|
EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER
|
Facility
|
OP
|
$2,172.87
|
|
|
Service Code
|
CPT 21554
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,069.26 |
| Max. Negotiated Rate |
$2,172.87 |
| Rate for Payer: BCBS Complete |
$2,172.87
|
| Rate for Payer: Mclaren Medicaid |
$2,069.26
|
| Rate for Payer: Meridian Medicaid |
$2,172.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,069.26
|
| Rate for Payer: UHCCP Medicaid |
$2,069.26
|
|
|
EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM
|
Facility
|
OP
|
$2,172.87
|
|
|
Service Code
|
CPT 21556
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,069.26 |
| Max. Negotiated Rate |
$2,172.87 |
| Rate for Payer: BCBS Complete |
$2,172.87
|
| Rate for Payer: Mclaren Medicaid |
$2,069.26
|
| Rate for Payer: Meridian Medicaid |
$2,172.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,069.26
|
| Rate for Payer: UHCCP Medicaid |
$2,069.26
|
|
|
EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER
|
Facility
|
OP
|
$2,172.87
|
|
|
Service Code
|
CPT 27043
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,069.26 |
| Max. Negotiated Rate |
$2,172.87 |
| Rate for Payer: BCBS Complete |
$2,172.87
|
| Rate for Payer: Mclaren Medicaid |
$2,069.26
|
| Rate for Payer: Meridian Medicaid |
$2,172.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,069.26
|
| Rate for Payer: UHCCP Medicaid |
$2,069.26
|
|
|
EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER
|
Facility
|
OP
|
$1,230.09
|
|
|
Service Code
|
CPT 23071
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,171.43 |
| Max. Negotiated Rate |
$1,230.09 |
| Rate for Payer: BCBS Complete |
$1,230.09
|
| Rate for Payer: Mclaren Medicaid |
$1,171.43
|
| Rate for Payer: Meridian Medicaid |
$1,230.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,171.43
|
| Rate for Payer: UHCCP Medicaid |
$1,171.43
|
|
|
EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER
|
Facility
|
OP
|
$2,172.87
|
|
|
Service Code
|
CPT 27337
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,069.26 |
| Max. Negotiated Rate |
$2,172.87 |
| Rate for Payer: BCBS Complete |
$2,172.87
|
| Rate for Payer: Mclaren Medicaid |
$2,069.26
|
| Rate for Payer: Meridian Medicaid |
$2,172.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,069.26
|
| Rate for Payer: UHCCP Medicaid |
$2,069.26
|
|
|
EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER
|
Facility
|
OP
|
$2,172.87
|
|
|
Service Code
|
CPT 24071
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,069.26 |
| Max. Negotiated Rate |
$2,172.87 |
| Rate for Payer: BCBS Complete |
$2,172.87
|
| Rate for Payer: Mclaren Medicaid |
$2,069.26
|
| Rate for Payer: Meridian Medicaid |
$2,172.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,069.26
|
| Rate for Payer: UHCCP Medicaid |
$2,069.26
|
|
|
EYELASH TINTING
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 00176
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$81.80
|
|
|
Service Code
|
NDC 67877049030
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.17 |
| Max. Negotiated Rate |
$73.62 |
| Rate for Payer: Aetna Commercial |
$69.53
|
| Rate for Payer: BCBS Trust/PPO |
$66.77
|
| Rate for Payer: BCN Commercial |
$63.22
|
| Rate for Payer: Cash Price |
$65.44
|
| Rate for Payer: Cofinity Commercial |
$70.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.44
|
| Rate for Payer: Healthscope Commercial |
$73.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.53
|
| Rate for Payer: Nomi Health Commercial |
$67.08
|
| Rate for Payer: PHP Commercial |
$69.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.17
|
| Rate for Payer: Priority Health HMO/PPO |
$71.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$54.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.98
|
| Rate for Payer: UHC Core |
$68.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.35
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$81.80
|
|
|
Service Code
|
NDC 67877049030
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.43 |
| Max. Negotiated Rate |
$73.62 |
| Rate for Payer: Aetna Commercial |
$69.53
|
| Rate for Payer: Aetna Medicare |
$21.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.56
|
| Rate for Payer: BCBS Complete |
$32.72
|
| Rate for Payer: BCBS MAPPO |
$20.45
|
| Rate for Payer: BCBS Trust/PPO |
$67.25
|
| Rate for Payer: BCN Commercial |
$63.60
|
| Rate for Payer: BCN Medicare Advantage |
$20.45
|
| Rate for Payer: Cash Price |
$65.44
|
| Rate for Payer: Cofinity Commercial |
$70.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20.45
|
| Rate for Payer: Healthscope Commercial |
$73.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.53
|
| Rate for Payer: Nomi Health Commercial |
