|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$193.80
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.17 |
| Max. Negotiated Rate |
$174.42 |
| Rate for Payer: Aetna Commercial |
$164.73
|
| Rate for Payer: Aetna Medicare |
$50.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$60.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$60.56
|
| Rate for Payer: BCBS Complete |
$35.87
|
| Rate for Payer: BCBS MAPPO |
$48.45
|
| Rate for Payer: BCBS Trust/PPO |
$159.32
|
| Rate for Payer: BCN Commercial |
$159.32
|
| Rate for Payer: BCN Medicare Advantage |
$48.45
|
| Rate for Payer: Cash Price |
$155.04
|
| Rate for Payer: Cofinity Commercial |
$166.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.45
|
| Rate for Payer: Healthscope Commercial |
$174.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.35
|
| Rate for Payer: Mclaren Medicaid |
$34.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$50.87
|
| Rate for Payer: Meridian Medicaid |
$35.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.72
|
| Rate for Payer: Molina Medicare/Medicaid |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$164.73
|
| Rate for Payer: Nomi Health Commercial |
$158.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$145.35
|
| Rate for Payer: PACE Senior Care Partners |
$46.03
|
| Rate for Payer: PACE SWMI |
$48.45
|
| Rate for Payer: PHP Commercial |
$164.73
|
| Rate for Payer: PHP Medicare Advantage |
$48.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$34.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$168.61
|
| Rate for Payer: Priority Health Medicare |
$48.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.88
|
| Rate for Payer: Railroad Medicare Medicare |
$48.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.54
|
| Rate for Payer: UHC Core |
$161.82
|
| Rate for Payer: UHC Exchange |
$48.45
|
| Rate for Payer: UHC Medicaid |
$34.17
|
| Rate for Payer: UHC Medicare Advantage |
$48.45
|
| Rate for Payer: UHCCP Medicaid |
$34.17
|
| Rate for Payer: VA VA |
$48.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.35
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$222.30
|
|
|
Service Code
|
NDC 63739056410
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: Aetna Medicare |
$57.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$69.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$69.47
|
| Rate for Payer: BCBS Complete |
$41.15
|
| Rate for Payer: BCBS MAPPO |
$55.58
|
| Rate for Payer: BCBS Trust/PPO |
$182.75
|
| Rate for Payer: BCN Commercial |
$182.75
|
| Rate for Payer: BCN Medicare Advantage |
$55.58
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.58
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.72
|
| Rate for Payer: Mclaren Medicaid |
$39.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.35
|
| Rate for Payer: Meridian Medicaid |
$41.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.91
|
| Rate for Payer: Molina Medicare/Medicaid |
$61.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: Nomi Health Commercial |
$182.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.72
|
| Rate for Payer: PACE Senior Care Partners |
$52.80
|
| Rate for Payer: PACE SWMI |
$55.58
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: PHP Medicare Advantage |
$55.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$39.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$193.40
|
| Rate for Payer: Priority Health Medicare |
$56.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.72
|
| Rate for Payer: Railroad Medicare Medicare |
$55.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$195.62
|
| Rate for Payer: UHC Core |
$185.62
|
| Rate for Payer: UHC Exchange |
$55.58
|
| Rate for Payer: UHC Medicaid |
$39.19
|
| Rate for Payer: UHC Medicare Advantage |
$55.58
|
| Rate for Payer: UHCCP Medicaid |
$39.19
|
| Rate for Payer: VA VA |
$55.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.72
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$276.36
|
|
|
Service Code
|
NDC 00904687045
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$248.72 |
| Rate for Payer: Aetna Commercial |
$234.91
|
| Rate for Payer: Aetna Medicare |
$71.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$86.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$86.36
|
| Rate for Payer: BCBS Complete |
$51.15
|
| Rate for Payer: BCBS MAPPO |
$69.09
|
| Rate for Payer: BCBS Trust/PPO |
$227.20
|
| Rate for Payer: BCN Commercial |
$227.20
|
| Rate for Payer: BCN Medicare Advantage |
$69.09
|
| Rate for Payer: Cash Price |
$221.09
|
| Rate for Payer: Cofinity Commercial |
$237.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$69.09
|
| Rate for Payer: Healthscope Commercial |
$248.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.27
|
| Rate for Payer: Mclaren Medicaid |
$48.72
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$72.54
|
| Rate for Payer: Meridian Medicaid |
$51.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.45
|
| Rate for Payer: Molina Medicare/Medicaid |
$76.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.91
|
| Rate for Payer: Nomi Health Commercial |
$226.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.27
|
| Rate for Payer: PACE Senior Care Partners |
$65.64
|
| Rate for Payer: PACE SWMI |
$69.09
|
| Rate for Payer: PHP Commercial |
$234.91
|
| Rate for Payer: PHP Medicare Advantage |
$69.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$48.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$240.43
|
| Rate for Payer: Priority Health Medicare |
$69.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$192.35
|
| Rate for Payer: Railroad Medicare Medicare |
$69.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.20
|
| Rate for Payer: UHC Core |
$230.76
|
| Rate for Payer: UHC Exchange |
$69.09
|
| Rate for Payer: UHC Medicaid |
$48.72
|
| Rate for Payer: UHC Medicare Advantage |
$69.09
|
| Rate for Payer: UHCCP Medicaid |
$48.72
|
| Rate for Payer: VA VA |
$69.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.27
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$212.80
|
|
|
Service Code
|
NDC 51079005120
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.11 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna Commercial |
