|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$637.00
|
|
|
Service Code
|
NDC 68084035511
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.30 |
| Max. Negotiated Rate |
$573.30 |
| Rate for Payer: Aetna Commercial |
$541.45
|
| Rate for Payer: Aetna Medicare |
$165.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$199.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$199.06
|
| Rate for Payer: BCBS Complete |
$117.91
|
| Rate for Payer: BCBS MAPPO |
$159.25
|
| Rate for Payer: BCBS Trust/PPO |
$523.68
|
| Rate for Payer: BCN Commercial |
$523.68
|
| Rate for Payer: BCN Medicare Advantage |
$159.25
|
| Rate for Payer: Cash Price |
$509.60
|
| Rate for Payer: Cofinity Commercial |
$547.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$509.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$159.25
|
| Rate for Payer: Healthscope Commercial |
$573.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$477.75
|
| Rate for Payer: Mclaren Medicaid |
$112.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$167.21
|
| Rate for Payer: Meridian Medicaid |
$117.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$183.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$175.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$541.45
|
| Rate for Payer: Nomi Health Commercial |
$522.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$477.75
|
| Rate for Payer: PACE Senior Care Partners |
$151.29
|
| Rate for Payer: PACE SWMI |
$159.25
|
| Rate for Payer: PHP Commercial |
$541.45
|
| Rate for Payer: PHP Medicare Advantage |
$159.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$112.30
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$554.19
|
| Rate for Payer: Priority Health Medicare |
$160.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$443.35
|
| Rate for Payer: Railroad Medicare Medicare |
$159.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$560.56
|
| Rate for Payer: UHC Core |
$531.89
|
| Rate for Payer: UHC Exchange |
$159.25
|
| Rate for Payer: UHC Medicaid |
$112.30
|
| Rate for Payer: UHC Medicare Advantage |
$159.25
|
| Rate for Payer: UHCCP Medicaid |
$112.30
|
| Rate for Payer: VA VA |
$159.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$477.75
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 00406051262
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.25 |
| Max. Negotiated Rate |
$74.03 |
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: BCBS Trust/PPO |
$67.93
|
| Rate for Payer: BCN Commercial |
$67.93
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$70.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.69
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$71.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$57.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$72.38
|
| Rate for Payer: UHC Core |
$68.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.69
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
IP
|
$8.23
|
|
|
Service Code
|
NDC 00406051223
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Aetna Commercial |
$7.00
|
| Rate for Payer: BCBS Trust/PPO |
$6.80
|
| Rate for Payer: BCN Commercial |
$6.80
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cofinity Commercial |
$7.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.58
|
| Rate for Payer: Healthscope Commercial |
$7.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.00
|
| Rate for Payer: Nomi Health Commercial |
$6.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.17
|
| Rate for Payer: PHP Commercial |
$7.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$7.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.24
|
| Rate for Payer: UHC Core |
$6.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.17
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
NDC 47781019601
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.42 |
| Max. Negotiated Rate |
$176.40 |
| Rate for Payer: Aetna Commercial |
$166.60
|
| Rate for Payer: BCBS Trust/PPO |
$161.88
|
| Rate for Payer: BCN Commercial |
$161.88
|
| Rate for Payer: Cash Price |
$156.80
|
| Rate for Payer: Cofinity Commercial |
$168.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.80
|
| Rate for Payer: Healthscope Commercial |
$176.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.60
|
| Rate for Payer: Nomi Health Commercial |
$160.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$147.00
|
| Rate for Payer: PHP Commercial |
$166.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$170.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.48
|
| Rate for Payer: UHC Core |
$163.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.00
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$8.23
|
|
|
Service Code
|
NDC 00406051223
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Aetna Commercial |
$7.00
|
| Rate for Payer: Aetna Medicare |
