|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.55 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$202.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$323.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.73
|
| Rate for Payer: UHC Core |
$210.59
|
| Rate for Payer: UHC Exchange |
$158.85
|
| Rate for Payer: UMR Bronson Commercial |
$149.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$124.79
|
|
|
Service Code
|
NDC 55111019690
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.17 |
| Max. Negotiated Rate |
$112.31 |
| Rate for Payer: Aetna American Axle |
$81.11
|
| Rate for Payer: Aetna Commercial |
$106.07
|
| Rate for Payer: Aetna Medicare |
$62.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.11
|
| Rate for Payer: BCBS Complete |
$49.92
|
| Rate for Payer: Cash Price |
$99.83
|
| Rate for Payer: Cofinity Advantage |
$87.35
|
| Rate for Payer: Cofinity Commercial |
$107.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.83
|
| Rate for Payer: Healthscope Commercial |
$112.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$93.59
|
| Rate for Payer: PHP Commercial |
$106.07
|
| Rate for Payer: Priority Health SBD |
$78.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$81.11
|
| Rate for Payer: UHC Core |
$65.02
|
| Rate for Payer: UHC Exchange |
$49.04
|
| Rate for Payer: UMR Bronson Commercial |
$46.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.59
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 00904629461
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$109.98
|
|
|
Service Code
|
NDC 50228012490
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.69 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna American Axle |
$71.49
|
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna Medicare |
$54.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: BCBS Complete |
$43.99
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Advantage |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$87.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.49
|
| Rate for Payer: UHC Core |
$57.30
|
| Rate for Payer: UHC Exchange |
$43.22
|
| Rate for Payer: UMR Bronson Commercial |
$40.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$327.83
|
|
|
Service Code
|
NDC 60505025302
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.30 |
| Max. Negotiated Rate |
$295.05 |
| Rate for Payer: Aetna American Axle |
$213.09
|
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: Aetna Medicare |
$163.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.09
|
| Rate for Payer: BCBS Complete |
$131.13
|
| Rate for Payer: Cash Price |
$262.26
|
| Rate for Payer: Cofinity Advantage |
$229.48
|
| Rate for Payer: Cofinity Commercial |
$281.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.26
|
| Rate for Payer: Healthscope Commercial |
$295.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.87
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health SBD |
$206.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.09
|
| Rate for Payer: UHC Core |
$170.80
|
| Rate for Payer: UHC Exchange |
$128.84
|
| Rate for Payer: UMR Bronson Commercial |
$121.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.87
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$124.79
|
|
|
Service Code
|
NDC 55111019690
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.91 |
| Max. Negotiated Rate |
$112.31 |
| Rate for Payer: Aetna American Axle |
$81.11
|
| Rate for Payer: Aetna Commercial |
$106.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.11
|
| Rate for Payer: Cash Price |
$99.83
|
| Rate for Payer: Cofinity Advantage |
$87.35
|
| Rate for Payer: Cofinity Commercial |
$107.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.83
|
| Rate for Payer: Healthscope Commercial |
$112.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$93.59
|
| Rate for Payer: PHP Commercial |
$106.07
|
| Rate for Payer: Priority Health SBD |
$78.62
|
| Rate for Payer: UMR Bronson Commercial |
$54.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.59
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$116.33
|
|
|
Service Code
|
NDC 67877027690
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.04 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Aetna American Axle |
$75.61
|
| Rate for Payer: Aetna Commercial |
$98.88
|
| Rate for Payer: Aetna Medicare |
$58.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.61
|
| Rate for Payer: BCBS Complete |
$46.53
|
| Rate for Payer: Cash Price |
$93.06
|
| Rate for Payer: Cofinity Advantage |
$81.43
|
| Rate for Payer: Cofinity Commercial |
$100.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.06
|
| Rate for Payer: Healthscope Commercial |
$104.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.25
|
| Rate for Payer: PHP Commercial |
$98.88
|
| Rate for Payer: Priority Health SBD |
$73.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.61
|
| Rate for Payer: UHC Core |
$60.61
|
| Rate for Payer: UHC Exchange |
$45.72
|
| Rate for Payer: UMR Bronson Commercial |
$43.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.25
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$327.83
|
|
|
Service Code
|
NDC 60505025302
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.25 |
| Max. Negotiated Rate |
$295.05 |
| Rate for Payer: Aetna American Axle |
$213.09
|
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.09
|
| Rate for Payer: Cash Price |
$262.26
|
| Rate for Payer: Cofinity Advantage |
$229.48
|
| Rate for Payer: Cofinity Commercial |
