|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$91.39
|
|
|
Service Code
|
NDC 00409166020
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Aetna Medicare |
$23.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.56
|
| Rate for Payer: BCBS Complete |
$36.56
|
| Rate for Payer: BCBS MAPPO |
$22.85
|
| Rate for Payer: BCBS Trust/PPO |
$75.13
|
| Rate for Payer: BCN Commercial |
$71.06
|
| Rate for Payer: BCN Medicare Advantage |
$22.85
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.85
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Nomi Health Commercial |
$74.94
|
| Rate for Payer: PACE Senior Care Partners |
$21.71
|
| Rate for Payer: PACE SWMI |
$22.85
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: PHP Medicare Advantage |
$22.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.40
|
| Rate for Payer: Priority Health HMO/PPO |
$79.51
|
| Rate for Payer: Priority Health Medicare |
$23.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.23
|
| Rate for Payer: Railroad Medicare Medicare |
$22.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.42
|
| Rate for Payer: UHC Core |
$76.31
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.85
|
| Rate for Payer: UHC Exchange |
$22.85
|
| Rate for Payer: UHC Medicare Advantage |
$22.85
|
| Rate for Payer: VA VA |
$22.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.54
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$58.14
|
|
|
Service Code
|
NDC 00781349380
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$52.33 |
| Rate for Payer: Aetna Commercial |
$49.42
|
| Rate for Payer: Aetna Medicare |
$15.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.17
|
| Rate for Payer: BCBS Complete |
$23.26
|
| Rate for Payer: BCBS MAPPO |
$14.54
|
| Rate for Payer: BCBS Trust/PPO |
$47.80
|
| Rate for Payer: BCN Commercial |
$45.20
|
| Rate for Payer: BCN Medicare Advantage |
$14.54
|
| Rate for Payer: Cash Price |
$46.51
|
| Rate for Payer: Cofinity Commercial |
$50.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.54
|
| Rate for Payer: Healthscope Commercial |
$52.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.42
|
| Rate for Payer: Nomi Health Commercial |
$47.67
|
| Rate for Payer: PACE Senior Care Partners |
$13.81
|
| Rate for Payer: PACE SWMI |
$14.54
|
| Rate for Payer: PHP Commercial |
$49.42
|
| Rate for Payer: PHP Medicare Advantage |
$14.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.79
|
| Rate for Payer: Priority Health HMO/PPO |
$50.58
|
| Rate for Payer: Priority Health Medicare |
$14.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.95
|
| Rate for Payer: Railroad Medicare Medicare |
$14.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.16
|
| Rate for Payer: UHC Core |
$48.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$14.54
|
| Rate for Payer: UHC Exchange |
$14.54
|
| Rate for Payer: UHC Medicare Advantage |
$14.54
|
| Rate for Payer: VA VA |
$14.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.60
|
|
|
DEXTROMETHORPHAN 20 MG-QUINIDINE 10 MG CAPSULE
|
Facility
|
IP
|
$5,446.77
|
|
|
Service Code
|
NDC 64597030160
|
| Hospital Charge Code |
107672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,540.40 |
| Max. Negotiated Rate |
$4,902.09 |
| Rate for Payer: Aetna Commercial |
$4,629.75
|
| Rate for Payer: BCBS Trust/PPO |
$4,446.20
|
| Rate for Payer: BCN Commercial |
$4,209.26
|
| Rate for Payer: Cash Price |
$4,357.42
|
| Rate for Payer: Cofinity Commercial |
$4,684.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,357.42
|
| Rate for Payer: Healthscope Commercial |
$4,902.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,085.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,629.75
|
| Rate for Payer: Nomi Health Commercial |
$4,466.35
|
| Rate for Payer: PHP Commercial |
$4,629.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,540.40
|
| Rate for Payer: Priority Health HMO/PPO |
$4,738.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3,649.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,793.16
|
| Rate for Payer: UHC Core |
$4,548.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,085.08
|
|
|
DEXTROMETHORPHAN 20 MG-QUINIDINE 10 MG CAPSULE
|
Facility
|
OP
|
$5,446.77
|
|
|
Service Code
|
NDC 64597030160
|
| Hospital Charge Code |
107672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,293.61 |
| Max. Negotiated Rate |
$4,902.09 |
| Rate for Payer: Aetna Commercial |
$4,629.75
|
| Rate for Payer: Aetna Medicare |
$1,416.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,702.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,702.12
|
| Rate for Payer: BCBS Complete |
$2,178.71
|
| Rate for Payer: BCBS MAPPO |
$1,361.69
|