$2.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.57
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.57
|
| Rate for Payer: BCBS Complete |
$1.52
|
| Rate for Payer: BCBS MAPPO |
$2.06
|
| Rate for Payer: BCBS Trust/PPO |
$6.77
|
| Rate for Payer: BCN Commercial |
$6.77
|
| Rate for Payer: BCN Medicare Advantage |
$2.06
|
| Rate for Payer: Cash Price |
$6.58
|
| Rate for Payer: Cofinity Commercial |
$7.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$7.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.17
|
| Rate for Payer: Mclaren Medicaid |
$1.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.16
|
| Rate for Payer: Meridian Medicaid |
$1.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$2.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.00
|
| Rate for Payer: Nomi Health Commercial |
$6.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.17
|
| Rate for Payer: PACE Senior Care Partners |
$1.95
|
| Rate for Payer: PACE SWMI |
$2.06
|
| Rate for Payer: PHP Commercial |
$7.00
|
| Rate for Payer: PHP Medicare Advantage |
$2.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$7.16
|
| Rate for Payer: Priority Health Medicare |
$2.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.73
|
| Rate for Payer: Railroad Medicare Medicare |
$2.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.24
|
| Rate for Payer: UHC Core |
$6.87
|
| Rate for Payer: UHC Exchange |
$2.06
|
| Rate for Payer: UHC Medicaid |
$1.45
|
| Rate for Payer: UHC Medicare Advantage |
$2.06
|
| Rate for Payer: UHCCP Medicaid |
$1.45
|
| Rate for Payer: VA VA |
$2.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.17
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
NDC 47781019601
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.55 |
| Max. Negotiated Rate |
$176.40 |
| Rate for Payer: Aetna Commercial |
$166.60
|
| Rate for Payer: Aetna Medicare |
$50.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.25
|
| Rate for Payer: BCBS Complete |
$36.28
|
| Rate for Payer: BCBS MAPPO |
$49.00
|
| Rate for Payer: BCBS Trust/PPO |
$161.13
|
| Rate for Payer: BCN Commercial |
$161.13
|
| Rate for Payer: BCN Medicare Advantage |
$49.00
|
| Rate for Payer: Cash Price |
$156.80
|
| Rate for Payer: Cofinity Commercial |
$168.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.00
|
| Rate for Payer: Healthscope Commercial |
$176.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.00
|
| Rate for Payer: Mclaren Medicaid |
$34.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.45
|
| Rate for Payer: Meridian Medicaid |
$36.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.35
|
| Rate for Payer: Molina Medicare/Medicaid |
$53.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.60
|
| Rate for Payer: Nomi Health Commercial |
$160.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$147.00
|
| Rate for Payer: PACE Senior Care Partners |
$46.55
|
| Rate for Payer: PACE SWMI |
$49.00
|
| Rate for Payer: PHP Commercial |
$166.60
|
| Rate for Payer: PHP Medicare Advantage |
$49.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$34.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$170.52
|
| Rate for Payer: Priority Health Medicare |
$49.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.42
|
| Rate for Payer: Railroad Medicare Medicare |
$49.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.48
|
| Rate for Payer: UHC Core |
$163.66
|
| Rate for Payer: UHC Exchange |
$49.00
|
| Rate for Payer: UHC Medicaid |
$34.55
|
| Rate for Payer: UHC Medicare Advantage |
$49.00
|
| Rate for Payer: UHCCP Medicaid |
$34.55
|
| Rate for Payer: VA VA |
$49.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.00
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET
|
Facility
|
OP
|
$13.06
|
|
|
Service Code
|
NDC 00406052223
|
| Hospital Charge Code |
31863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$11.75 |
| Rate for Payer: Aetna Commercial |
$11.10
|
| Rate for Payer: Aetna Medicare |
$3.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.08
|
| Rate for Payer: BCBS Complete |
$2.42
|
| Rate for Payer: BCBS MAPPO |
$3.27
|
| Rate for Payer: BCBS Trust/PPO |
$10.74
|
| Rate for Payer: BCN Commercial |
$10.74
|
| Rate for Payer: BCN Medicare Advantage |
$3.27
|
| Rate for Payer: Cash Price |
$10.45
|
| Rate for Payer: Cofinity Commercial |
$11.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.27
|
| Rate for Payer: Healthscope Commercial |
$11.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.79
|
| Rate for Payer: Mclaren Medicaid |
$2.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.43
|
| Rate for Payer: Meridian Medicaid |
$2.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.75
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.10
|
| Rate for Payer: Nomi Health Commercial |
$10.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.79
|
| Rate for Payer: PACE Senior Care Partners |