$281.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.26
|
| Rate for Payer: Healthscope Commercial |
$295.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.87
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health SBD |
$206.53
|
| Rate for Payer: UMR Bronson Commercial |
$144.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.87
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$97.29
|
|
|
Service Code
|
NDC 16729021815
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$87.56 |
| Rate for Payer: Aetna American Axle |
$63.24
|
| Rate for Payer: Aetna Commercial |
$82.70
|
| Rate for Payer: Aetna Medicare |
$48.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.24
|
| Rate for Payer: BCBS Complete |
$38.92
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cofinity Advantage |
$68.10
|
| Rate for Payer: Cofinity Commercial |
$83.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.83
|
| Rate for Payer: Healthscope Commercial |
$87.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$72.97
|
| Rate for Payer: PHP Commercial |
$82.70
|
| Rate for Payer: Priority Health SBD |
$61.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.24
|
| Rate for Payer: UHC Core |
$50.69
|
| Rate for Payer: UHC Exchange |
$38.23
|
| Rate for Payer: UMR Bronson Commercial |
$36.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.97
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$109.98
|
|
|
Service Code
|
NDC 50228012490
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.39 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna American Axle |
$71.49
|
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Advantage |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UMR Bronson Commercial |
$48.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$2.61
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.70
|
| Rate for Payer: UHC Core |
$1.36
|
| Rate for Payer: UHC Exchange |
$1.03
|
| Rate for Payer: UMR Bronson Commercial |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 68084053611
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
IP
|
$97.29
|
|
|
Service Code
|
NDC 16729021815
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$87.56 |
| Rate for Payer: Aetna American Axle |
$63.24
|
| Rate for Payer: Aetna Commercial |
$82.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.24
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cofinity Advantage |
$68.10
|
| Rate for Payer: Cofinity Commercial |
$83.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.83
|
| Rate for Payer: Healthscope Commercial |
$87.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$72.97
|
| Rate for Payer: PHP Commercial |
$82.70
|
| Rate for Payer: Priority Health SBD |
$61.29
|
| Rate for Payer: UMR Bronson Commercial |
$42.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.97
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$208.05
|
|
|
Service Code
|
NDC 00904629401
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.98 |
| Max. Negotiated Rate |
$187.25 |
| Rate for Payer: Aetna American Axle |
$135.23
|
| Rate for Payer: Aetna Commercial |
$176.84
|
| Rate for Payer: Aetna Medicare |
$104.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.23
|
| Rate for Payer: BCBS Complete |
$83.22
|
| Rate for Payer: Cash Price |
$166.44
|
| Rate for Payer: Cofinity Advantage |
$145.63
|
| Rate for Payer: Cofinity Commercial |
$178.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.44
|
| Rate for Payer: Healthscope Commercial |
$187.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$166.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$156.04
|
| Rate for Payer: PHP Commercial |
$176.84
|
| Rate for Payer: Priority Health SBD |
$131.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$135.23
|
| Rate for Payer: UHC Core |
$108.39
|
| Rate for Payer: UHC Exchange |
$81.76
|
| Rate for Payer: UMR Bronson Commercial |
$76.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.04
|
|
|
CLOPIDOGREL 75 MG TABLET
|
Facility
|
OP
|
$260.30
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
22142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$234.27 |
| Rate for Payer: Aetna American Axle |
$169.19
|
| Rate for Payer: Aetna Commercial |
$221.25
|
| Rate for Payer: Aetna Medicare |
$130.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.19
|
| Rate for Payer: BCBS Complete |
$104.12
|
| Rate for Payer: Cash Price |
$208.24
|
| Rate for Payer: Cofinity Advantage |
$182.21
|
| Rate for Payer: Cofinity Commercial |
$223.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.24
|
| Rate for Payer: Healthscope Commercial |
$234.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.22
|
| Rate for Payer: PHP Commercial |
$221.25
|
| Rate for Payer: Priority Health SBD |
$163.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.19
|
| Rate for Payer: UHC Core |
$135.62
|
| Rate for Payer: UHC Exchange |
$102.30
|
| Rate for Payer: UMR Bronson Commercial |
$96.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.22
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
OP
|
$497.28
|
|
|
Service Code
|
NDC 60505475401
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.99 |
| Max. Negotiated Rate |
$447.55 |
| Rate for Payer: Aetna American Axle |
$323.23
|
| Rate for Payer: Aetna Commercial |
$422.69
|
| Rate for Payer: Aetna Medicare |
$248.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$323.23
|
| Rate for Payer: BCBS Complete |
$198.91
|
| Rate for Payer: Cash Price |