$67.08
|
| Rate for Payer: PACE Senior Care Partners |
$19.43
|
| Rate for Payer: PACE SWMI |
$20.45
|
| Rate for Payer: PHP Commercial |
$69.53
|
| Rate for Payer: PHP Medicare Advantage |
$20.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.17
|
| Rate for Payer: Priority Health HMO/PPO |
$71.17
|
| Rate for Payer: Priority Health Medicare |
$20.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$54.81
|
| Rate for Payer: Railroad Medicare Medicare |
$20.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.98
|
| Rate for Payer: UHC Core |
$68.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$20.45
|
| Rate for Payer: UHC Exchange |
$20.45
|
| Rate for Payer: UHC Medicare Advantage |
$20.45
|
| Rate for Payer: VA VA |
$20.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.35
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$488.96
|
|
|
Service Code
|
NDC 00904710304
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$440.06 |
| Rate for Payer: Aetna Commercial |
$415.62
|
| Rate for Payer: Aetna Medicare |
$127.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$152.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$152.80
|
| Rate for Payer: BCBS Complete |
$195.58
|
| Rate for Payer: BCBS MAPPO |
$122.24
|
| Rate for Payer: BCBS Trust/PPO |
$401.97
|
| Rate for Payer: BCN Commercial |
$380.17
|
| Rate for Payer: BCN Medicare Advantage |
$122.24
|
| Rate for Payer: Cash Price |
$391.17
|
| Rate for Payer: Cofinity Commercial |
$420.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$391.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$122.24
|
| Rate for Payer: Healthscope Commercial |
$440.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$366.72
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$128.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$140.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$415.62
|
| Rate for Payer: Nomi Health Commercial |
$400.95
|
| Rate for Payer: PACE Senior Care Partners |
$116.13
|
| Rate for Payer: PACE SWMI |
$122.24
|
| Rate for Payer: PHP Commercial |
$415.62
|
| Rate for Payer: PHP Medicare Advantage |
$122.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.82
|
| Rate for Payer: Priority Health HMO/PPO |
$425.40
|
| Rate for Payer: Priority Health Medicare |
$123.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$327.60
|
| Rate for Payer: Railroad Medicare Medicare |
$122.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$430.28
|
| Rate for Payer: UHC Core |
$408.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$122.24
|
| Rate for Payer: UHC Exchange |
$122.24
|
| Rate for Payer: UHC Medicare Advantage |
$122.24
|
| Rate for Payer: VA VA |
$122.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$366.72
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$76.95
|
|
|
Service Code
|
NDC 00781569031
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.28 |
| Max. Negotiated Rate |
$69.25 |
| Rate for Payer: Aetna Commercial |
$65.41
|
| Rate for Payer: Aetna Medicare |
$20.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.05
|
| Rate for Payer: BCBS Complete |
$30.78
|
| Rate for Payer: BCBS MAPPO |
$19.24
|
| Rate for Payer: BCBS Trust/PPO |
$63.26
|
| Rate for Payer: BCN Commercial |
$59.83
|
| Rate for Payer: BCN Medicare Advantage |
$19.24
|
| Rate for Payer: Cash Price |
$61.56
|
| Rate for Payer: Cofinity Commercial |
$66.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.24
|
| Rate for Payer: Healthscope Commercial |
$69.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.41
|
| Rate for Payer: Nomi Health Commercial |
$63.10
|
| Rate for Payer: PACE Senior Care Partners |
$18.28
|
| Rate for Payer: PACE SWMI |
$19.24
|
| Rate for Payer: PHP Commercial |
$65.41
|
| Rate for Payer: PHP Medicare Advantage |
$19.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.02
|
| Rate for Payer: Priority Health HMO/PPO |
$66.95
|
| Rate for Payer: Priority Health Medicare |
$19.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$51.56
|
| Rate for Payer: Railroad Medicare Medicare |
$19.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.72
|
| Rate for Payer: UHC Core |
$64.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.24
|
| Rate for Payer: UHC Exchange |
$19.24
|
| Rate for Payer: UHC Medicare Advantage |
$19.24
|
| Rate for Payer: VA VA |
$19.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.71
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$488.96
|
|
|
Service Code
|
NDC 00904710304
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$317.82 |
| Max. Negotiated Rate |
$440.06 |
| Rate for Payer: Aetna Commercial |
$415.62
|
| Rate for Payer: BCBS Trust/PPO |
