|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$163.40
|
|
|
Service Code
|
NDC 50268-190-15
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.66 |
| Max. Negotiated Rate |
$147.06 |
| Rate for Payer: Aetna Commercial |
$138.89
|
| Rate for Payer: BCBS Trust/PPO |
$126.28
|
| Rate for Payer: BCN Commercial |
$126.28
|
| Rate for Payer: Cash Price |
$130.72
|
| Rate for Payer: Cofinity Commercial |
$140.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.72
|
| Rate for Payer: Healthscope Commercial |
$147.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$138.89
|
| Rate for Payer: PHP Commercial |
$138.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$143.79
|
| Rate for Payer: UHC Core |
$136.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.55
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$115.71
|
|
|
Service Code
|
NDC 68084-753-25
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.57 |
| Max. Negotiated Rate |
$104.14 |
| Rate for Payer: Aetna Commercial |
$98.35
|
| Rate for Payer: BCBS Trust/PPO |
$89.42
|
| Rate for Payer: BCN Commercial |
$89.42
|
| Rate for Payer: Cash Price |
$92.57
|
| Rate for Payer: Cofinity Commercial |
$99.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.57
|
| Rate for Payer: Healthscope Commercial |
$104.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.35
|
| Rate for Payer: PHP Commercial |
$98.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$100.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.82
|
| Rate for Payer: UHC Core |
$96.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.78
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$3.86
|
|
|
Service Code
|
NDC 68084-753-95
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: BCBS Trust/PPO |
$2.98
|
| Rate for Payer: BCN Commercial |
$2.98
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.09
|
| Rate for Payer: Healthscope Commercial |
$3.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.28
|
| Rate for Payer: PHP Commercial |
$3.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.40
|
| Rate for Payer: UHC Core |
$3.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$11.50 |
| Rate for Payer: Aetna Commercial |
$10.86
|
| Rate for Payer: BCBS Trust/PPO |
$9.88
|
| Rate for Payer: BCN Commercial |
$9.88
|
| Rate for Payer: Cash Price |
$10.22
|
| Rate for Payer: Cofinity Commercial |
$10.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.22
|
| Rate for Payer: Healthscope Commercial |
$11.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.86
|
| Rate for Payer: PHP Commercial |
$10.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.25
|
| Rate for Payer: UHC Core |
$10.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.58
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$18.86
|
|
|
Service Code
|
NDC 17478-100-02
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Aetna Commercial |
$16.03
|
| Rate for Payer: BCBS Trust/PPO |
$14.58
|
| Rate for Payer: BCN Commercial |
$14.58
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cofinity Commercial |
$16.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.09
|
| Rate for Payer: Healthscope Commercial |
$16.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.03
|
| Rate for Payer: PHP Commercial |
$16.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.60
|
| Rate for Payer: UHC Core |
$15.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.14
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$40.25
|
|
|
Service Code
|
NDC 24208-735-01
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.55 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna Commercial |
$34.21
|
| Rate for Payer: BCBS Trust/PPO |
$31.11
|
| Rate for Payer: BCN Commercial |
$31.11
|
| Rate for Payer: Cash Price |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$34.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.20
|
| Rate for Payer: Healthscope Commercial |
$36.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.21
|
| Rate for Payer: PHP Commercial |
$34.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.42
|
| Rate for Payer: UHC Core |
$33.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.19
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
IP
|
$98.98
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.37 |
| Max. Negotiated Rate |
$89.08 |
| Rate for Payer: Aetna Commercial |
$84.13
|
| Rate for Payer: BCBS Trust/PPO |
$76.49
|
| Rate for Payer: BCN Commercial |
$76.49
|
| Rate for Payer: Cash Price |
$79.18
|
| Rate for Payer: Cofinity Commercial |
$85.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.18
|
| Rate for Payer: Healthscope Commercial |
$89.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$84.13
|
| Rate for Payer: PHP Commercial |
$84.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$86.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.10
|
| Rate for Payer: UHC Core |
$82.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.24
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$648.69
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$395.64 |
| Max. Negotiated Rate |
$583.82 |
| Rate for Payer: Aetna Commercial |
$551.39
|
| Rate for Payer: BCBS Trust/PPO |
$501.31
|
| Rate for Payer: BCN Commercial |
