|
MAGNESIUM SULFATE 4.06 MEQ/ML (50 %) INJECTION (TPN COMPONENT)
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
180902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$95.20
|
| Rate for Payer: Aetna Medicare |
$29.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$35.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$35.00
|
| Rate for Payer: BCBS Complete |
$44.80
|
| Rate for Payer: BCBS MAPPO |
$28.00
|
| Rate for Payer: BCBS Trust/PPO |
$92.08
|
| Rate for Payer: BCN Commercial |
$87.08
|
| Rate for Payer: BCN Medicare Advantage |
$28.00
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cofinity Commercial |
$96.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28.00
|
| Rate for Payer: Healthscope Commercial |
$100.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$29.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.20
|
| Rate for Payer: Nomi Health Commercial |
$91.84
|
| Rate for Payer: PACE Senior Care Partners |
$26.60
|
| Rate for Payer: PACE SWMI |
$28.00
|
| Rate for Payer: PHP Commercial |
$95.20
|
| Rate for Payer: PHP Medicare Advantage |
$28.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.80
|
| Rate for Payer: Priority Health HMO/PPO |
$97.44
|
| Rate for Payer: Priority Health Medicare |
$28.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$75.04
|
| Rate for Payer: Railroad Medicare Medicare |
$28.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.56
|
| Rate for Payer: UHC Core |
$93.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$28.00
|
| Rate for Payer: UHC Exchange |
$28.00
|
| Rate for Payer: UHC Medicare Advantage |
$28.00
|
| Rate for Payer: VA VA |
$28.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.00
|
|
|
MAGNESIUM SULFATE 4.06 MEQ/ML (50 %) INJECTION (TPN COMPONENT)
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
180902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$95.20
|
| Rate for Payer: BCBS Trust/PPO |
$91.43
|
| Rate for Payer: BCN Commercial |
$86.55
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cofinity Commercial |
$96.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.60
|
| Rate for Payer: Healthscope Commercial |
$100.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.20
|
| Rate for Payer: Nomi Health Commercial |
$91.84
|
| Rate for Payer: PHP Commercial |
$95.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.80
|
| Rate for Payer: Priority Health HMO/PPO |
$97.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$75.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.56
|
| Rate for Payer: UHC Core |
$93.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.00
|
|
|
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$152.02
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.10 |
| Max. Negotiated Rate |
$136.82 |
| Rate for Payer: Aetna Commercial |
$129.22
|
| Rate for Payer: Aetna Medicare |
$39.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.51
|
| Rate for Payer: BCBS Complete |
$60.81
|
| Rate for Payer: BCBS MAPPO |
$38.00
|
| Rate for Payer: BCBS Trust/PPO |
$124.98
|
| Rate for Payer: BCN Commercial |
$118.20
|
| Rate for Payer: BCN Medicare Advantage |
$38.00
|
| Rate for Payer: Cash Price |
$121.62
|
| Rate for Payer: Cofinity Commercial |
$130.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.00
|
| Rate for Payer: Healthscope Commercial |
$136.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.22
|
| Rate for Payer: Nomi Health Commercial |
$124.66
|
| Rate for Payer: PACE Senior Care Partners |
$36.10
|
| Rate for Payer: PACE SWMI |
$38.00
|
| Rate for Payer: PHP Commercial |
$129.22
|
| Rate for Payer: PHP Medicare Advantage |
$38.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.81
|
| Rate for Payer: Priority Health HMO/PPO |
$132.26
|
| Rate for Payer: Priority Health Medicare |
$38.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$101.85
|
| Rate for Payer: Railroad Medicare Medicare |
$38.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$133.78
|
| Rate for Payer: UHC Core |
$126.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.00
|
| Rate for Payer: UHC Exchange |
$38.00
|
| Rate for Payer: UHC Medicare Advantage |
$38.00
|
| Rate for Payer: VA VA |
$38.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.02
|
|
|
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$152.02
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.81 |
| Max. Negotiated Rate |
$136.82 |
| Rate for Payer: Aetna Commercial |
$129.22
|
| Rate for Payer: BCBS Trust/PPO |
$124.09
|
| Rate for Payer: BCN Commercial |
$117.48
|