$3.10
|
| Rate for Payer: PACE SWMI |
$3.27
|
| Rate for Payer: PHP Commercial |
$11.10
|
| Rate for Payer: PHP Medicare Advantage |
$3.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$11.36
|
| Rate for Payer: Priority Health Medicare |
$3.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.09
|
| Rate for Payer: Railroad Medicare Medicare |
$3.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.49
|
| Rate for Payer: UHC Core |
$10.91
|
| Rate for Payer: UHC Exchange |
$3.27
|
| Rate for Payer: UHC Medicaid |
$2.30
|
| Rate for Payer: UHC Medicare Advantage |
$3.27
|
| Rate for Payer: UHCCP Medicaid |
$2.30
|
| Rate for Payer: VA VA |
$3.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.79
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET
|
Facility
|
OP
|
$1,305.50
|
|
|
Service Code
|
NDC 00406052262
|
| Hospital Charge Code |
31863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.16 |
| Max. Negotiated Rate |
$1,174.95 |
| Rate for Payer: Aetna Commercial |
$1,109.67
|
| Rate for Payer: Aetna Medicare |
$339.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$407.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$407.97
|
| Rate for Payer: BCBS Complete |
$241.65
|
| Rate for Payer: BCBS MAPPO |
$326.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,073.25
|
| Rate for Payer: BCN Commercial |
$1,073.25
|
| Rate for Payer: BCN Medicare Advantage |
$326.38
|
| Rate for Payer: Cash Price |
$1,044.40
|
| Rate for Payer: Cofinity Commercial |
$1,122.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,044.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$326.38
|
| Rate for Payer: Healthscope Commercial |
$1,174.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$979.12
|
| Rate for Payer: Mclaren Medicaid |
$230.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$342.69
|
| Rate for Payer: Meridian Medicaid |
$241.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$375.33
|
| Rate for Payer: Molina Medicare/Medicaid |
$359.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,109.67
|
| Rate for Payer: Nomi Health Commercial |
$1,070.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$979.12
|
| Rate for Payer: PACE Senior Care Partners |
$310.06
|
| Rate for Payer: PACE SWMI |
$326.38
|
| Rate for Payer: PHP Commercial |
$1,109.67
|
| Rate for Payer: PHP Medicare Advantage |
$326.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$230.16
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,135.79
|
| Rate for Payer: Priority Health Medicare |
$329.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$908.63
|
| Rate for Payer: Railroad Medicare Medicare |
$326.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,148.84
|
| Rate for Payer: UHC Core |
$1,090.09
|
| Rate for Payer: UHC Exchange |
$326.38
|
| Rate for Payer: UHC Medicaid |
$230.16
|
| Rate for Payer: UHC Medicare Advantage |
$326.38
|
| Rate for Payer: UHCCP Medicaid |
$230.16
|
| Rate for Payer: VA VA |
$326.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$979.12
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET
|
Facility
|
IP
|
$13.06
|
|
|
Service Code
|
NDC 00406052223
|
| Hospital Charge Code |
31863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$11.75 |
| Rate for Payer: Aetna Commercial |
$11.10
|
| Rate for Payer: BCBS Trust/PPO |
$10.79
|
| Rate for Payer: BCN Commercial |
$10.79
|
| Rate for Payer: Cash Price |
$10.45
|
| Rate for Payer: Cofinity Commercial |
$11.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.45
|
| Rate for Payer: Healthscope Commercial |
$11.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.10
|
| Rate for Payer: Nomi Health Commercial |
$10.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.79
|
| Rate for Payer: PHP Commercial |
$11.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$11.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.49
|
| Rate for Payer: UHC Core |
$10.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.79
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET
|
Facility
|
IP
|
$1,305.50
|
|
|
Service Code
|
NDC 00406052262
|
| Hospital Charge Code |
31863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$908.63 |
| Max. Negotiated Rate |
$1,174.95 |
| Rate for Payer: Aetna Commercial |
$1,109.67
|
| Rate for Payer: BCBS Trust/PPO |
$1,078.21
|
| Rate for Payer: BCN Commercial |
$1,078.21
|
| Rate for Payer: Cash Price |
$1,044.40
|
| Rate for Payer: Cofinity Commercial |
$1,122.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,044.40
|
| Rate for Payer: Healthscope Commercial |
$1,174.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$979.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,109.67
|
| Rate for Payer: Nomi Health Commercial |
$1,070.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$979.12
|
| Rate for Payer: PHP Commercial |
$1,109.67