| Rate for Payer: BCBS Trust/PPO |
$4,477.79
|
| Rate for Payer: BCN Commercial |
$4,234.86
|
| Rate for Payer: BCN Medicare Advantage |
$1,361.69
|
| Rate for Payer: Cash Price |
$4,357.42
|
| Rate for Payer: Cofinity Commercial |
$4,684.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,357.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,361.69
|
| Rate for Payer: Healthscope Commercial |
$4,902.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,085.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,429.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,565.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,629.75
|
| Rate for Payer: Nomi Health Commercial |
$4,466.35
|
| Rate for Payer: PACE Senior Care Partners |
$1,293.61
|
| Rate for Payer: PACE SWMI |
$1,361.69
|
| Rate for Payer: PHP Commercial |
$4,629.75
|
| Rate for Payer: PHP Medicare Advantage |
$1,361.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,540.40
|
| Rate for Payer: Priority Health HMO/PPO |
$4,738.69
|
| Rate for Payer: Priority Health Medicare |
$1,375.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3,649.34
|
| Rate for Payer: Railroad Medicare Medicare |
$1,361.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,793.16
|
| Rate for Payer: UHC Core |
$4,548.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,361.69
|
| Rate for Payer: UHC Exchange |
$1,361.69
|
| Rate for Payer: UHC Medicare Advantage |
$1,361.69
|
| Rate for Payer: VA VA |
$1,361.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,085.08
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 09900000386
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: Aetna Medicare |
$0.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.18
|
| Rate for Payer: BCBS Complete |
$0.24
|
| Rate for Payer: BCBS MAPPO |
$0.15
|
| Rate for Payer: BCBS Trust/PPO |
$0.49
|
| Rate for Payer: BCN Commercial |
$0.46
|
| Rate for Payer: BCN Medicare Advantage |
$0.15
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cofinity Commercial |
$0.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.15
|
| Rate for Payer: Healthscope Commercial |
$0.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.50
|
| Rate for Payer: Nomi Health Commercial |
$0.48
|
| Rate for Payer: PACE Senior Care Partners |
$0.14
|
| Rate for Payer: PACE SWMI |
$0.15
|
| Rate for Payer: PHP Commercial |
$0.50
|
| Rate for Payer: PHP Medicare Advantage |
$0.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.38
|
| Rate for Payer: Priority Health HMO/PPO |
$0.51
|
| Rate for Payer: Priority Health Medicare |
$0.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.40
|
| Rate for Payer: Railroad Medicare Medicare |
$0.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.52
|
| Rate for Payer: UHC Core |
$0.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.15
|
| Rate for Payer: UHC Exchange |
$0.15
|
| Rate for Payer: UHC Medicare Advantage |
$0.15
|
| Rate for Payer: VA VA |
$0.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.44
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.80
|
|
|
Service Code
|
NDC 00121063805
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna Commercial |
$5.78
|
| Rate for Payer: BCBS Trust/PPO |
$5.55
|
| Rate for Payer: BCN Commercial |
$5.26
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cofinity Commercial |
$5.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.44
|
| Rate for Payer: Healthscope Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.78
|
| Rate for Payer: Nomi Health Commercial |
$5.58
|
| Rate for Payer: PHP Commercial |
$5.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.42
|
| Rate for Payer: Priority Health HMO/PPO |
$5.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.98
|
| Rate for Payer: UHC Core |
$5.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.10
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 69339014919
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$4.92
|
| Rate for Payer: BCN Commercial |
$4.66
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cofinity Commercial |
$5.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.82
|
| Rate for Payer: Healthscope Commercial |
$5.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.13
|
| Rate for Payer: Nomi Health Commercial |
$4.94
|
| Rate for Payer: PHP Commercial |
$5.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.92
|
| Rate for Payer: Priority Health HMO/PPO |
$5.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.31
|
| Rate for Payer: UHC Core |
$5.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.52
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 69339014905
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: Aetna Medicare |