| Rate for Payer: Cash Price |
$121.62
|
| Rate for Payer: Cofinity Commercial |
$130.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.62
|
| Rate for Payer: Healthscope Commercial |
$136.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.22
|
| Rate for Payer: Nomi Health Commercial |
$124.66
|
| Rate for Payer: PHP Commercial |
$129.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.81
|
| Rate for Payer: Priority Health HMO/PPO |
$132.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$101.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$133.78
|
| Rate for Payer: UHC Core |
$126.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.02
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION
|
Facility
|
OP
|
$15.37
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Commercial |
$13.86
|
| Rate for Payer: Aetna Medicare |
$4.24
|
| Rate for Payer: Aetna Medicare |
$4.00
|
| Rate for Payer: Aetna Medicare |
$5.57
|
| Rate for Payer: Aetna Medicare |
$5.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.80
|
| Rate for Payer: BCBS Complete |
$6.15
|
| Rate for Payer: BCBS Complete |
$6.52
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: BCBS Complete |
$8.58
|
| Rate for Payer: BCBS MAPPO |
$3.84
|
| Rate for Payer: BCBS MAPPO |
$4.08
|
| Rate for Payer: BCBS MAPPO |
$5.56
|
| Rate for Payer: BCBS MAPPO |
$5.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.64
|
| Rate for Payer: BCBS Trust/PPO |
$18.29
|
| Rate for Payer: BCBS Trust/PPO |
$13.40
|
| Rate for Payer: BCBS Trust/PPO |
$17.63
|
| Rate for Payer: BCN Commercial |
$11.95
|
| Rate for Payer: BCN Commercial |
$16.67
|
| Rate for Payer: BCN Commercial |
$12.67
|
| Rate for Payer: BCN Commercial |
$17.30
|
| Rate for Payer: BCN Medicare Advantage |
$4.08
|
| Rate for Payer: BCN Medicare Advantage |
$5.56
|
| Rate for Payer: BCN Medicare Advantage |
$3.84
|
| Rate for Payer: BCN Medicare Advantage |
$5.36
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$13.04
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$14.02
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.36
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$14.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.22
|
| Rate for Payer: Nomi Health Commercial |
$17.58
|
| Rate for Payer: Nomi Health Commercial |
$18.24
|
| Rate for Payer: Nomi Health Commercial |
$12.60
|
| Rate for Payer: Nomi Health Commercial |
$13.37
|
| Rate for Payer: PACE Senior Care Partners |
$3.65
|
| Rate for Payer: PACE Senior Care Partners |
$5.09
|
| Rate for Payer: PACE Senior Care Partners |
$5.28
|
| Rate for Payer: PACE Senior Care Partners |
$3.87
|
| Rate for Payer: PACE SWMI |
$4.08
|
| Rate for Payer: PACE SWMI |
$3.84
|
| Rate for Payer: PACE SWMI |
$5.36
|
| Rate for Payer: PACE SWMI |
$5.56
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$13.86
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: PHP Medicare Advantage |
$4.08
|
| Rate for Payer: PHP Medicare Advantage |
$3.84
|
| Rate for Payer: PHP Medicare Advantage |
$5.56
|
| Rate for Payer: PHP Medicare Advantage |
$5.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.99
|
| Rate for Payer: Priority Health HMO/PPO |
$14.18
|
| Rate for Payer: Priority Health HMO/PPO |
$19.36
|
| Rate for Payer: Priority Health HMO/PPO |
$18.65
|
| Rate for Payer: Priority Health HMO/PPO |
$13.37
|
| Rate for Payer: Priority Health Medicare |
$5.41
|
| Rate for Payer: Priority Health Medicare |
$3.88
|
| Rate for Payer: Priority Health Medicare |
$4.12
|
| Rate for Payer: Priority Health Medicare |
$5.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.30
|
| Rate for Payer: Railroad Medicare Medicare |
$4.08
|
| Rate for Payer: Railroad Medicare Medicare |
$5.36
|
| Rate for Payer: Railroad Medicare Medicare |
$3.84
|
| Rate for Payer: Railroad Medicare Medicare |
$5.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.34
|
| Rate for Payer: UHC Core |
$12.83
|
| Rate for Payer: UHC Core |
$18.58
|
| Rate for Payer: UHC Core |
$13.61
|
| Rate for Payer: UHC Core |
$17.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.08
|
| Rate for Payer: UHC Exchange |
$5.56
|
| Rate for Payer: UHC Exchange |
$4.08
|
| Rate for Payer: UHC Exchange |
$3.84
|
| Rate for Payer: UHC Exchange |
$5.36
|
| Rate for Payer: UHC Medicare Advantage |
$5.56
|
| Rate for Payer: UHC Medicare Advantage |
$3.84
|
| Rate for Payer: UHC Medicare Advantage |
$5.36
|
| Rate for Payer: UHC Medicare Advantage |
$4.08
|
| Rate for Payer: VA VA |
$4.08
|
| Rate for Payer: VA VA |
$5.56
|
| Rate for Payer: VA VA |
$5.36
|
| Rate for Payer: VA VA |