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,135.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$908.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,148.84
|
| Rate for Payer: UHC Core |
$1,090.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$979.12
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$346.01
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
173651
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.82 |
| Max. Negotiated Rate |
$311.41 |
| Rate for Payer: Aetna Commercial |
$294.11
|
| Rate for Payer: BCBS Trust/PPO |
$285.77
|
| Rate for Payer: BCN Commercial |
$285.77
|
| Rate for Payer: Cash Price |
$276.81
|
| Rate for Payer: Cofinity Commercial |
$297.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.81
|
| Rate for Payer: Healthscope Commercial |
$311.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.11
|
| Rate for Payer: Nomi Health Commercial |
$283.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$259.51
|
| Rate for Payer: PHP Commercial |
$294.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$301.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$240.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$304.49
|
| Rate for Payer: UHC Core |
$288.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.51
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR
|
Facility
|
OP
|
$346.01
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
173651
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.00 |
| Max. Negotiated Rate |
$311.41 |
| Rate for Payer: Aetna Commercial |
$294.11
|
| Rate for Payer: Aetna Medicare |
$89.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$108.13
|
| Rate for Payer: Amish Plain Church Group Commercial |
$108.13
|
| Rate for Payer: BCBS Complete |
$64.05
|
| Rate for Payer: BCBS MAPPO |
$86.50
|
| Rate for Payer: BCBS Trust/PPO |
$284.45
|
| Rate for Payer: BCN Commercial |
$284.45
|
| Rate for Payer: BCN Medicare Advantage |
$86.50
|
| Rate for Payer: Cash Price |
$276.81
|
| Rate for Payer: Cofinity Commercial |
$297.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$86.50
|
| Rate for Payer: Healthscope Commercial |
$311.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.51
|
| Rate for Payer: Mclaren Medicaid |
$61.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$90.83
|
| Rate for Payer: Meridian Medicaid |
$64.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.48
|
| Rate for Payer: Molina Medicare/Medicaid |
$95.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.11
|
| Rate for Payer: Nomi Health Commercial |
$283.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$259.51
|
| Rate for Payer: PACE Senior Care Partners |
$82.18
|
| Rate for Payer: PACE SWMI |
$86.50
|
| Rate for Payer: PHP Commercial |
$294.11
|
| Rate for Payer: PHP Medicare Advantage |
$86.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$61.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$301.03
|
| Rate for Payer: Priority Health Medicare |
$87.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$240.82
|
| Rate for Payer: Railroad Medicare Medicare |
$86.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$304.49
|
| Rate for Payer: UHC Core |
$288.92
|
| Rate for Payer: UHC Exchange |
$86.50
|
| Rate for Payer: UHC Medicaid |
$61.00
|
| Rate for Payer: UHC Medicare Advantage |
$86.50
|
| Rate for Payer: UHCCP Medicaid |
$61.00
|
| Rate for Payer: VA VA |
$86.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.51
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR
|
Facility
|
OP
|
$545.43
|
|
|
Service Code
|
NDC 59011042020
|
| Hospital Charge Code |
173653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.16 |
| Max. Negotiated Rate |
$490.89 |
| Rate for Payer: Aetna Commercial |
$463.62
|
| Rate for Payer: Aetna Medicare |
$141.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$170.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$170.45
|
| Rate for Payer: BCBS Complete |
$100.96
|
| Rate for Payer: BCBS MAPPO |
$136.36
|
| Rate for Payer: BCBS Trust/PPO |
$448.40
|
| Rate for Payer: BCN Commercial |
$448.40
|
| Rate for Payer: BCN Medicare Advantage |
$136.36
|
| Rate for Payer: Cash Price |
$436.34
|
| Rate for Payer: Cofinity Commercial |
$469.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$436.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$136.36
|
| Rate for Payer: Healthscope Commercial |
$490.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$409.07
|
| Rate for Payer: Mclaren Medicaid |
$96.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$143.18
|
| Rate for Payer: Meridian Medicaid |
$100.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$149.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$463.62
|
| Rate for Payer: Nomi Health Commercial |
$447.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$409.07
|
| Rate for Payer: PACE Senior Care Partners |