$1.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.88
|
| Rate for Payer: BCBS Complete |
$2.41
|
| Rate for Payer: BCBS MAPPO |
$1.51
|
| Rate for Payer: BCBS Trust/PPO |
$4.96
|
| Rate for Payer: BCN Commercial |
$4.69
|
| Rate for Payer: BCN Medicare Advantage |
$1.51
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cofinity Commercial |
$5.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.51
|
| Rate for Payer: Healthscope Commercial |
$5.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.13
|
| Rate for Payer: Nomi Health Commercial |
$4.94
|
| Rate for Payer: PACE Senior Care Partners |
$1.43
|
| Rate for Payer: PACE SWMI |
$1.51
|
| Rate for Payer: PHP Commercial |
$5.13
|
| Rate for Payer: PHP Medicare Advantage |
$1.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.92
|
| Rate for Payer: Priority Health HMO/PPO |
$5.25
|
| Rate for Payer: Priority Health Medicare |
$1.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.04
|
| Rate for Payer: Railroad Medicare Medicare |
$1.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.31
|
| Rate for Payer: UHC Core |
$5.04
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.51
|
| Rate for Payer: UHC Exchange |
$1.51
|
| Rate for Payer: UHC Medicare Advantage |
$1.51
|
| Rate for Payer: VA VA |
$1.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.52
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 69339014919
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: Aetna Medicare |
$1.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.88
|
| Rate for Payer: BCBS Complete |
$2.41
|
| Rate for Payer: BCBS MAPPO |
$1.51
|
| Rate for Payer: BCBS Trust/PPO |
$4.96
|
| Rate for Payer: BCN Commercial |
$4.69
|
| Rate for Payer: BCN Medicare Advantage |
$1.51
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cofinity Commercial |
$5.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.51
|
| Rate for Payer: Healthscope Commercial |
$5.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.13
|
| Rate for Payer: Nomi Health Commercial |
$4.94
|
| Rate for Payer: PACE Senior Care Partners |
$1.43
|
| Rate for Payer: PACE SWMI |
$1.51
|
| Rate for Payer: PHP Commercial |
$5.13
|
| Rate for Payer: PHP Medicare Advantage |
$1.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.92
|
| Rate for Payer: Priority Health HMO/PPO |
$5.25
|
| Rate for Payer: Priority Health Medicare |
$1.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.04
|
| Rate for Payer: Railroad Medicare Medicare |
$1.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.31
|
| Rate for Payer: UHC Core |
$5.04
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.51
|
| Rate for Payer: UHC Exchange |
$1.51
|
| Rate for Payer: UHC Medicare Advantage |
$1.51
|
| Rate for Payer: VA VA |
$1.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.52
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.80
|
|
|
Service Code
|
NDC 00121063805
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna Commercial |
$5.78
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.12
|
| Rate for Payer: BCBS Complete |
$2.72
|
| Rate for Payer: BCBS MAPPO |
$1.70
|
| Rate for Payer: BCBS Trust/PPO |
$5.59
|
| Rate for Payer: BCN Commercial |
$5.29
|
| Rate for Payer: BCN Medicare Advantage |
$1.70
|
| Rate for Payer: Cash Price |
$5.44
|
| Rate for Payer: Cofinity Commercial |
$5.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.70
|
| Rate for Payer: Healthscope Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.78
|
| Rate for Payer: Nomi Health Commercial |
$5.58
|
| Rate for Payer: PACE Senior Care Partners |
$1.62
|
| Rate for Payer: PACE SWMI |
$1.70
|
| Rate for Payer: PHP Commercial |
$5.78
|
| Rate for Payer: PHP Medicare Advantage |
$1.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.42
|
| Rate for Payer: Priority Health HMO/PPO |
$5.92
|
| Rate for Payer: Priority Health Medicare |
$1.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.56
|
| Rate for Payer: Railroad Medicare Medicare |
$1.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.98
|
| Rate for Payer: UHC Core |
$5.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.70
|
| Rate for Payer: UHC Exchange |
$1.70
|
| Rate for Payer: UHC Medicare Advantage |
$1.70
|
| Rate for Payer: VA VA |
$1.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.10
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 69339014905
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$4.92
|
| Rate for Payer: BCN Commercial |
$4.66
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cofinity Commercial |
$5.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.82
|
| Rate for Payer: Healthscope Commercial |