$399.14
|
| Rate for Payer: BCN Commercial |
$377.87
|
| Rate for Payer: Cash Price |
$391.17
|
| Rate for Payer: Cofinity Commercial |
$420.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$391.17
|
| Rate for Payer: Healthscope Commercial |
$440.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$366.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$415.62
|
| Rate for Payer: Nomi Health Commercial |
$400.95
|
| Rate for Payer: PHP Commercial |
$415.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.82
|
| Rate for Payer: Priority Health HMO/PPO |
$425.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$327.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$430.28
|
| Rate for Payer: UHC Core |
$408.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$366.72
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$76.95
|
|
|
Service Code
|
NDC 00781569031
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.02 |
| Max. Negotiated Rate |
$69.25 |
| Rate for Payer: Aetna Commercial |
$65.41
|
| Rate for Payer: BCBS Trust/PPO |
$62.81
|
| Rate for Payer: BCN Commercial |
$59.47
|
| Rate for Payer: Cash Price |
$61.56
|
| Rate for Payer: Cofinity Commercial |
$66.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.56
|
| Rate for Payer: Healthscope Commercial |
$69.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.41
|
| Rate for Payer: Nomi Health Commercial |
$63.10
|
| Rate for Payer: PHP Commercial |
$65.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.02
|
| Rate for Payer: Priority Health HMO/PPO |
$66.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$51.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.72
|
| Rate for Payer: UHC Core |
$64.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.71
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$1,190.92
|
|
|
Service Code
|
NDC 66582041431
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$774.10 |
| Max. Negotiated Rate |
$1,071.83 |
| Rate for Payer: Aetna Commercial |
$1,012.28
|
| Rate for Payer: BCBS Trust/PPO |
$972.15
|
| Rate for Payer: BCN Commercial |
$920.34
|
| Rate for Payer: Cash Price |
$952.74
|
| Rate for Payer: Cofinity Commercial |
$1,024.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$952.74
|
| Rate for Payer: Healthscope Commercial |
$1,071.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$893.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,012.28
|
| Rate for Payer: Nomi Health Commercial |
$976.55
|
| Rate for Payer: PHP Commercial |
$1,012.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$774.10
|
| Rate for Payer: Priority Health HMO/PPO |
$1,036.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$797.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,048.01
|
| Rate for Payer: UHC Core |
$994.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$893.19
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$1,190.92
|
|
|
Service Code
|
NDC 66582041431
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$282.84 |
| Max. Negotiated Rate |
$1,071.83 |
| Rate for Payer: Aetna Commercial |
$1,012.28
|
| Rate for Payer: Aetna Medicare |
$309.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$372.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$372.16
|
| Rate for Payer: BCBS Complete |
$476.37
|
| Rate for Payer: BCBS MAPPO |
$297.73
|
| Rate for Payer: BCBS Trust/PPO |
$979.06
|
| Rate for Payer: BCN Commercial |
$925.94
|
| Rate for Payer: BCN Medicare Advantage |
$297.73
|
| Rate for Payer: Cash Price |
$952.74
|
| Rate for Payer: Cofinity Commercial |
$1,024.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$952.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$297.73
|
| Rate for Payer: Healthscope Commercial |
$1,071.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$893.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$312.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$342.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,012.28
|
| Rate for Payer: Nomi Health Commercial |
$976.55
|
| Rate for Payer: PACE Senior Care Partners |
$282.84
|
| Rate for Payer: PACE SWMI |
$297.73
|
| Rate for Payer: PHP Commercial |
$1,012.28
|
| Rate for Payer: PHP Medicare Advantage |
$297.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$774.10
|
| Rate for Payer: Priority Health HMO/PPO |
$1,036.10
|
| Rate for Payer: Priority Health Medicare |
$300.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$797.92
|
| Rate for Payer: Railroad Medicare Medicare |
$297.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,048.01
|
| Rate for Payer: UHC Core |
$994.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$297.73
|
| Rate for Payer: UHC Exchange |