$129.54
|
| Rate for Payer: PACE SWMI |
$136.36
|
| Rate for Payer: PHP Commercial |
$463.62
|
| Rate for Payer: PHP Medicare Advantage |
$136.36
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.16
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$474.52
|
| Rate for Payer: Priority Health Medicare |
$137.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$379.62
|
| Rate for Payer: Railroad Medicare Medicare |
$136.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$479.98
|
| Rate for Payer: UHC Core |
$455.43
|
| Rate for Payer: UHC Exchange |
$136.36
|
| Rate for Payer: UHC Medicaid |
$96.16
|
| Rate for Payer: UHC Medicare Advantage |
$136.36
|
| Rate for Payer: UHCCP Medicaid |
$96.16
|
| Rate for Payer: VA VA |
$136.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$409.07
|
|
|
OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$545.43
|
|
|
Service Code
|
NDC 59011042020
|
| Hospital Charge Code |
173653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$379.62 |
| Max. Negotiated Rate |
$490.89 |
| Rate for Payer: Aetna Commercial |
$463.62
|
| Rate for Payer: BCBS Trust/PPO |
$450.47
|
| Rate for Payer: BCN Commercial |
$450.47
|
| Rate for Payer: Cash Price |
$436.34
|
| Rate for Payer: Cofinity Commercial |
$469.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$436.34
|
| Rate for Payer: Healthscope Commercial |
$490.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$409.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$463.62
|
| Rate for Payer: Nomi Health Commercial |
$447.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$409.07
|
| Rate for Payer: PHP Commercial |
$463.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$474.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$379.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$479.98
|
| Rate for Payer: UHC Core |
$455.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$409.07
|
|
|
OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR
|
Facility
|
OP
|
$933.77
|
|
|
Service Code
|
NDC 59011044020
|
| Hospital Charge Code |
173655
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.62 |
| Max. Negotiated Rate |
$840.39 |
| Rate for Payer: Aetna Commercial |
$793.70
|
| Rate for Payer: Aetna Medicare |
$242.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$291.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$291.80
|
| Rate for Payer: BCBS Complete |
$172.84
|
| Rate for Payer: BCBS MAPPO |
$233.44
|
| Rate for Payer: BCBS Trust/PPO |
$767.65
|
| Rate for Payer: BCN Commercial |
$767.65
|
| Rate for Payer: BCN Medicare Advantage |
$233.44
|
| Rate for Payer: Cash Price |
$747.02
|
| Rate for Payer: Cofinity Commercial |
$803.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$747.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$233.44
|
| Rate for Payer: Healthscope Commercial |
$840.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$700.33
|
| Rate for Payer: Mclaren Medicaid |
$164.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$245.11
|
| Rate for Payer: Meridian Medicaid |
$172.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$268.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$256.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$793.70
|
| Rate for Payer: Nomi Health Commercial |
$765.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$700.33
|
| Rate for Payer: PACE Senior Care Partners |
$221.77
|
| Rate for Payer: PACE SWMI |
$233.44
|
| Rate for Payer: PHP Commercial |
$793.70
|
| Rate for Payer: PHP Medicare Advantage |
$233.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$164.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$812.38
|
| Rate for Payer: Priority Health Medicare |
$235.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$649.90
|
| Rate for Payer: Railroad Medicare Medicare |
$233.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$821.72
|
| Rate for Payer: UHC Core |
$779.70
|
| Rate for Payer: UHC Exchange |
$233.44
|
| Rate for Payer: UHC Medicaid |
$164.62
|
| Rate for Payer: UHC Medicare Advantage |
$233.44
|
| Rate for Payer: UHCCP Medicaid |
$164.62
|
| Rate for Payer: VA VA |
$233.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$700.33
|
|
|
OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$933.77
|
|
|
Service Code
|
NDC 59011044020
|
| Hospital Charge Code |
173655
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$649.90 |
| Max. Negotiated Rate |
$840.39 |
| Rate for Payer: Aetna Commercial |
$793.70
|
| Rate for Payer: BCBS Trust/PPO |
$771.20
|
| Rate for Payer: BCN Commercial |
$771.20
|
| Rate for Payer: Cash Price |
$747.02
|
| Rate for Payer: Cofinity Commercial |
$803.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$747.02
|
| Rate for Payer: Healthscope Commercial |
$840.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$700.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$793.70