$501.31
|
| Rate for Payer: Cash Price |
$518.95
|
| Rate for Payer: Cofinity Commercial |
$557.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$518.95
|
| Rate for Payer: Healthscope Commercial |
$583.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$486.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$551.39
|
| Rate for Payer: PHP Commercial |
$551.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$454.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$564.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$395.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$570.85
|
| Rate for Payer: UHC Core |
$541.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$486.52
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$218.92
|
|
|
Service Code
|
NDC 27505-003-67
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.52 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: BCBS Trust/PPO |
$169.18
|
| Rate for Payer: BCN Commercial |
$169.18
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$164.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.08
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$190.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$192.65
|
| Rate for Payer: UHC Core |
$182.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$164.19
|
|
|
DAPTOMYCIN 350 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$91.80
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
186972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.99 |
| Max. Negotiated Rate |
$82.62 |
| Rate for Payer: Aetna Commercial |
$78.03
|
| Rate for Payer: Aetna Commercial |
$45.39
|
| Rate for Payer: Aetna Commercial |
$72.82
|
| Rate for Payer: Aetna Commercial |
$60.26
|
| Rate for Payer: BCBS Trust/PPO |
$41.27
|
| Rate for Payer: BCBS Trust/PPO |
$54.78
|
| Rate for Payer: BCBS Trust/PPO |
$70.94
|
| Rate for Payer: BCBS Trust/PPO |
$66.21
|
| Rate for Payer: BCN Commercial |
$66.21
|
| Rate for Payer: BCN Commercial |
$41.27
|
| Rate for Payer: BCN Commercial |
$70.94
|
| Rate for Payer: BCN Commercial |
$54.78
|
| Rate for Payer: Cash Price |
$73.44
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cash Price |
$42.72
|
| Rate for Payer: Cash Price |
$56.71
|
| Rate for Payer: Cofinity Commercial |
$60.97
|
| Rate for Payer: Cofinity Commercial |
$45.92
|
| Rate for Payer: Cofinity Commercial |
$73.68
|
| Rate for Payer: Cofinity Commercial |
$78.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.44
|
| Rate for Payer: Healthscope Commercial |
$63.80
|
| Rate for Payer: Healthscope Commercial |
$48.06
|
| Rate for Payer: Healthscope Commercial |
$77.10
|
| Rate for Payer: Healthscope Commercial |
$82.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$72.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$78.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$45.39
|
| Rate for Payer: PHP Commercial |
$45.39
|
| Rate for Payer: PHP Commercial |
$78.03
|
| Rate for Payer: PHP Commercial |
$72.82
|
| Rate for Payer: PHP Commercial |
$60.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$74.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$46.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$79.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$55.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.78
|
| Rate for Payer: UHC Core |
$76.65
|
| Rate for Payer: UHC Core |
$59.19
|
| Rate for Payer: UHC Core |
$44.59
|
| Rate for Payer: UHC Core |
$71.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.17
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$86.56
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
36989
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.79 |
| Max. Negotiated Rate |
$77.90 |
| Rate for Payer: Aetna Commercial |
$73.58
|
| Rate for Payer: Aetna Commercial |
$109.81
|
| Rate for Payer: Aetna Commercial |
$73.35
|
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Commercial |
$1,129.95
|
| Rate for Payer: BCBS Trust/PPO |
$66.68
|
| Rate for Payer: BCBS Trust/PPO |
$99.84
|
| Rate for Payer: BCBS Trust/PPO |
$66.89
|
| Rate for Payer: BCBS Trust/PPO |
$1,027.32
|
| Rate for Payer: BCBS Trust/PPO |
$66.38
|
| Rate for Payer: BCN Commercial |
$66.89
|
| Rate for Payer: BCN Commercial |
$99.84
|
| Rate for Payer: BCN Commercial |
$66.38
|
| Rate for Payer: BCN Commercial |
$66.68
|
| Rate for Payer: BCN Commercial |
$1,027.32
|
| Rate for Payer: Cash Price |
$69.25
|
| Rate for Payer: Cash Price |
$68.71
|
| Rate for Payer: Cash Price |
$103.35
|
| Rate for Payer: Cash Price |
$69.03
|
| Rate for Payer: Cash Price |
$1,063.48
|
| Rate for Payer: Cofinity Commercial |
$73.87
|
| Rate for Payer: Cofinity Commercial |
$74.44
|
| Rate for Payer: Cofinity Commercial |
$1,143.24
|
| Rate for Payer: Cofinity Commercial |
$111.10
|
| Rate for Payer: Cofinity Commercial |
$74.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,063.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.03
|
| Rate for Payer: Healthscope Commercial |
$77.90
|
| Rate for Payer: Healthscope Commercial |
$1,196.42
|
| Rate for Payer: Healthscope Commercial |
$77.30
|
| Rate for Payer: Healthscope Commercial |
$77.66
|
| Rate for Payer: Healthscope Commercial |