$297.73
|
| Rate for Payer: UHC Medicare Advantage |
$297.73
|
| Rate for Payer: VA VA |
$297.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$893.19
|
|
|
FACIAL
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 00174
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$42.90 |
| Rate for Payer: Aetna Medicare |
$33.00
|
| Rate for Payer: BCBS Complete |
$26.40
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.90
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$37.40
|
|
|
Service Code
|
NDC 63323073809
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: BCBS Trust/PPO |
$30.53
|
| Rate for Payer: BCN Commercial |
$28.90
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.92
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.79
|
| Rate for Payer: Nomi Health Commercial |
$30.67
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.31
|
| Rate for Payer: Priority Health HMO/PPO |
$32.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.91
|
| Rate for Payer: UHC Core |
$31.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$37.40
|
|
|
Service Code
|
NDC 63323073809
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: Aetna Medicare |
$9.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.69
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: BCBS MAPPO |
$9.35
|
| Rate for Payer: BCBS Trust/PPO |
$30.75
|
| Rate for Payer: BCN Commercial |
$29.08
|
| Rate for Payer: BCN Medicare Advantage |
$9.35
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.35
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.79
|
| Rate for Payer: Nomi Health Commercial |
$30.67
|
| Rate for Payer: PACE Senior Care Partners |
$8.88
|
| Rate for Payer: PACE SWMI |
$9.35
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: PHP Medicare Advantage |
$9.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.31
|
| Rate for Payer: Priority Health HMO/PPO |
$32.54
|
| Rate for Payer: Priority Health Medicare |
$9.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.06
|
| Rate for Payer: Railroad Medicare Medicare |
$9.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.91
|
| Rate for Payer: UHC Core |
$31.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.35
|
| Rate for Payer: UHC Exchange |
$9.35
|
| Rate for Payer: UHC Medicare Advantage |
$9.35
|
| Rate for Payer: VA VA |
$9.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
OP
|
$37.40
|
|
|
Service Code
|
NDC 63323073809
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: Aetna Medicare |
$9.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.69
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: BCBS MAPPO |
$9.35
|
| Rate for Payer: BCBS Trust/PPO |
$30.75
|
| Rate for Payer: BCN Commercial |
$29.08
|
| Rate for Payer: BCN Medicare Advantage |
$9.35
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.35
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.79
|
| Rate for Payer: Nomi Health Commercial |
$30.67
|
| Rate for Payer: PACE Senior Care Partners |
$8.88
|
| Rate for Payer: PACE SWMI |
$9.35
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: PHP Medicare Advantage |
$9.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.31
|
| Rate for Payer: Priority Health HMO/PPO |
$32.54
|
| Rate for Payer: Priority Health Medicare |
$9.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.06
|
| Rate for Payer: Railroad Medicare Medicare |
$9.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.91
|
| Rate for Payer: UHC Core |
$31.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.35
|
| Rate for Payer: UHC Exchange |
$9.35
|
| Rate for Payer: UHC Medicare Advantage |
$9.35
|
| Rate for Payer: VA VA |
$9.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$37.40
|
|
|
Service Code
|
NDC 63323073809
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: BCBS Trust/PPO |
$30.53
|
| Rate for Payer: BCN Commercial |
$28.90
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.92
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.79
|
| Rate for Payer: Nomi Health Commercial |
$30.67
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.31
|
| Rate for Payer: Priority Health HMO/PPO |
$32.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.91
|
| Rate for Payer: UHC Core |
$31.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079096620
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.23 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: BCBS Trust/PPO |
$120.85
|
| Rate for Payer: BCN Commercial |
$114.41
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO |
$128.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.28
|
| Rate for Payer: UHC Core |
$123.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$99.88