$5.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.13
|
| Rate for Payer: Nomi Health Commercial |
$4.94
|
| Rate for Payer: PHP Commercial |
$5.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.92
|
| Rate for Payer: Priority Health HMO/PPO |
$5.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.31
|
| Rate for Payer: UHC Core |
$5.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.52
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 09900000386
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: BCBS Trust/PPO |
$0.48
|
| Rate for Payer: BCN Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cofinity Commercial |
$0.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.47
|
| Rate for Payer: Healthscope Commercial |
$0.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.50
|
| Rate for Payer: Nomi Health Commercial |
$0.48
|
| Rate for Payer: PHP Commercial |
$0.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.38
|
| Rate for Payer: Priority Health HMO/PPO |
$0.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.52
|
| Rate for Payer: UHC Core |
$0.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$95.70
|
|
|
Service Code
|
NDC 00990793009
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.73 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Aetna Commercial |
$81.34
|
| Rate for Payer: Aetna Medicare |
$24.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.91
|
| Rate for Payer: BCBS Complete |
$38.28
|
| Rate for Payer: BCBS MAPPO |
$23.92
|
| Rate for Payer: BCBS Trust/PPO |
$78.67
|
| Rate for Payer: BCN Commercial |
$74.41
|
| Rate for Payer: BCN Medicare Advantage |
$23.92
|
| Rate for Payer: Cash Price |
$76.56
|
| Rate for Payer: Cofinity Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.92
|
| Rate for Payer: Healthscope Commercial |
$86.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.34
|
| Rate for Payer: Nomi Health Commercial |
$78.47
|
| Rate for Payer: PACE Senior Care Partners |
$22.73
|
| Rate for Payer: PACE SWMI |
$23.92
|
| Rate for Payer: PHP Commercial |
$81.34
|
| Rate for Payer: PHP Medicare Advantage |
$23.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.20
|
| Rate for Payer: Priority Health HMO/PPO |
$83.26
|
| Rate for Payer: Priority Health Medicare |
$24.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.12
|
| Rate for Payer: Railroad Medicare Medicare |
$23.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.22
|
| Rate for Payer: UHC Core |
$79.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.92
|
| Rate for Payer: UHC Exchange |
$23.92
|
| Rate for Payer: UHC Medicare Advantage |
$23.92
|
| Rate for Payer: VA VA |
$23.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.78
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.45 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: BCBS Trust/PPO |
$57.08
|
| Rate for Payer: BCN Commercial |
$54.03
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health HMO/PPO |
$60.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$18.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.85
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS MAPPO |
$17.48
|
| Rate for Payer: BCBS Trust/PPO |
$57.48
|
| Rate for Payer: BCN Commercial |
$54.36
|
| Rate for Payer: BCN Medicare Advantage |
$17.48
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.48
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: PACE Senior Care Partners |
$16.61
|
| Rate for Payer: PACE SWMI |
$17.48
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: PHP Medicare Advantage |
$17.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health HMO/PPO |
$60.83
|
| Rate for Payer: Priority Health Medicare |
$17.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.85
|
| Rate for Payer: Railroad Medicare Medicare |
$17.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.48
|
| Rate for Payer: UHC Exchange |
$17.48
|
| Rate for Payer: UHC Medicare Advantage |
$17.48
|
| Rate for Payer: VA VA |
$17.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$61.18
|
|
|
Service Code
|
NDC 00338002302
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna Medicare |
$15.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.12
|
| Rate for Payer: BCBS Complete |
$24.47
|
| Rate for Payer: BCBS MAPPO |
$15.30
|
| Rate for Payer: BCBS Trust/PPO |
$50.30
|
| Rate for Payer: BCN Commercial |
$47.57
|
| Rate for Payer: BCN Medicare Advantage |
$15.30
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.30
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: Nomi Health Commercial |
$50.17
|
| Rate for Payer: PACE Senior Care Partners |
$14.53
|
| Rate for Payer: PACE SWMI |
$15.30