|
| Rate for Payer: Nomi Health Commercial |
$765.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$700.33
|
| Rate for Payer: PHP Commercial |
$793.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$812.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$649.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$821.72
|
| Rate for Payer: UHC Core |
$779.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$700.33
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 00904676130
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: BCBS Trust/PPO |
$7.80
|
| Rate for Payer: BCN Commercial |
$7.80
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cofinity Commercial |
$8.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.56
|
| Rate for Payer: Healthscope Commercial |
$8.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.03
|
| Rate for Payer: Nomi Health Commercial |
$7.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.09
|
| Rate for Payer: PHP Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.32
|
| Rate for Payer: UHC Core |
$7.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.09
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$9.32
|
|
|
Service Code
|
NDC 00904742730
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: BCBS Trust/PPO |
$7.70
|
| Rate for Payer: BCN Commercial |
$7.70
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$8.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.46
|
| Rate for Payer: Healthscope Commercial |
$8.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.92
|
| Rate for Payer: Nomi Health Commercial |
$7.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.99
|
| Rate for Payer: PHP Commercial |
$7.92
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.20
|
| Rate for Payer: UHC Core |
$7.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.99
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$10.71
|
|
|
Service Code
|
NDC 00904743535
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$9.10
|
| Rate for Payer: BCBS Trust/PPO |
$8.85
|
| Rate for Payer: BCN Commercial |
$8.85
|
| Rate for Payer: Cash Price |
$8.57
|
| Rate for Payer: Cofinity Commercial |
$9.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.57
|
| Rate for Payer: Healthscope Commercial |
$9.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.10
|
| Rate for Payer: Nomi Health Commercial |
$8.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.03
|
| Rate for Payer: PHP Commercial |
$9.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$9.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.42
|
| Rate for Payer: UHC Core |
$8.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.03
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$41.06
|
|
|
Service Code
|
NDC 41100081125
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$36.95 |
| Rate for Payer: Aetna Commercial |
$34.90
|
| Rate for Payer: Aetna Medicare |
$10.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.83
|
| Rate for Payer: BCBS Complete |
$7.60
|
| Rate for Payer: BCBS MAPPO |
$10.27
|
| Rate for Payer: BCBS Trust/PPO |
$33.76
|
| Rate for Payer: BCN Commercial |
$33.76
|
| Rate for Payer: BCN Medicare Advantage |
$10.27
|
| Rate for Payer: Cash Price |
$32.85
|
| Rate for Payer: Cofinity Commercial |
$35.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.27
|
| Rate for Payer: Healthscope Commercial |
$36.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.80
|
| Rate for Payer: Mclaren Medicaid |
$7.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.78
|
| Rate for Payer: Meridian Medicaid |
$7.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.90
|
| Rate for Payer: Nomi Health Commercial |
$33.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.80
|
| Rate for Payer: PACE Senior Care Partners |
$9.75
|
| Rate for Payer: PACE SWMI |
$10.27
|
| Rate for Payer: PHP Commercial |
$34.90
|
| Rate for Payer: PHP Medicare Advantage |
$10.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$35.72
|
| Rate for Payer: Priority Health Medicare |
$10.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.58
|
| Rate for Payer: Railroad Medicare Medicare |
$10.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.13
|
| Rate for Payer: UHC Core |
$34.29
|
| Rate for Payer: UHC Exchange |
$10.27
|
| Rate for Payer: UHC Medicaid |
$7.24
|
| Rate for Payer: UHC Medicare Advantage |
$10.27
|
| Rate for Payer: UHCCP Medicaid |
$7.24
|
| Rate for Payer: VA VA |
$10.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.80
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$41.06
|
|
|
Service Code
|
NDC 41100081125
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.58 |
| Max. Negotiated Rate |
$36.95 |
| Rate for Payer: Aetna Commercial |
$34.90
|
| Rate for Payer: BCBS Trust/PPO |
$33.91
|
| Rate for Payer: BCN Commercial |
