercial |
$256.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.87
|
| Rate for Payer: PHP Commercial |
$241.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$247.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.40
|
| Rate for Payer: UHC Core |
$237.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.41
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.66
|
|
|
Service Code
|
NDC 67457-903-20
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.04 |
| Max. Negotiated Rate |
$22.19 |
| Rate for Payer: Aetna Commercial |
$20.96
|
| Rate for Payer: BCBS Trust/PPO |
$19.06
|
| Rate for Payer: BCN Commercial |
$19.06
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$21.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.73
|
| Rate for Payer: Healthscope Commercial |
$22.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.96
|
| Rate for Payer: PHP Commercial |
$20.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.70
|
| Rate for Payer: UHC Core |
$20.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.50
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.35
|
|
|
Service Code
|
NDC 0143-9311-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$20.36
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Core |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.76
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.66
|
|
|
Service Code
|
NDC 67457-903-00
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.04 |
| Max. Negotiated Rate |
$22.19 |
| Rate for Payer: Aetna Commercial |
$20.96
|
| Rate for Payer: BCBS Trust/PPO |
$19.06
|
| Rate for Payer: BCN Commercial |
$19.06
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$21.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.73
|
| Rate for Payer: Healthscope Commercial |
$22.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.96
|
| Rate for Payer: PHP Commercial |
$20.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.70
|
| Rate for Payer: UHC Core |
$20.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.50
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29.01
|
|
|
Service Code
|
NDC 72266-147-01
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.69 |
| Max. Negotiated Rate |
$26.11 |
| Rate for Payer: Aetna Commercial |
$24.66
|
| Rate for Payer: BCBS Trust/PPO |
$22.42
|
| Rate for Payer: BCN Commercial |
$22.42
|
| Rate for Payer: Cash Price |
$23.21
|
| Rate for Payer: Cofinity Commercial |
$24.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.21
|
| Rate for Payer: Healthscope Commercial |
$26.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.66
|
| Rate for Payer: PHP Commercial |
$24.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.53
|
| Rate for Payer: UHC Core |
$24.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.76
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.31
|
|
|
Service Code
|
NDC 55150-222-20
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.44 |
| Max. Negotiated Rate |
$22.78 |
| Rate for Payer: Aetna Commercial |
$21.51
|
| Rate for Payer: BCBS Trust/PPO |
$19.56
|
| Rate for Payer: BCN Commercial |
$19.56
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cofinity Commercial |
$21.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.25
|
| Rate for Payer: Healthscope Commercial |
$22.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.51
|
| Rate for Payer: PHP Commercial |
$21.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.27
|
| Rate for Payer: UHC Core |
$21.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.98
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29.01
|
|
|
Service Code
|
NDC 72266-147-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.69 |
| Max. Negotiated Rate |
$26.11 |
| Rate for Payer: Aetna Commercial |
$24.66
|
| Rate for Payer: BCBS Trust/PPO |
$22.42
|
| Rate for Payer: BCN Commercial |
$22.42
|
| Rate for Payer: Cash Price |
$23.21
|
| Rate for Payer: Cofinity Commercial |
$24.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.21
|
| Rate for Payer: Healthscope Commercial |
$26.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.66
|
| Rate for Payer: PHP Commercial |
$24.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.53
|
| Rate for Payer: UHC Core |
$24.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.76
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.06
|
|
|
Service Code
|
NDC 55150-221-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.01 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Aetna Commercial |
$15.35
|
| Rate for Payer: BCBS Trust/PPO |
$13.96
|
| Rate for Payer: BCN Commercial |
$13.96
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cofinity Commercial |
$15.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.45
|
| Rate for Payer: Healthscope Commercial |
$16.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.35
|
| Rate for Payer: PHP Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.89
|
| Rate for Payer: UHC Core |
$15.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.54
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.35
|
|
|
Service Code
|
NDC 0143-9507-01
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$20.36
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Core |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.76
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.35
|
|
|
Service Code
|
NDC 0409-6695-02
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$20.36
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Core |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.76
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.35
|
|
|
Service Code
|
NDC 0143-9507-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$20.36
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Core |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.76