$3.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.08
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION
|
Facility
|
IP
|
$21.44
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.94 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Commercial |
$13.86
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: BCBS Trust/PPO |
$17.50
|
| Rate for Payer: BCBS Trust/PPO |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$13.31
|
| Rate for Payer: BCBS Trust/PPO |
$12.55
|
| Rate for Payer: BCN Commercial |
$16.57
|
| Rate for Payer: BCN Commercial |
$11.88
|
| Rate for Payer: BCN Commercial |
$17.19
|
| Rate for Payer: BCN Commercial |
$12.60
|
| Rate for Payer: Cash Price |
$13.04
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$14.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$14.67
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Nomi Health Commercial |
$12.60
|
| Rate for Payer: Nomi Health Commercial |
$13.37
|
| Rate for Payer: Nomi Health Commercial |
$18.24
|
| Rate for Payer: Nomi Health Commercial |
$17.58
|
| Rate for Payer: PHP Commercial |
$13.86
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health HMO/PPO |
$18.65
|
| Rate for Payer: Priority Health HMO/PPO |
$19.36
|
| Rate for Payer: Priority Health HMO/PPO |
$13.37
|
| Rate for Payer: Priority Health HMO/PPO |
$14.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.87
|
| Rate for Payer: UHC Core |
$17.90
|
| Rate for Payer: UHC Core |
$18.58
|
| Rate for Payer: UHC Core |
$13.61
|
| Rate for Payer: UHC Core |
$12.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.08
|
|
|
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IVPB (CODE)
|
Facility
|
IP
|
$111.65
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
163707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.57 |
| Max. Negotiated Rate |
$100.48 |
| Rate for Payer: Aetna Commercial |
$94.90
|
| Rate for Payer: BCBS Trust/PPO |
$91.14
|
| Rate for Payer: BCN Commercial |
$86.28
|
| Rate for Payer: Cash Price |
$89.32
|
| Rate for Payer: Cofinity Commercial |
$96.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.32
|
| Rate for Payer: Healthscope Commercial |
$100.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.90
|
| Rate for Payer: Nomi Health Commercial |
$91.55
|
| Rate for Payer: PHP Commercial |
$94.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.57
|
| Rate for Payer: Priority Health HMO/PPO |
$97.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.25
|
| Rate for Payer: UHC Core |
$93.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.74
|
|
|
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IVPB (CODE)
|
Facility
|
OP
|
$111.65
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
163707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.52 |
| Max. Negotiated Rate |
$100.48 |
| Rate for Payer: Aetna Commercial |
$94.90
|
| Rate for Payer: Aetna Medicare |
$29.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.89
|
| Rate for Payer: BCBS Complete |
$44.66
|
| Rate for Payer: BCBS MAPPO |
$27.91
|
| Rate for Payer: BCBS Trust/PPO |
$91.79
|
| Rate for Payer: BCN Commercial |
$86.81
|
| Rate for Payer: BCN Medicare Advantage |
$27.91
|
| Rate for Payer: Cash Price |
$89.32
|
| Rate for Payer: Cofinity Commercial |
$96.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.91
|
| Rate for Payer: Healthscope Commercial |
$100.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$29.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.90
|
| Rate for Payer: Nomi Health Commercial |
$91.55
|
| Rate for Payer: PACE Senior Care Partners |
$26.52
|
| Rate for Payer: PACE SWMI |
$27.91
|
| Rate for Payer: PHP Commercial |
$94.90
|
| Rate for Payer: PHP Medicare Advantage |
$27.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.57
|
| Rate for Payer: Priority Health HMO/PPO |
$97.14
|
| Rate for Payer: Priority Health Medicare |
$28.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.81
|
| Rate for Payer: Railroad Medicare Medicare |
$27.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.25
|
| Rate for Payer: UHC Core |
$93.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$27.91
|
| Rate for Payer: UHC Exchange |
$27.91
|
| Rate for Payer: UHC Medicare Advantage |
$27.91
|
| Rate for Payer: VA VA |
$27.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.74
|
|
|
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST; BILATERAL
|
Facility
|
OP
|
$265.65
|
|
|
Service Code
|
CPT C8908
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$252.98 |
| Max. Negotiated Rate |
$265.65 |