$33.91
|
| Rate for Payer: Cash Price |
$32.85
|
| Rate for Payer: Cofinity Commercial |
$35.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.85
|
| Rate for Payer: Healthscope Commercial |
$36.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.90
|
| Rate for Payer: Nomi Health Commercial |
$33.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.80
|
| Rate for Payer: PHP Commercial |
$34.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$35.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.13
|
| Rate for Payer: UHC Core |
$34.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.80
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 70000000101
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: BCBS Trust/PPO |
$8.47
|
| Rate for Payer: BCN Commercial |
$8.47
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: Nomi Health Commercial |
$8.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.70
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.03
|
| Rate for Payer: UHC Core |
$8.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$13.23
|
|
|
Service Code
|
NDC 45802041059
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Aetna Medicare |
$3.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.13
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.13
|
| Rate for Payer: BCBS Complete |
$2.45
|
| Rate for Payer: BCBS MAPPO |
$3.31
|
| Rate for Payer: BCBS Trust/PPO |
$10.88
|
| Rate for Payer: BCN Commercial |
$10.88
|
| Rate for Payer: BCN Medicare Advantage |
$3.31
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$11.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.31
|
| Rate for Payer: Healthscope Commercial |
$11.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.92
|
| Rate for Payer: Mclaren Medicaid |
$2.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.47
|
| Rate for Payer: Meridian Medicaid |
$2.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.25
|
| Rate for Payer: Nomi Health Commercial |
$10.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.92
|
| Rate for Payer: PACE Senior Care Partners |
$3.14
|
| Rate for Payer: PACE SWMI |
$3.31
|
| Rate for Payer: PHP Commercial |
$11.25
|
| Rate for Payer: PHP Medicare Advantage |
$3.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$11.51
|
| Rate for Payer: Priority Health Medicare |
$3.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.64
|
| Rate for Payer: UHC Core |
$11.05
|
| Rate for Payer: UHC Exchange |
$3.31
|
| Rate for Payer: UHC Medicaid |
$2.33
|
| Rate for Payer: UHC Medicare Advantage |
$3.31
|
| Rate for Payer: UHCCP Medicaid |
$2.33
|
| Rate for Payer: VA VA |
$3.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.92
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$22.75
|
|
|
Service Code
|
NDC 50024043100
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Aetna Commercial |
$19.34
|
| Rate for Payer: Aetna Medicare |
$5.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.11
|
| Rate for Payer: BCBS Complete |
$4.21
|
| Rate for Payer: BCBS MAPPO |
$5.69
|
| Rate for Payer: BCBS Trust/PPO |
$18.70
|
| Rate for Payer: BCN Commercial |
$18.70
|
| Rate for Payer: BCN Medicare Advantage |
$5.69
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$19.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.69
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.06
|
| Rate for Payer: Mclaren Medicaid |
$4.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.97
|
| Rate for Payer: Meridian Medicaid |
$4.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.54
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: PACE Senior Care Partners |
$5.40
|
| Rate for Payer: PACE SWMI |
$5.69
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: PHP Medicare Advantage |
$5.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$19.79
|
| Rate for Payer: Priority Health Medicare |
$5.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.83
|
| Rate for Payer: Railroad Medicare Medicare |
$5.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.02
|
| Rate for Payer: UHC Core |
$19.00
|
| Rate for Payer: UHC Exchange |
$5.69
|
| Rate for Payer: UHC Medicaid |
$4.01
|
| Rate for Payer: UHC Medicare Advantage |
$5.69
|
| Rate for Payer: UHCCP Medicaid |
$4.01
|
| Rate for Payer: VA VA |
$5.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.06
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$22.75
|
|
|
Service Code
|
NDC 50024043100
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Aetna Commercial |
$19.34
|
| Rate for Payer: BCBS Trust/PPO |
$18.79
|
| Rate for Payer: BCN Commercial |
$18.79
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$19.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$19.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.02
|
| Rate for Payer: UHC Core |
$19.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.06
|
|