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.35
|
|
|
Service Code
|
NDC 0143-9311-01
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$20.36
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Core |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.76
|
|
|
ETOMIDATE 2 MG/ML IV (CODE)
|
Facility
|
IP
|
$26.35
|
|
|
Service Code
|
NDC 0409-6695-02
|
| Hospital Charge Code |
163720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$20.36
|
| Rate for Payer: BCN Commercial |
$20.36
|
| Rate for Payer: Cash Price |
$21.08
|
| Rate for Payer: Cofinity Commercial |
$22.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.08
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.40
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Core |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.76
|
|
|
ETONOGESTREL IMPLANT SYSTEM
|
Professional
|
Both
|
$1,336.00
|
|
|
Service Code
|
HCPCS J7307
|
| Min. Negotiated Rate |
$935.20 |
| Max. Negotiated Rate |
$1,214.09 |
| Rate for Payer: Aetna Commercial |
$1,092.48
|
| Rate for Payer: BCBS Complete |
$1,214.09
|
| Rate for Payer: BCBS Trust/PPO |
$1,107.77
|
| Rate for Payer: BCN Commercial |
$1,107.77
|
| Rate for Payer: Cash Price |
$1,068.80
|
| Rate for Payer: Cash Price |
$1,068.80
|
| Rate for Payer: Mclaren Medicaid |
$1,156.28
|
| Rate for Payer: Meridian Medicaid |
$1,214.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,156.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$935.20
|
|
|
EUFLEXXA INJ PER DOSE
|
Professional
|
Both
|
$289.30
|
|
|
Service Code
|
HCPCS J7323
|
| Min. Negotiated Rate |
$115.72 |
| Max. Negotiated Rate |
$202.51 |
| Rate for Payer: Aetna Commercial |
$176.10
|
| Rate for Payer: Aetna Medicare |
$136.68
|
| Rate for Payer: BCBS Complete |
$115.72
|
| Rate for Payer: BCBS MAPPO |
$131.42
|
| Rate for Payer: BCBS Trust/PPO |
$129.70
|
| Rate for Payer: BCN Commercial |
$137.68
|
| Rate for Payer: BCN Medicare Advantage |
$131.42
|
| Rate for Payer: Cash Price |
$231.44
|
| Rate for Payer: Cash Price |
$231.44
|
| Rate for Payer: Cofinity Commercial |
$176.10
|
| Rate for Payer: Cofinity Commercial |
$189.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$131.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$137.99
|
| Rate for Payer: PACE SWMI |
$131.42
|
| Rate for Payer: PHP Medicare Advantage |
$131.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.51
|
| Rate for Payer: Priority Health Medicare |
$131.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$131.42
|
| Rate for Payer: UHC Medicare Advantage |
$135.36
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS
|
Facility
|
OP
|
$1,116.73
|
|
|
Service Code
|
CPT 11420
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,063.55 |
| Max. Negotiated Rate |
$1,116.73 |
| Rate for Payer: BCBS Complete |
$1,116.73
|
| Rate for Payer: Mclaren Medicaid |
$1,063.55
|
| Rate for Payer: Meridian Medicaid |
$1,116.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,063.55
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM
|
Facility
|
OP
|
$484.61
|
|
|
Service Code
|
CPT 11421
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$461.54 |
| Max. Negotiated Rate |
$484.61 |
| Rate for Payer: BCBS Complete |
$484.61
|
| Rate for Payer: Mclaren Medicaid |
$461.54
|
| Rate for Payer: Meridian Medicaid |
$484.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$461.54
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM
|
Facility
|
OP
|
$1,116.73
|
|
|
Service Code
|
CPT 11422
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,063.55 |
| Max. Negotiated Rate |
$1,116.73 |
| Rate for Payer: BCBS Complete |
$1,116.73
|
| Rate for Payer: Mclaren Medicaid |
$1,063.55
|
| Rate for Payer: Meridian Medicaid |
$1,116.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,063.55
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM
|
Facility
|
OP
|
$1,116.73
|
|
|
Service Code
|
CPT 11423
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,063.55 |
| Max. Negotiated Rate |
$1,116.73 |
| Rate for Payer: BCBS Complete |
$1,116.73
|
| Rate for Payer: Mclaren Medicaid |
$1,063.55
|
| Rate for Payer: Meridian Medicaid |
$1,116.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,063.55
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM
|
Facility
|
OP
|
$1,116.73
|
|
|
Service Code
|
CPT 11424
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,063.55 |
| Max. Negotiated Rate |
$1,116.73 |
| Rate for Payer: BCBS Complete |
$1,116.73
|
| Rate for Payer: Mclaren Medicaid |
$1,063.55
|
| Rate for Payer: Meridian Medicaid |
$1,116.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,063.55
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM
|
Facility
|
OP
|
$1,957.20
|
|
|
Service Code
|
CPT 11426
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,864.00 |
| Max. Negotiated Rate |
$1,957.20 |
| Rate for Payer: BCBS Complete |
$1,957.20
|
| Rate for Payer: Mclaren Medicaid |
$1,864.00
|
| Rate for Payer: Meridian Medicaid |
$1,957.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,864.00
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS
|
Facility
|
OP
|
$484.61
|
|
|
Service Code
|
CPT 11400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$461.54 |
| Max. Negotiated Rate |
$484.61 |
| Rate for Payer: BCBS Complete |
$484.61
|
| Rate for Payer: Mclaren Medicaid |
$461.54
|
| Rate for Payer: Meridian Medicaid |
$484.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$461.54
|
|
|
EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM
|
Facility
|
OP
|
$484.61
|
|
|
Service Code
|
CPT 11402
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$461.54 |
| Max. Negotiated Rate |
$484.61 |
| Rate for Payer: BCBS Complete |
$484.61
|
| Rate for Payer: Mclaren Medicaid |
$461.54
|
| Rate for Payer: Meridian Medicaid |
$484.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$461.54
|
|