$116.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$997.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,129.95
|
| Rate for Payer: PHP Commercial |
$73.58
|
| Rate for Payer: PHP Commercial |
$1,129.95
|
| Rate for Payer: PHP Commercial |
$73.01
|
| Rate for Payer: PHP Commercial |
$73.35
|
| Rate for Payer: PHP Commercial |
$109.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$930.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$112.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$74.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,156.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$78.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$810.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$113.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,169.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.58
|
| Rate for Payer: UHC Core |
$107.87
|
| Rate for Payer: UHC Core |
$1,110.01
|
| Rate for Payer: UHC Core |
$71.72
|
| Rate for Payer: UHC Core |
$72.05
|
| Rate for Payer: UHC Core |
$72.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$997.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.92
|
|
|
DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$1,116.73
|
|
|
Service Code
|
CPT 11044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,063.55 |
| Max. Negotiated Rate |
$1,116.73 |
| Rate for Payer: BCBS Complete |
$1,116.73
|
| Rate for Payer: Mclaren Medicaid |
$1,063.55
|
| Rate for Payer: Meridian Medicaid |
$1,116.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,063.55
|
|
|
DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$274.65
|
|
|
Service Code
|
CPT 11042
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$261.57 |
| Max. Negotiated Rate |
$274.65 |
| Rate for Payer: BCBS Complete |
$274.65
|
| Rate for Payer: Mclaren Medicaid |
$261.57
|
| Rate for Payer: Meridian Medicaid |
$274.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$261.57
|
|
|
DERMABOND SKIN ADHESIVE
|
Facility
|
IP
|
$86.16
|
|
|
Service Code
|
NDC 9900-0001-99
|
| Hospital Charge Code |
158456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.55 |
| Max. Negotiated Rate |
$77.54 |
| Rate for Payer: Aetna Commercial |
$73.24
|
| Rate for Payer: BCBS Trust/PPO |
$66.58
|
| Rate for Payer: BCN Commercial |
$66.58
|
| Rate for Payer: Cash Price |
$68.93
|
| Rate for Payer: Cofinity Commercial |
$74.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.93
|
| Rate for Payer: Healthscope Commercial |
$77.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.24
|
| Rate for Payer: PHP Commercial |
$73.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$74.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.82
|
| Rate for Payer: UHC Core |
$71.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.62
|
|
|
DERMAPLANNING
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 00175
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: BCBS Complete |
$16.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.00
|
|
|
DESIPRAMINE 25 MG TABLET
|
Facility
|
IP
|
$500.16
|
|
|
Service Code
|
NDC 45963-342-02
|
| Hospital Charge Code |
2286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$305.05 |
| Max. Negotiated Rate |
$450.14 |
| Rate for Payer: Aetna Commercial |
$425.14
|
| Rate for Payer: BCBS Trust/PPO |
$386.52
|
| Rate for Payer: BCN Commercial |
$386.52
|
| Rate for Payer: Cash Price |
$400.13
|
| Rate for Payer: Cofinity Commercial |
$430.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$400.13
|
| Rate for Payer: Healthscope Commercial |
$450.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$375.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$425.14
|
| Rate for Payer: PHP Commercial |
$425.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$350.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$435.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$305.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$440.14
|
| Rate for Payer: UHC Core |
$417.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$375.12
|
|
|
DESMOPRESSIN 0.2 MG TABLET
|
Facility
|
IP
|
$274.32
|
|
|
Service Code
|
NDC 68084-604-21
|
| Hospital Charge Code |
16053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.31 |
| Max. Negotiated Rate |
$246.89 |
| Rate for Payer: Aetna Commercial |
$233.17
|
| Rate for Payer: BCBS Trust/PPO |
$211.99
|
| Rate for Payer: BCN Commercial |
$211.99
|
| Rate for Payer: Cash Price |
$219.46
|
| Rate for Payer: Cofinity Commercial |
$235.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.46
|
| Rate for Payer: Healthscope Commercial |
$246.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$233.17
|
| Rate for Payer: PHP Commercial |
$233.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$238.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.40
|
| Rate for Payer: UHC Core |
$229.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.74
|
|
|
DESMOPRESSIN 0.2 MG TABLET
|
Facility
|
IP
|
$9.15
|
|
|
Service Code
|
NDC 68084-604-11
|
| Hospital Charge Code |
16053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$8.24 |
| Rate for Payer: Aetna Commercial |
$7.78
|
| Rate for Payer: BCBS Trust/PPO |
$7.07
|
| Rate for Payer: BCN Commercial |
$7.07
|
| Rate for Payer: Cash Price |
$7.32
|
| Rate for Payer: Cofinity Commercial |