| Rate for Payer: BCBS Complete |
$265.65
|
| Rate for Payer: Mclaren Medicaid |
$252.98
|
| Rate for Payer: Meridian Medicaid |
$265.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$252.98
|
| Rate for Payer: UHCCP Medicaid |
$252.98
|
|
|
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)
|
Facility
|
OP
|
$1,190.46
|
|
|
Service Code
|
CPT 27570
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,133.70 |
| Max. Negotiated Rate |
$1,190.46 |
| Rate for Payer: BCBS Complete |
$1,190.46
|
| Rate for Payer: Mclaren Medicaid |
$1,133.70
|
| Rate for Payer: Meridian Medicaid |
$1,190.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,133.70
|
| Rate for Payer: UHCCP Medicaid |
$1,133.70
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$94.92
|
|
|
Service Code
|
NDC 00338035702
|
| Hospital Charge Code |
4749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.70 |
| Max. Negotiated Rate |
$85.43 |
| Rate for Payer: Aetna Commercial |
$80.68
|
| Rate for Payer: BCBS Trust/PPO |
$77.48
|
| Rate for Payer: BCN Commercial |
$73.35
|
| Rate for Payer: Cash Price |
$75.94
|
| Rate for Payer: Cofinity Commercial |
$81.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.94
|
| Rate for Payer: Healthscope Commercial |
$85.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.68
|
| Rate for Payer: Nomi Health Commercial |
$77.83
|
| Rate for Payer: PHP Commercial |
$80.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.70
|
| Rate for Payer: Priority Health HMO/PPO |
$82.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$83.53
|
| Rate for Payer: UHC Core |
$79.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.19
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$94.92
|
|
|
Service Code
|
NDC 00338035702
|
| Hospital Charge Code |
4749
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$85.43 |
| Rate for Payer: Aetna Commercial |
$80.68
|
| Rate for Payer: Aetna Medicare |
$24.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.66
|
| Rate for Payer: BCBS Complete |
$37.97
|
| Rate for Payer: BCBS MAPPO |
$23.73
|
| Rate for Payer: BCBS Trust/PPO |
$78.03
|
| Rate for Payer: BCN Commercial |
$73.80
|
| Rate for Payer: BCN Medicare Advantage |
$23.73
|
| Rate for Payer: Cash Price |
$75.94
|
| Rate for Payer: Cofinity Commercial |
$81.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.73
|
| Rate for Payer: Healthscope Commercial |
$85.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.68
|
| Rate for Payer: Nomi Health Commercial |
$77.83
|
| Rate for Payer: PACE Senior Care Partners |
$22.54
|
| Rate for Payer: PACE SWMI |
$23.73
|
| Rate for Payer: PHP Commercial |
$80.68
|
| Rate for Payer: PHP Medicare Advantage |
$23.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.70
|
| Rate for Payer: Priority Health HMO/PPO |
$82.58
|
| Rate for Payer: Priority Health Medicare |
$23.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.60
|
| Rate for Payer: Railroad Medicare Medicare |
$23.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$83.53
|
| Rate for Payer: UHC Core |
$79.26
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.73
|
| Rate for Payer: UHC Exchange |
$23.73
|
| Rate for Payer: UHC Medicare Advantage |
$23.73
|
| Rate for Payer: VA VA |
$23.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.19
|
|
|
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST
|
Facility
|
OP
|
$2,365.09
|
|
|
Service Code
|
CPT 56440
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,252.32 |
| Max. Negotiated Rate |
$2,365.09 |
| Rate for Payer: BCBS Complete |
$2,365.09
|
| Rate for Payer: Mclaren Medicaid |
$2,252.32
|
| Rate for Payer: Meridian Medicaid |
$2,365.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,252.32
|
| Rate for Payer: UHCCP Medicaid |
$2,252.32
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
IP
|
$467.40
|
|
|
Service Code
|
NDC 51079042320
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$303.81 |
| Max. Negotiated Rate |
$420.66 |
| Rate for Payer: Aetna Commercial |
$397.29
|
| Rate for Payer: BCBS Trust/PPO |
$381.54
|
| Rate for Payer: BCN Commercial |
$361.21
|
| Rate for Payer: Cash Price |
$373.92
|
| Rate for Payer: Cofinity Commercial |
$401.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.92
|
| Rate for Payer: Healthscope Commercial |
$420.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$350.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$397.29
|
| Rate for Payer: Nomi Health Commercial |
$383.27
|
| Rate for Payer: PHP Commercial |
$397.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.81