$397.82
|
| Rate for Payer: Cofinity Advantage |
$348.10
|
| Rate for Payer: Cofinity Commercial |
$427.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$397.82
|
| Rate for Payer: Healthscope Commercial |
$447.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$348.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$372.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$397.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$422.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$372.96
|
| Rate for Payer: PHP Commercial |
$422.69
|
| Rate for Payer: Priority Health SBD |
$313.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$323.23
|
| Rate for Payer: UHC Core |
$259.08
|
| Rate for Payer: UHC Exchange |
$195.43
|
| Rate for Payer: UMR Bronson Commercial |
$183.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$372.96
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
IP
|
$497.28
|
|
|
Service Code
|
NDC 60505475401
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.80 |
| Max. Negotiated Rate |
$447.55 |
| Rate for Payer: Aetna American Axle |
$323.23
|
| Rate for Payer: Aetna Commercial |
$422.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$323.23
|
| Rate for Payer: Cash Price |
$397.82
|
| Rate for Payer: Cofinity Advantage |
$348.10
|
| Rate for Payer: Cofinity Commercial |
$427.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$397.82
|
| Rate for Payer: Healthscope Commercial |
$447.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$348.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$372.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$422.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$372.96
|
| Rate for Payer: PHP Commercial |
$422.69
|
| Rate for Payer: Priority Health SBD |
$313.29
|
| Rate for Payer: UMR Bronson Commercial |
$218.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$372.96
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
NDC 13107031901
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.28 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna American Axle |
$288.60
|
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna Medicare |
$222.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: BCBS Complete |
$177.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Advantage |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$355.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.00
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.60
|
| Rate for Payer: UHC Core |
$231.32
|
| Rate for Payer: UHC Exchange |
$174.49
|
| Rate for Payer: UMR Bronson Commercial |
$164.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.00
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
NDC 51672404201
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.28 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna American Axle |
$288.60
|
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna Medicare |
$222.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: BCBS Complete |
$177.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Advantage |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$355.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.00
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.60
|
| Rate for Payer: UHC Core |
$231.32
|
| Rate for Payer: UHC Exchange |
$174.49
|
| Rate for Payer: UMR Bronson Commercial |
$164.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.00
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
NDC 51672404201
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.36 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna American Axle |
$288.60
|
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Advantage |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.00
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UMR Bronson Commercial |
$195.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.00
|
|
|
CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
NDC 13107031901
|
| Hospital Charge Code |
1759
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.36 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna American Axle |
$288.60
|
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Advantage |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.00
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UMR Bronson Commercial |
$195.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.00
|
|
|
CLOSED TREATMENT OF CALCANEAL FRACTURE; WITH MANIPULATION
|
Facility
|
OP
|
$857.47
|
|
|
Service Code
|
CPT 28405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$128.54 |
| Max. Negotiated Rate |
$857.47 |
| Rate for Payer: Aetna Medicare |
$255.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$307.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$307.23
|
| Rate for Payer: BCBS Complete |
$134.98
|
| Rate for Payer: BCBS MAPPO |
$245.78
|
| Rate for Payer: BCBS Trust/PPO |
$857.47
|
| Rate for Payer: BCN Commercial |
$857.47
|
| Rate for Payer: BCN Medicare Advantage |
$245.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$245.78
|
| Rate for Payer: Mclaren Medicaid |
$245.78
|
| Rate for Payer: Mclaren Medicare |
$245.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$258.07
|
| Rate for Payer: Meridian Medicaid |
$258.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$282.65
|
| Rate for Payer: Molina Medicare/Medicaid |
$270.36
|
| Rate for Payer: Nomi Health Commercial |
$737.34
|
| Rate for Payer: PACE Medicare |
$233.49
|
| Rate for Payer: PACE SWMI |
