|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
IP
|
$91.44
|
|
|
Service Code
|
NDC 68084-750-25
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.77 |
| Max. Negotiated Rate |
$82.30 |
| Rate for Payer: Aetna Commercial |
$77.72
|
| Rate for Payer: BCBS Trust/PPO |
$70.66
|
| Rate for Payer: BCN Commercial |
$70.66
|
| Rate for Payer: Cash Price |
$73.15
|
| Rate for Payer: Cofinity Commercial |
$78.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.15
|
| Rate for Payer: Healthscope Commercial |
$82.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.72
|
| Rate for Payer: PHP Commercial |
$77.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$79.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$55.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.47
|
| Rate for Payer: UHC Core |
$76.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.58
|
|
|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
IP
|
$321.60
|
|
|
Service Code
|
NDC 0378-2402-01
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.14 |
| Max. Negotiated Rate |
$289.44 |
| Rate for Payer: Aetna Commercial |
$273.36
|
| Rate for Payer: BCBS Trust/PPO |
$248.53
|
| Rate for Payer: BCN Commercial |
$248.53
|
| Rate for Payer: Cash Price |
$257.28
|
| Rate for Payer: Cofinity Commercial |
$276.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.28
|
| Rate for Payer: Healthscope Commercial |
$289.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$273.36
|
| Rate for Payer: PHP Commercial |
$273.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$279.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$196.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$283.01
|
| Rate for Payer: UHC Core |
$268.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.20
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
IP
|
$94.00
|
|
|
Service Code
|
NDC 70954-212-10
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.33 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: BCBS Trust/PPO |
$72.64
|
| Rate for Payer: BCN Commercial |
$72.64
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$84.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.90
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$81.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$57.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$82.72
|
| Rate for Payer: UHC Core |
$78.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
IP
|
$329.00
|
|
|
Service Code
|
NDC 0591-5335-01
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.66 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: BCBS Trust/PPO |
$254.25
|
| Rate for Payer: BCN Commercial |
$254.25
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$286.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$200.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$289.52
|
| Rate for Payer: UHC Core |
$274.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
IP
|
$190.96
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
108755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$116.47 |
| Max. Negotiated Rate |
$171.86 |
| Rate for Payer: Aetna Commercial |
$162.32
|
| Rate for Payer: BCBS Trust/PPO |
$147.57
|
| Rate for Payer: BCN Commercial |
$147.57
|
| Rate for Payer: Cash Price |
$152.77
|
| Rate for Payer: Cofinity Commercial |
$164.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.77
|
| Rate for Payer: Healthscope Commercial |
$171.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$162.32
|
| Rate for Payer: PHP Commercial |
$162.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$166.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$116.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$168.04
|
| Rate for Payer: UHC Core |
$159.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.22
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
IP
|
$201.40
|
|
|
Service Code
|
NDC 43386-330-01
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.83 |
| Max. Negotiated Rate |
$181.26 |
| Rate for Payer: Aetna Commercial |
$171.19
|
| Rate for Payer: BCBS Trust/PPO |
$155.64
|
| Rate for Payer: BCN Commercial |
$155.64
|
| Rate for Payer: Cash Price |
$161.12
|
| Rate for Payer: Cofinity Commercial |
$173.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.12
|
| Rate for Payer: Healthscope Commercial |
$181.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.19
|
| Rate for Payer: PHP Commercial |
$171.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$175.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$122.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$177.23
|
| Rate for Payer: UHC Core |
$168.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.05
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
IP
|
$595.68
|
|
|
Service Code
|
NDC 51862-486-01
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$363.31 |
| Max. Negotiated Rate |
$536.11 |
| Rate for Payer: Aetna Commercial |
$506.33
|
| Rate for Payer: BCBS Trust/PPO |
$460.34
|
| Rate for Payer: BCN Commercial |
$460.34
|
| Rate for Payer: Cash Price |
$476.54
|
| Rate for Payer: Cofinity Commercial |
$512.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.54
|
| Rate for Payer: Healthscope Commercial |
$536.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$506.33
|
| Rate for Payer: PHP Commercial |
$506.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$518.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$363.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$524.20
|
| Rate for Payer: UHC Core |
$497.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.76
|
|
|
TROLAMINE SALICYLATE 10 % TOPICAL CREAM
|
Facility
IP
|
$13.39
|
|
|
Service Code
|
NDC 9629512985
|
| Hospital Charge Code |
27680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Aetna Commercial |
$11.38
|
| Rate for Payer: BCBS Trust/PPO |
$10.35
|
| Rate for Payer: BCN Commercial |
$10.35
|
| Rate for Payer: Cash Price |
$10.71
|
| Rate for Payer: Cofinity Commercial |