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: PHP Medicare Advantage |
$15.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health HMO/PPO |
$53.23
|
| Rate for Payer: Priority Health Medicare |
$15.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.99
|
| Rate for Payer: Railroad Medicare Medicare |
$15.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.84
|
| Rate for Payer: UHC Core |
$51.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.30
|
| Rate for Payer: UHC Exchange |
$15.30
|
| Rate for Payer: UHC Medicare Advantage |
$15.30
|
| Rate for Payer: VA VA |
$15.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$61.18
|
|
|
Service Code
|
NDC 00338002302
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.77 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: BCBS Trust/PPO |
$49.94
|
| Rate for Payer: BCN Commercial |
$47.28
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: Nomi Health Commercial |
$50.17
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health HMO/PPO |
$53.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.84
|
| Rate for Payer: UHC Core |
$51.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$95.70
|
|
|
Service Code
|
NDC 00990793009
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.20 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Aetna Commercial |
$81.34
|
| Rate for Payer: BCBS Trust/PPO |
$78.12
|
| Rate for Payer: BCN Commercial |
$73.96
|
| Rate for Payer: Cash Price |
$76.56
|
| Rate for Payer: Cofinity Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.56
|
| Rate for Payer: Healthscope Commercial |
$86.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.34
|
| Rate for Payer: Nomi Health Commercial |
$78.47
|
| Rate for Payer: PHP Commercial |
$81.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.20
|
| Rate for Payer: Priority Health HMO/PPO |
$83.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.22
|
| Rate for Payer: UHC Core |
$79.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.78
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
300148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$18.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.85
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS MAPPO |
$17.48
|
| Rate for Payer: BCBS Trust/PPO |
$57.48
|
| Rate for Payer: BCN Commercial |
$54.36
|
| Rate for Payer: BCN Medicare Advantage |
$17.48
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.48
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: PACE Senior Care Partners |
$16.61
|
| Rate for Payer: PACE SWMI |
$17.48
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: PHP Medicare Advantage |
$17.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health HMO/PPO |
$60.83
|
| Rate for Payer: Priority Health Medicare |
$17.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.85
|
| Rate for Payer: Railroad Medicare Medicare |
$17.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.48
|
| Rate for Payer: UHC Exchange |
$17.48
|
| Rate for Payer: UHC Medicare Advantage |
$17.48
|
| Rate for Payer: VA VA |
$17.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
300148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.45 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: BCBS Trust/PPO |
$57.08
|
| Rate for Payer: BCN Commercial |
$54.03
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health HMO/PPO |
$60.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
OP
|
$63.80
|
|
|
Service Code
|
NDC 00264752020
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna Medicare |
$16.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.94
|
| Rate for Payer: BCBS Complete |
$25.52
|
| Rate for Payer: BCBS MAPPO |
$15.95
|
| Rate for Payer: BCBS Trust/PPO |
$52.45
|
| Rate for Payer: BCN Commercial |
$49.60
|
| Rate for Payer: BCN Medicare Advantage |
$15.95
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.95
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Nomi Health Commercial |
$52.32
|
| Rate for Payer: PACE Senior Care Partners |
$15.15
|
| Rate for Payer: PACE SWMI |
$15.95
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: PHP Medicare Advantage |
$15.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.47
|
| Rate for Payer: Priority Health HMO/PPO |
$55.51
|
| Rate for Payer: Priority Health Medicare |
$16.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.75
|
| Rate for Payer: Railroad Medicare Medicare |
$15.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.14
|
| Rate for Payer: UHC Core |
$53.27
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.95
|
| Rate for Payer: UHC Exchange |
$15.95
|
| Rate for Payer: UHC Medicare Advantage |
$15.95