$245.78
|
| Rate for Payer: PHP Medicare Advantage |
$245.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$128.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$794.84
|
| Rate for Payer: Priority Health Medicare |
$245.78
|
| Rate for Payer: Priority Health Tiered Network |
$635.87
|
| Rate for Payer: Railroad Medicare Medicare |
$245.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$245.78
|
| Rate for Payer: UHC Medicaid |
$128.54
|
| Rate for Payer: UHCCP Medicaid |
$128.54
|
| Rate for Payer: VA VA |
$245.78
|
|
|
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID [NAVICULAR]); WITHOUT MANIPULATION, EACH BONE
|
Facility
|
OP
|
$794.84
|
|
|
Service Code
|
CPT 25630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$128.54 |
| Max. Negotiated Rate |
$794.84 |
| Rate for Payer: Aetna Medicare |
$255.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$307.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$307.23
|
| Rate for Payer: BCBS Complete |
$134.98
|
| Rate for Payer: BCBS MAPPO |
$245.78
|
| Rate for Payer: BCBS Trust/PPO |
$245.11
|
| Rate for Payer: BCN Commercial |
$245.11
|
| Rate for Payer: BCN Medicare Advantage |
$245.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$245.78
|
| Rate for Payer: Mclaren Medicaid |
$245.78
|
| Rate for Payer: Mclaren Medicare |
$245.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$258.07
|
| Rate for Payer: Meridian Medicaid |
$258.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$282.65
|
| Rate for Payer: Molina Medicare/Medicaid |
$270.36
|
| Rate for Payer: Nomi Health Commercial |
$737.34
|
| Rate for Payer: PACE Medicare |
$233.49
|
| Rate for Payer: PACE SWMI |
$245.78
|
| Rate for Payer: PHP Medicare Advantage |
$245.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$128.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$794.84
|
| Rate for Payer: Priority Health Medicare |
$245.78
|
| Rate for Payer: Priority Health Tiered Network |
$635.87
|
| Rate for Payer: Railroad Medicare Medicare |
$245.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$245.78
|
| Rate for Payer: UHC Medicaid |
$128.54
|
| Rate for Payer: UHCCP Medicaid |
$128.54
|
| Rate for Payer: VA VA |
$245.78
|
|
|
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
|
$5,181.40
|
|
|
Service Code
|
CPT 25605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$837.96 |
| Max. Negotiated Rate |
$5,181.40 |
| Rate for Payer: Aetna Medicare |
$1,666.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,002.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,002.76
|
| Rate for Payer: BCBS Complete |
$879.93
|
| Rate for Payer: BCBS MAPPO |
$1,602.21
|
| Rate for Payer: BCBS Trust/PPO |
$869.92
|
| Rate for Payer: BCN Commercial |
$869.92
|
| Rate for Payer: BCN Medicare Advantage |
$1,602.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,602.21
|
| Rate for Payer: Mclaren Medicaid |
$1,602.21
|
| Rate for Payer: Mclaren Medicare |
$1,602.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,682.32
|
| Rate for Payer: Meridian Medicaid |
$1,682.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,842.54
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,762.43
|
| Rate for Payer: Nomi Health Commercial |
$4,806.63
|
| Rate for Payer: PACE Medicare |
$1,522.10
|
| Rate for Payer: PACE SWMI |
$1,602.21
|
| Rate for Payer: PHP Medicare Advantage |
$1,602.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$837.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5,181.40
|
| Rate for Payer: Priority Health Medicare |
$1,602.21
|
| Rate for Payer: Priority Health Tiered Network |
$4,145.12
|
| Rate for Payer: Railroad Medicare Medicare |
$1,602.21
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,602.21
|
| Rate for Payer: UHC Medicaid |
$837.96
|
| Rate for Payer: UHCCP Medicaid |
$837.96
|
| Rate for Payer: VA VA |
$1,602.21
|
|
|
CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITH MANIPULATION
|
Facility
|
OP
|
$794.84
|
|
|
Service Code
|
CPT 28495
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$128.54 |
| Max. Negotiated Rate |
$794.84 |
| Rate for Payer: Aetna Medicare |
$255.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$307.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$307.23
|
| Rate for Payer: BCBS Complete |
$134.98
|
| Rate for Payer: BCBS MAPPO |
$245.78
|
| Rate for Payer: BCBS Trust/PPO |
$172.71
|
| Rate for Payer: BCN Commercial |
$172.71
|
| Rate for Payer: BCN Medicare Advantage |
$245.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$245.78
|
| Rate for Payer: Mclaren Medicaid |
$245.78
|
| Rate for Payer: Mclaren Medicare |
$245.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$258.07
|
| Rate for Payer: Meridian Medicaid |
$258.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$282.65
|
| Rate for Payer: Molina Medicare/Medicaid |
$270.36
|
| Rate for Payer: Nomi Health Commercial |
$737.34
|
| Rate for Payer: PACE Medicare |
$233.49
|
| Rate for Payer: PACE SWMI |
$245.78
|
| Rate for Payer: PHP Medicare Advantage |
$245.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$128.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$794.84
|
| Rate for Payer: Priority Health Medicare |
$245.78
|
| Rate for Payer: Priority Health Tiered Network |
$635.87
|
| Rate for Payer: Railroad Medicare Medicare |
$245.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$245.78
|
| Rate for Payer: UHC Medicaid |
$128.54
|
| Rate for Payer: UHCCP Medicaid |
$128.54
|
| Rate for Payer: VA VA |
$245.78
|
|