$11.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.71
|
| Rate for Payer: Healthscope Commercial |
$12.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.38
|
| Rate for Payer: PHP Commercial |
$11.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.78
|
| Rate for Payer: UHC Core |
$11.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.04
|
|
|
TROLAMINE SALICYLATE 10 % TOPICAL CREAM
|
Facility
IP
|
$11.86
|
|
|
Service Code
|
NDC 96295-129854
|
| Hospital Charge Code |
27680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Aetna Commercial |
$10.08
|
| Rate for Payer: BCBS Trust/PPO |
$9.17
|
| Rate for Payer: BCN Commercial |
$9.17
|
| Rate for Payer: Cash Price |
$9.49
|
| Rate for Payer: Cofinity Commercial |
$10.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.49
|
| Rate for Payer: Healthscope Commercial |
$10.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.08
|
| Rate for Payer: PHP Commercial |
$10.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.44
|
| Rate for Payer: UHC Core |
$9.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.90
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE
|
Facility
IP
|
$182.04
|
|
|
Service Code
|
NDC 68803-612-10
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.03 |
| Max. Negotiated Rate |
$163.84 |
| Rate for Payer: Aetna Commercial |
$154.73
|
| Rate for Payer: BCBS Trust/PPO |
$140.68
|
| Rate for Payer: BCN Commercial |
$140.68
|
| Rate for Payer: Cash Price |
$145.63
|
| Rate for Payer: Cofinity Commercial |
$156.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.63
|
| Rate for Payer: Healthscope Commercial |
$163.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$154.73
|
| Rate for Payer: PHP Commercial |
$154.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$158.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$111.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$160.20
|
| Rate for Payer: UHC Core |
$152.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.53
|
|
|
ULIPRISTAL 30 MG TABLET
|
Facility
IP
|
$123.70
|
|
|
Service Code
|
NDC 50102-911-01
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.44 |
| Max. Negotiated Rate |
$111.33 |
| Rate for Payer: Aetna Commercial |
$105.14
|
| Rate for Payer: BCBS Trust/PPO |
$95.60
|
| Rate for Payer: BCN Commercial |
$95.60
|
| Rate for Payer: Cash Price |
$98.96
|
| Rate for Payer: Cofinity Commercial |
$106.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.96
|
| Rate for Payer: Healthscope Commercial |
$111.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$105.14
|
| Rate for Payer: PHP Commercial |
$105.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$107.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$75.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.86
|
| Rate for Payer: UHC Core |
$103.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.78
|
|
|
ULIPRISTAL 30 MG TABLET
|
Facility
IP
|
$133.35
|
|
|
Service Code
|
NDC 73302-456-01
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.33 |
| Max. Negotiated Rate |
$120.02 |
| Rate for Payer: Aetna Commercial |
$113.35
|
| Rate for Payer: BCBS Trust/PPO |
$103.05
|
| Rate for Payer: BCN Commercial |
$103.05
|
| Rate for Payer: Cash Price |
$106.68
|
| Rate for Payer: Cofinity Commercial |
$114.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.68
|
| Rate for Payer: Healthscope Commercial |
$120.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.35
|
| Rate for Payer: PHP Commercial |
$113.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$116.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$81.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$117.35
|
| Rate for Payer: UHC Core |
$111.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.01
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
IP
|
$1,152.59
|
|
|
Service Code
|
NDC 0173-0873-10
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$702.96 |
| Max. Negotiated Rate |
$1,037.33 |
| Rate for Payer: Aetna Commercial |
$979.70
|
| Rate for Payer: BCBS Trust/PPO |
$890.72
|
| Rate for Payer: BCN Commercial |
$890.72
|
| Rate for Payer: Cash Price |
$922.07
|
| Rate for Payer: Cofinity Commercial |
$991.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$922.07
|
| Rate for Payer: Healthscope Commercial |
$1,037.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$864.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$979.70
|
| Rate for Payer: PHP Commercial |
$979.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$806.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,002.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$702.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,014.28
|
| Rate for Payer: UHC Core |
$962.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$864.44
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
IP
|
$108.71
|
|
|
Service Code
|
NDC 0173-0873-06
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$97.84 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: BCBS Trust/PPO |
$84.01
|
| Rate for Payer: BCN Commercial |
$84.01
|
| Rate for Payer: Cash Price |
$86.97
|
| Rate for Payer: Cofinity Commercial |
$93.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.97
|
| Rate for Payer: Healthscope Commercial |
$97.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.40
|
| Rate for Payer: PHP Commercial |
$92.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$94.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$66.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.66
|
| Rate for Payer: UHC Core |
$90.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.53
|
|
|
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION
|
Facility
IP
|
$211.30
|
|
|
Service Code
|
NDC 0173-0869-06
|
| Hospital Charge Code |
169758
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.87 |
| Max. Negotiated Rate |
$190.17 |
| Rate for Payer: Aetna Commercial |
$179.60
|
| Rate for Payer: BCBS Trust/PPO |
$163.29
|