|
| Rate for Payer: Priority Health HMO/PPO |
$406.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$313.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$411.31
|
| Rate for Payer: UHC Core |
$390.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$350.55
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
OP
|
$467.40
|
|
|
Service Code
|
NDC 51079042320
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.01 |
| Max. Negotiated Rate |
$420.66 |
| Rate for Payer: Aetna Commercial |
$397.29
|
| Rate for Payer: Aetna Medicare |
$121.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$146.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$146.06
|
| Rate for Payer: BCBS Complete |
$186.96
|
| Rate for Payer: BCBS MAPPO |
$116.85
|
| Rate for Payer: BCBS Trust/PPO |
$384.25
|
| Rate for Payer: BCN Commercial |
$363.40
|
| Rate for Payer: BCN Medicare Advantage |
$116.85
|
| Rate for Payer: Cash Price |
$373.92
|
| Rate for Payer: Cofinity Commercial |
$401.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$116.85
|
| Rate for Payer: Healthscope Commercial |
$420.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$350.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$122.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$397.29
|
| Rate for Payer: Nomi Health Commercial |
$383.27
|
| Rate for Payer: PACE Senior Care Partners |
$111.01
|
| Rate for Payer: PACE SWMI |
$116.85
|
| Rate for Payer: PHP Commercial |
$397.29
|
| Rate for Payer: PHP Medicare Advantage |
$116.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.81
|
| Rate for Payer: Priority Health HMO/PPO |
$406.64
|
| Rate for Payer: Priority Health Medicare |
$118.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$313.16
|
| Rate for Payer: Railroad Medicare Medicare |
$116.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$411.31
|
| Rate for Payer: UHC Core |
$390.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$116.85
|
| Rate for Payer: UHC Exchange |
$116.85
|
| Rate for Payer: UHC Medicare Advantage |
$116.85
|
| Rate for Payer: VA VA |
$116.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$350.55
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
OP
|
$163.40
|
|
|
Service Code
|
NDC 50268052215
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.81 |
| Max. Negotiated Rate |
$147.06 |
| Rate for Payer: Aetna Commercial |
$138.89
|
| Rate for Payer: Aetna Medicare |
$42.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$51.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$51.06
|
| Rate for Payer: BCBS Complete |
$65.36
|
| Rate for Payer: BCBS MAPPO |
$40.85
|
| Rate for Payer: BCBS Trust/PPO |
$134.33
|
| Rate for Payer: BCN Commercial |
$127.04
|
| Rate for Payer: BCN Medicare Advantage |
$40.85
|
| 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: Health Alliance Plan Medicare Advantage |
$40.85
|
| Rate for Payer: Healthscope Commercial |
$147.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$42.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$46.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.89
|
| Rate for Payer: Nomi Health Commercial |
$133.99
|
| Rate for Payer: PACE Senior Care Partners |
$38.81
|
| Rate for Payer: PACE SWMI |
$40.85
|
| Rate for Payer: PHP Commercial |
$138.89
|
| Rate for Payer: PHP Medicare Advantage |
$40.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.21
|
| Rate for Payer: Priority Health HMO/PPO |
$142.16
|
| Rate for Payer: Priority Health Medicare |
$41.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$109.48
|
| Rate for Payer: Railroad Medicare Medicare |
$40.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$143.79
|
| Rate for Payer: UHC Core |
$136.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$40.85
|
| Rate for Payer: UHC Exchange |
$40.85
|
| Rate for Payer: UHC Medicare Advantage |
$40.85
|
| Rate for Payer: VA VA |
$40.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.55
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
NDC 50268052211
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna Commercial |
$2.78
|
| Rate for Payer: BCBS Trust/PPO |
$2.67
|
| Rate for Payer: BCN Commercial |
$2.53
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$2.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.78
|
| Rate for Payer: Nomi Health Commercial |
$2.68
|
| Rate for Payer: PHP Commercial |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.13
|
| Rate for Payer: Priority Health HMO/PPO |
$2.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.88
|
| Rate for Payer: UHC Core |