$7.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.32
|
| Rate for Payer: Healthscope Commercial |
$8.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.78
|
| Rate for Payer: PHP Commercial |
$7.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.05
|
| Rate for Payer: UHC Core |
$7.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.86
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$59.26
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
9748
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.14 |
| Max. Negotiated Rate |
$53.33 |
| Rate for Payer: Aetna Commercial |
$50.37
|
| Rate for Payer: Aetna Commercial |
$137.20
|
| Rate for Payer: Aetna Commercial |
$587.46
|
| Rate for Payer: Aetna Commercial |
$62.27
|
| Rate for Payer: BCBS Trust/PPO |
$56.62
|
| Rate for Payer: BCBS Trust/PPO |
$124.74
|
| Rate for Payer: BCBS Trust/PPO |
$534.11
|
| Rate for Payer: BCBS Trust/PPO |
$45.80
|
| Rate for Payer: BCN Commercial |
$534.11
|
| Rate for Payer: BCN Commercial |
$124.74
|
| Rate for Payer: BCN Commercial |
$56.62
|
| Rate for Payer: BCN Commercial |
$45.80
|
| Rate for Payer: Cash Price |
$552.90
|
| Rate for Payer: Cash Price |
$58.61
|
| Rate for Payer: Cash Price |
$129.13
|
| Rate for Payer: Cash Price |
$47.41
|
| Rate for Payer: Cofinity Commercial |
$594.37
|
| Rate for Payer: Cofinity Commercial |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$50.96
|
| Rate for Payer: Cofinity Commercial |
$138.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$552.90
|
| Rate for Payer: Healthscope Commercial |
$145.27
|
| Rate for Payer: Healthscope Commercial |
$622.02
|
| Rate for Payer: Healthscope Commercial |
$53.33
|
| Rate for Payer: Healthscope Commercial |
$65.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$518.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$587.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.27
|
| Rate for Payer: PHP Commercial |
$587.46
|
| Rate for Payer: PHP Commercial |
$62.27
|
| Rate for Payer: PHP Commercial |
$137.20
|
| Rate for Payer: PHP Commercial |
$50.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$483.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$63.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$140.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$601.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$421.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$98.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$608.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.47
|
| Rate for Payer: UHC Core |
$49.48
|
| Rate for Payer: UHC Core |
$134.78
|
| Rate for Payer: UHC Core |
$61.17
|
| Rate for Payer: UHC Core |
$577.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$518.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.94
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$1,329.91
|
|
|
Service Code
|
CPT 64624
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,266.58 |
| Max. Negotiated Rate |
$1,329.91 |
| Rate for Payer: BCBS Complete |
$1,329.91
|
| Rate for Payer: Mclaren Medicaid |
$1,266.58
|
| Rate for Payer: Meridian Medicaid |
$1,329.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,266.58
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE
|
Facility
|
OP
|
$627.82
|
|
|
Service Code
|
CPT 64620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$597.92 |
| Max. Negotiated Rate |
$627.82 |
| Rate for Payer: BCBS Complete |
$627.82
|
| Rate for Payer: Mclaren Medicaid |
$597.92
|
| Rate for Payer: Meridian Medicaid |
$627.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$597.92
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
|
Facility
|
OP
|
$627.82
|
|
|
Service Code
|
CPT 64640
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$597.92 |
| Max. Negotiated Rate |
$627.82 |
| Rate for Payer: BCBS Complete |
$627.82
|
| Rate for Payer: Mclaren Medicaid |
$597.92
|
| Rate for Payer: Meridian Medicaid |
$627.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$597.92
|
|
|
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT
|
Facility
|
OP
|
$1,329.91
|
|
|
Service Code
|
CPT 64635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,266.58 |
| Max. Negotiated Rate |
$1,329.91 |
| Rate for Payer: BCBS Complete |
$1,329.91
|
| Rate for Payer: Mclaren Medicaid |
$1,266.58
|
| Rate for Payer: Meridian Medicaid |
$1,329.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,266.58
|
|
|
DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)
|
Facility
|
OP
|
$812.82
|
|
|
Service Code
|
CPT 46930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$774.12 |
| Max. Negotiated Rate |
$812.82 |
| Rate for Payer: BCBS Complete |
$812.82
|
| Rate for Payer: Mclaren Medicaid |
$774.12
|
| Rate for Payer: Meridian Medicaid |
$812.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$774.12
|
|
|
DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION
|
Facility
|
OP
|
$1,933.98
|
|
|
Service Code
|
CPT 46922
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,841.89 |
| Max. Negotiated Rate |
$1,933.98 |
| Rate for Payer: BCBS Complete |
$1,933.98
|
| Rate for Payer: Mclaren Medicaid |
$1,841.89
|
| Rate for Payer: Meridian Medicaid |
$1,933.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,841.89
|
|