| Rate for Payer: BCN Commercial |
$163.29
|
| Rate for Payer: Cash Price |
$169.04
|
| Rate for Payer: Cofinity Commercial |
$181.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.04
|
| Rate for Payer: Healthscope Commercial |
$190.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.60
|
| Rate for Payer: PHP Commercial |
$179.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$183.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$128.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$185.94
|
| Rate for Payer: UHC Core |
$176.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.48
|
|
|
UNLISTED LAPAROSCOPIC PROCEDURE, LIVER
|
Facility
OP
|
$3,974.31
|
|
|
Service Code
|
CPT 47379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,785.06 |
| Max. Negotiated Rate |
$3,974.31 |
| Rate for Payer: BCBS Complete |
$3,974.31
|
| Rate for Payer: Mclaren Medicaid |
$3,785.06
|
| Rate for Payer: Meridian Medicaid |
$3,974.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,785.06
|
|
|
UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM
|
Facility
OP
|
$162.43
|
|
|
Service Code
|
CPT 22999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$154.70 |
| Max. Negotiated Rate |
$162.43 |
| Rate for Payer: BCBS Complete |
$162.43
|
| Rate for Payer: Mclaren Medicaid |
$154.70
|
| Rate for Payer: Meridian Medicaid |
$162.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$154.70
|
|
|
UNLISTED PROCEDURE, ANUS
|
Facility
OP
|
$629.53
|
|
|
Service Code
|
CPT 46999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$599.55 |
| Max. Negotiated Rate |
$629.53 |
| Rate for Payer: BCBS Complete |
$629.53
|
| Rate for Payer: Mclaren Medicaid |
$599.55
|
| Rate for Payer: Meridian Medicaid |
$629.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$599.55
|
|
|
UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES
|
Facility
OP
|
$168.25
|
|
|
Service Code
|
CPT 41899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$160.23 |
| Max. Negotiated Rate |
$168.25 |
| Rate for Payer: BCBS Complete |
$168.25
|
| Rate for Payer: Mclaren Medicaid |
$160.23
|
| Rate for Payer: Meridian Medicaid |
$168.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$160.23
|
|
|
UNLISTED PROCEDURE, NERVOUS SYSTEM
|
Facility
OP
|
$204.01
|
|
|
Service Code
|
CPT 64999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$194.29 |
| Max. Negotiated Rate |
$204.01 |
| Rate for Payer: BCBS Complete |
$204.01
|
| Rate for Payer: Mclaren Medicaid |
$194.29
|
| Rate for Payer: Meridian Medicaid |
$204.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$194.29
|
|
|
UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE
|
Facility
OP
|
$137.89
|
|
|
Service Code
|
CPT 17999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$131.33 |
| Max. Negotiated Rate |
$137.89 |
| Rate for Payer: BCBS Complete |
$137.89
|
| Rate for Payer: Mclaren Medicaid |
$131.33
|
| Rate for Payer: Meridian Medicaid |
$137.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$131.33
|
|
|
URINARY SUSPENSORY
|
Professional
|
$65.00
|
|
|
Service Code
|
HCPCS A5105
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Aetna Commercial |
$37.97
|
| Rate for Payer: BCBS Complete |
$26.00
|
| Rate for Payer: BCN Commercial |
$44.89
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
IP
|
$1,171.79
|
|
|
Service Code
|
NDC 0904-7168-61
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$714.67 |
| Max. Negotiated Rate |
$1,054.61 |
| Rate for Payer: Aetna Commercial |
$996.02
|
| Rate for Payer: BCBS Trust/PPO |
$905.56
|
| Rate for Payer: BCN Commercial |
$905.56
|
| Rate for Payer: Cash Price |
$937.43
|
| Rate for Payer: Cofinity Commercial |
$1,007.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$937.43
|
| Rate for Payer: Healthscope Commercial |
$1,054.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$878.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$996.02
|
| Rate for Payer: PHP Commercial |
$996.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$820.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,019.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$714.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,031.18
|
| Rate for Payer: UHC Core |
$978.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$878.84
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
IP
|
$106.02
|
|
|
Service Code
|
NDC 0378-4275-93
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.66 |
| Max. Negotiated Rate |
$95.42 |
| Rate for Payer: Aetna Commercial |
$90.12
|
| Rate for Payer: BCBS Trust/PPO |
$81.93
|
| Rate for Payer: BCN Commercial |
$81.93
|
| Rate for Payer: Cash Price |
$84.82
|
| Rate for Payer: Cofinity Commercial |
$91.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.82
|
| Rate for Payer: Healthscope Commercial |
$95.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.12
|
| Rate for Payer: PHP Commercial |
$90.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$92.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.30
|
| Rate for Payer: UHC Core |
$88.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.52
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
IP
|
$256.64
|
|
|
Service Code
|
NDC 0904-6565-07
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.52 |
| Max. Negotiated Rate |
$230.98 |
| Rate for Payer: Aetna Commercial |
$218.14
|
| Rate for Payer: BCBS Trust/PPO |
$198.33
|
| Rate for Payer: BCN Commercial |
$198.33
|
| Rate for Payer: Cash Price |
$205.31
|
| Rate for Payer: Cofinity Commercial |
$220.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.31
|
| Rate for Payer: Healthscope Commercial |
$230.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$218.14
|
| Rate for Payer: PHP Commercial |
$218.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$223.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$156.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.84
|
| Rate for Payer: UHC Core |
$214.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.48
|
|