|
| Rate for Payer: VA VA |
$15.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.85
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
NDC 00264752020
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.47 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: BCBS Trust/PPO |
$52.08
|
| Rate for Payer: BCN Commercial |
$49.30
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Nomi Health Commercial |
$52.32
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.47
|
| Rate for Payer: Priority Health HMO/PPO |
$55.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.14
|
| Rate for Payer: UHC Core |
$53.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.85
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$72.72
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$65.45 |
| Rate for Payer: Aetna Commercial |
$61.81
|
| Rate for Payer: Aetna Medicare |
$18.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.72
|
| Rate for Payer: BCBS Complete |
$29.09
|
| Rate for Payer: BCBS MAPPO |
$18.18
|
| Rate for Payer: BCBS Trust/PPO |
$59.78
|
| Rate for Payer: BCN Commercial |
$56.54
|
| Rate for Payer: BCN Medicare Advantage |
$18.18
|
| Rate for Payer: Cash Price |
$58.18
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.18
|
| Rate for Payer: Healthscope Commercial |
$65.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.81
|
| Rate for Payer: Nomi Health Commercial |
$59.63
|
| Rate for Payer: PACE Senior Care Partners |
$17.27
|
| Rate for Payer: PACE SWMI |
$18.18
|
| Rate for Payer: PHP Commercial |
$61.81
|
| Rate for Payer: PHP Medicare Advantage |
$18.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.27
|
| Rate for Payer: Priority Health HMO/PPO |
$63.27
|
| Rate for Payer: Priority Health Medicare |
$18.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$48.72
|
| Rate for Payer: Railroad Medicare Medicare |
$18.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.99
|
| Rate for Payer: UHC Core |
$60.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.18
|
| Rate for Payer: UHC Exchange |
$18.18
|
| Rate for Payer: UHC Medicare Advantage |
$18.18
|
| Rate for Payer: VA VA |
$18.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.54
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$72.72
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.27 |
| Max. Negotiated Rate |
$65.45 |
| Rate for Payer: Aetna Commercial |
$61.81
|
| Rate for Payer: BCBS Trust/PPO |
$59.36
|
| Rate for Payer: BCN Commercial |
$56.20
|
| Rate for Payer: Cash Price |
$58.18
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.18
|
| Rate for Payer: Healthscope Commercial |
$65.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.81
|
| Rate for Payer: Nomi Health Commercial |
$59.63
|
| Rate for Payer: PHP Commercial |
$61.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.27
|
| Rate for Payer: Priority Health HMO/PPO |
$63.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$48.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.99
|
| Rate for Payer: UHC Core |
$60.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.54
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$15.19
|
|
|
Service Code
|
NDC 00574006915
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$13.67 |
| Rate for Payer: Aetna Commercial |
$12.91
|
| Rate for Payer: Aetna Medicare |
$3.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.75
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: BCBS MAPPO |
$3.80
|
| Rate for Payer: BCBS Trust/PPO |
$12.49
|
| Rate for Payer: BCN Commercial |
$11.81
|
| Rate for Payer: BCN Medicare Advantage |
$3.80
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cofinity Commercial |
$13.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$13.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.39
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.91
|
| Rate for Payer: Nomi Health Commercial |
$12.46
|
| Rate for Payer: PACE Senior Care Partners |
$3.61
|
| Rate for Payer: PACE SWMI |
$3.80
|
| Rate for Payer: PHP Commercial |
$12.91
|
| Rate for Payer: PHP Medicare Advantage |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.87
|
| Rate for Payer: Priority Health HMO/PPO |
$13.22
|
| Rate for Payer: Priority Health Medicare |
$3.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.18
|
| Rate for Payer: Railroad Medicare Medicare |
$3.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.37
|
| Rate for Payer: UHC Core |
$12.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.80
|
| Rate for Payer: UHC Exchange |
$3.80
|
| Rate for Payer: UHC Medicare Advantage |
$3.80
|
| Rate for Payer: VA VA |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.39
|
|