|
|
|
Service Code
|
NDC 00904578017
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.72 |
| Max. Negotiated Rate |
$89.89 |
| Rate for Payer: Aetna Commercial |
$84.90
|
| Rate for Payer: Aetna Medicare |
$25.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.21
|
| Rate for Payer: BCBS Complete |
$39.95
|
| Rate for Payer: BCBS MAPPO |
$24.97
|
| Rate for Payer: BCBS Trust/PPO |
$82.11
|
| Rate for Payer: BCN Commercial |
$77.66
|
| Rate for Payer: BCN Medicare Advantage |
$24.97
|
| Rate for Payer: Cash Price |
$79.90
|
| Rate for Payer: Cofinity Commercial |
$85.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.97
|
| Rate for Payer: Healthscope Commercial |
$89.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.90
|
| Rate for Payer: Nomi Health Commercial |
$81.90
|
| Rate for Payer: PACE Senior Care Partners |
$23.72
|
| Rate for Payer: PACE SWMI |
$24.97
|
| Rate for Payer: PHP Commercial |
$84.90
|
| Rate for Payer: PHP Medicare Advantage |
$24.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.92
|
| Rate for Payer: Priority Health HMO/PPO |
$86.90
|
| Rate for Payer: Priority Health Medicare |
$25.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$66.92
|
| Rate for Payer: Railroad Medicare Medicare |
$24.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.89
|
| Rate for Payer: UHC Core |
$83.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$24.97
|
| Rate for Payer: UHC Exchange |
$24.97
|
| Rate for Payer: UHC Medicare Advantage |
$24.97
|
| Rate for Payer: VA VA |
$24.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.91
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 51079096601
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.47
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: BCBS MAPPO |
$0.37
|
| Rate for Payer: BCBS Trust/PPO |
$1.22
|
| Rate for Payer: BCN Commercial |
$1.16
|
| Rate for Payer: BCN Medicare Advantage |
$0.37
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.37
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: Nomi Health Commercial |
$1.22
|
| Rate for Payer: PACE Senior Care Partners |
$0.35
|
| Rate for Payer: PACE SWMI |
$0.37
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: PHP Medicare Advantage |
$0.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health HMO/PPO |
$1.30
|
| Rate for Payer: Priority Health Medicare |
$0.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.00
|
| Rate for Payer: Railroad Medicare Medicare |
$0.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.31
|
| Rate for Payer: UHC Core |
$1.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.37
|
| Rate for Payer: UHC Exchange |
$0.37
|
| Rate for Payer: UHC Medicare Advantage |
$0.37
|
| Rate for Payer: VA VA |
$0.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 63739064510
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.09 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: BCBS Trust/PPO |
$145.79
|
| Rate for Payer: BCN Commercial |
$138.02
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: Nomi Health Commercial |
$146.45
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health HMO/PPO |
$155.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.17
|
| Rate for Payer: UHC Core |
$149.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 60687059511
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Aetna Medicare |
$1.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.35
|
| Rate for Payer: BCBS Complete |
$1.73
|
| Rate for Payer: BCBS MAPPO |
$1.08
|
| Rate for Payer: BCBS Trust/PPO |
$3.56
|
| Rate for Payer: BCN Commercial |
$3.37
|
| Rate for Payer: BCN Medicare Advantage |
$1.08
|
| Rate for Payer: Cash Price |
$3.46
|
| Rate for Payer: Cofinity Commercial |
$3.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.08
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.68
|
| Rate for Payer: Nomi Health Commercial |
$3.55
|
| Rate for Payer: PACE Senior Care Partners |
$1.03
|
| Rate for Payer: PACE SWMI |
$1.08
|
| Rate for Payer: PHP Commercial |
$3.68
|
| Rate for Payer: PHP Medicare Advantage |
$1.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.81
|
| Rate for Payer: Priority Health HMO/PPO |
$3.77
|
| Rate for Payer: Priority Health Medicare |
$1.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.90
|
| Rate for Payer: Railroad Medicare Medicare |
$1.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.81
|
| Rate for Payer: UHC Core |
$3.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.08
|
| Rate for Payer: UHC Exchange |
$1.08
|
| Rate for Payer: UHC Medicare Advantage |
$1.08
|
| Rate for Payer: VA VA |
$1.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.25
|
|