$2.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.45
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 51079042301
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: BCBS Trust/PPO |
$3.82
|
| Rate for Payer: BCN Commercial |
$3.62
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.74
|
| Rate for Payer: Healthscope Commercial |
$4.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.98
|
| Rate for Payer: Nomi Health Commercial |
$3.84
|
| Rate for Payer: PHP Commercial |
$3.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.04
|
| Rate for Payer: Priority Health HMO/PPO |
$4.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.12
|
| Rate for Payer: UHC Core |
$3.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.51
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 51079042301
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: Aetna Medicare |
$1.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.46
|
| Rate for Payer: BCBS Complete |
$1.87
|
| Rate for Payer: BCBS MAPPO |
$1.17
|
| Rate for Payer: BCBS Trust/PPO |
$3.85
|
| Rate for Payer: BCN Commercial |
$3.64
|
| Rate for Payer: BCN Medicare Advantage |
$1.17
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.17
|
| Rate for Payer: Healthscope Commercial |
$4.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.98
|
| Rate for Payer: Nomi Health Commercial |
$3.84
|
| Rate for Payer: PACE Senior Care Partners |
$1.11
|
| Rate for Payer: PACE SWMI |
$1.17
|
| Rate for Payer: PHP Commercial |
$3.98
|
| Rate for Payer: PHP Medicare Advantage |
$1.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.04
|
| Rate for Payer: Priority Health HMO/PPO |
$4.07
|
| Rate for Payer: Priority Health Medicare |
$1.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.14
|
| Rate for Payer: Railroad Medicare Medicare |
$1.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.12
|
| Rate for Payer: UHC Core |
$3.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.17
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UHC Medicare Advantage |
$1.17
|
| Rate for Payer: VA VA |
$1.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.51
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 50268052211
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna Commercial |
$2.78
|
| Rate for Payer: Aetna Medicare |
$0.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.02
|
| Rate for Payer: BCBS Complete |
$1.31
|
| Rate for Payer: BCBS MAPPO |
$0.82
|
| Rate for Payer: BCBS Trust/PPO |
$2.69
|
| Rate for Payer: BCN Commercial |
$2.54
|
| Rate for Payer: BCN Medicare Advantage |
$0.82
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.82
|
| Rate for Payer: Healthscope Commercial |
$2.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.78
|
| Rate for Payer: Nomi Health Commercial |
$2.68
|
| Rate for Payer: PACE Senior Care Partners |
$0.78
|
| Rate for Payer: PACE SWMI |
$0.82
|
| Rate for Payer: PHP Commercial |
$2.78
|
| Rate for Payer: PHP Medicare Advantage |
$0.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.13
|
| Rate for Payer: Priority Health HMO/PPO |
$2.84
|
| Rate for Payer: Priority Health Medicare |
$0.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.19
|
| Rate for Payer: Railroad Medicare Medicare |
$0.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.88
|
| Rate for Payer: UHC Core |
$2.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.82
|
| Rate for Payer: UHC Exchange |
$0.82
|
| Rate for Payer: UHC Medicare Advantage |
$0.82
|
| Rate for Payer: VA VA |
$0.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.45
|
|
|
MECLIZINE 12.5 MG TABLET
|
Facility
|
IP
|
$163.40
|
|
|
Service Code
|
NDC 50268052215
|
| Hospital Charge Code |
12024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.21 |
| Max. Negotiated Rate |
$147.06 |
| Rate for Payer: Aetna Commercial |
$138.89
|
| Rate for Payer: BCBS Trust/PPO |
$133.38
|
| 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 Commercial |
$138.89
|
| Rate for Payer: Nomi Health Commercial |
$133.99
|
| Rate for Payer: PHP Commercial |
$138.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.21
|
| Rate for Payer: Priority Health HMO/PPO |
$142.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$109.48
|
| 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
|
|
|
MECLIZINE 25 MG TABLET
|
Facility
|
IP
|
$391.40
|
|
|
Service Code
|
NDC 00904737661
|
| Hospital Charge Code |
12025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.41 |
| Max. Negotiated Rate |
$352.26 |
| Rate for Payer: Aetna Commercial |
$332.69
|
| Rate for Payer: BCBS Trust/PPO |
$319.50
|
| Rate for Payer: BCN Commercial |
$302.47
|
| Rate for Payer: Cash Price |
$313.12
|
| Rate for Payer: Cofinity Commercial |
$336.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.12
|
| Rate for Payer: Healthscope Commercial |
$352.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$293.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$332.69
|
| Rate for Payer: Nomi Health Commercial |
$320.95
|
| Rate for Payer: PHP Commercial |
$332.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$254.41
|
| Rate for Payer: Priority Health HMO/PPO |
$340.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$262.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$344.43
|
| Rate for Payer: UHC Core |
$326.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$293.55
|
|
|
MECLIZINE 25 MG TABLET
|
Facility
|
OP
|
$391.40
|
|
|
Service Code
|
NDC 00904737661
|
| Hospital Charge Code |
12025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.96 |
| Max. Negotiated Rate |
$352.26 |
| Rate for Payer: Aetna Commercial |
$332.69
|
| Rate for Payer: Aetna Medicare |
$101.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$122.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$122.31
|
| Rate for Payer: BCBS Complete |
$156.56
|
| Rate for Payer: BCBS MAPPO |
$97.85
|
| Rate for Payer: BCBS Trust/PPO |
$321.77
|
| Rate for Payer: BCN Commercial |
$304.31
|
| Rate for Payer: BCN Medicare Advantage |
$97.85
|
| Rate for Payer: Cash Price |
$313.12
|
| Rate for Payer: Cofinity Commercial |
$336.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$97.85
|
| Rate for Payer: Healthscope Commercial |
$352.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$293.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$102.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$112.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$332.69
|
| Rate for Payer: Nomi Health Commercial |
$320.95
|
| Rate for Payer: PACE Senior Care Partners |
$92.96
|
| Rate for Payer: PACE SWMI |
$97.85
|
| Rate for Payer: PHP Commercial |
$332.69
|
| Rate for Payer: PHP Medicare Advantage |
$97.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$254.41
|
| Rate for Payer: Priority Health HMO/PPO |
$340.52
|
| Rate for Payer: Priority Health Medicare |
$98.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$262.24
|
| Rate for Payer: Railroad Medicare Medicare |
$97.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$344.43
|
| Rate for Payer: UHC Core |
$326.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$97.85
|
| Rate for Payer: UHC Exchange |
$97.85
|
| Rate for Payer: UHC Medicare Advantage |
$97.85
|
| Rate for Payer: VA VA |
$97.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$293.55
|
|
|
MECLIZINE 25 MG TABLET
|
Facility
|
IP
|
$127.92
|
|
|
Service Code
|
NDC 60687073065
|
| Hospital Charge Code |
12025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$115.13 |
| Rate for Payer: Aetna Commercial |
$108.73
|
| Rate for Payer: BCBS Trust/PPO |
$104.42
|
| Rate for Payer: BCN Commercial |
$98.86
|
| Rate for Payer: Cash Price |
$102.34
|
| Rate for Payer: Cofinity Commercial |
$110.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.34
|
| Rate for Payer: Healthscope Commercial |
$115.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.73
|
| Rate for Payer: Nomi Health Commercial |
$104.89
|
| Rate for Payer: PHP Commercial |
$108.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.15
|
| Rate for Payer: Priority Health HMO/PPO |
$111.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$85.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$112.57
|
| Rate for Payer: UHC Core |
$106.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.94
|
|
|
MECLIZINE 25 MG TABLET
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 60687073011
|
| Hospital Charge Code |
12025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: BCBS Trust/PPO |
$3.52
|
| Rate for Payer: BCN Commercial |
$3.33
|
| Rate for Payer: Cash Price |
$3.45
|
| Rate for Payer: Cofinity Commercial |
$3.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.45
|
| Rate for Payer: Healthscope Commercial |
$3.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.66
|
| Rate for Payer: Nomi Health Commercial |
$3.53
|
| Rate for Payer: PHP Commercial |
$3.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.80
|
| Rate for Payer: Priority Health HMO/PPO |
$3.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.79
|
| Rate for Payer: UHC Core |
$3.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.23
|
|