$180.88
|
| Rate for Payer: BCBS Trust/PPO |
$175.75
|
| Rate for Payer: BCN Commercial |
$175.75
|
| Rate for Payer: Cash Price |
$170.24
|
| Rate for Payer: Cofinity Commercial |
$183.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.24
|
| Rate for Payer: Healthscope Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.88
|
| Rate for Payer: Nomi Health Commercial |
$174.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.60
|
| Rate for Payer: PHP Commercial |
$180.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$185.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$187.26
|
| Rate for Payer: UHC Core |
$177.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.60
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$120.56
|
|
|
Service Code
|
NDC 65862056090
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.91 |
| Max. Negotiated Rate |
$108.50 |
| Rate for Payer: Aetna Commercial |
$102.48
|
| Rate for Payer: BCBS Trust/PPO |
$99.57
|
| Rate for Payer: BCN Commercial |
$99.57
|
| Rate for Payer: Cash Price |
$96.45
|
| Rate for Payer: Cofinity Commercial |
$103.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.45
|
| Rate for Payer: Healthscope Commercial |
$108.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.48
|
| Rate for Payer: Nomi Health Commercial |
$98.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.42
|
| Rate for Payer: PHP Commercial |
$102.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$104.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.09
|
| Rate for Payer: UHC Core |
$100.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.42
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 63739056410
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.72 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: BCBS Trust/PPO |
$183.60
|
| Rate for Payer: BCN Commercial |
$183.60
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: Nomi Health Commercial |
$182.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.72
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$193.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$195.62
|
| Rate for Payer: UHC Core |
$185.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.72
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$212.80
|
|
|
Service Code
|
NDC 51079005120
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.52 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna Commercial |
$180.88
|
| Rate for Payer: Aetna Medicare |
$55.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66.50
|
| Rate for Payer: BCBS Complete |
$39.39
|
| Rate for Payer: BCBS MAPPO |
$53.20
|
| Rate for Payer: BCBS Trust/PPO |
$174.94
|
| Rate for Payer: BCN Commercial |
$174.94
|
| Rate for Payer: BCN Medicare Advantage |
$53.20
|
| Rate for Payer: Cash Price |
$170.24
|
| Rate for Payer: Cofinity Commercial |
$183.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$53.20
|
| Rate for Payer: Healthscope Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.60
|
| Rate for Payer: Mclaren Medicaid |
$37.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$55.86
|
| Rate for Payer: Meridian Medicaid |
$39.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.18
|
| Rate for Payer: Molina Medicare/Medicaid |
$58.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.88
|
| Rate for Payer: Nomi Health Commercial |
$174.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.60
|
| Rate for Payer: PACE Senior Care Partners |
$50.54
|
| Rate for Payer: PACE SWMI |
$53.20
|
| Rate for Payer: PHP Commercial |
$180.88
|
| Rate for Payer: PHP Medicare Advantage |
$53.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$37.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$185.14
|
| Rate for Payer: Priority Health Medicare |
$53.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.11
|
| Rate for Payer: Railroad Medicare Medicare |
$53.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$187.26
|
| Rate for Payer: UHC Core |
$177.69
|
| Rate for Payer: UHC Exchange |
$53.20
|
| Rate for Payer: UHC Medicaid |
$37.52
|
| Rate for Payer: UHC Medicare Advantage |
$53.20
|
| Rate for Payer: UHCCP Medicaid |
$37.52
|
| Rate for Payer: VA VA |
$53.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.60
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$120.56
|
|
|
Service Code
|
NDC 65862056090
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$108.50 |
| Rate for Payer: Aetna Commercial |
$102.48
|
| Rate for Payer: Aetna Medicare |
$31.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37.67
|
| Rate for Payer: BCBS Complete |
$22.32
|
| Rate for Payer: BCBS MAPPO |
$30.14
|
| Rate for Payer: BCBS Trust/PPO |
$99.11
|
| Rate for Payer: BCN Commercial |
$99.11
|
| Rate for Payer: BCN Medicare Advantage |
$30.14
|
| Rate for Payer: Cash Price |
$96.45
|
| Rate for Payer: Cofinity Commercial |
$103.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$30.14
|
| Rate for Payer: Healthscope Commercial |
$108.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.42
|
| Rate for Payer: Mclaren Medicaid |
$21.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.65
|
| Rate for Payer: Meridian Medicaid |
$22.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.66
|
| Rate for Payer: Molina Medicare/Medicaid |
$33.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.48
|
| Rate for Payer: Nomi Health Commercial |
$98.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.42
|
| Rate for Payer: PACE Senior Care Partners |
$28.63
|
| Rate for Payer: PACE SWMI |
$30.14
|
| Rate for Payer: PHP Commercial |
$102.48
|
| Rate for Payer: PHP Medicare Advantage |
$30.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$21.25
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$104.89
|
| Rate for Payer: Priority Health Medicare |
$30.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.91
|
| Rate for Payer: Railroad Medicare Medicare |
$30.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.09
|
| Rate for Payer: UHC Core |
$100.67
|
| Rate for Payer: UHC Exchange |
$30.14
|
| Rate for Payer: UHC Medicaid |
$21.25
|
| Rate for Payer: UHC Medicare Advantage |
$30.14
|
| Rate for Payer: UHCCP Medicaid |
$21.25
|
| Rate for Payer: VA VA |
$30.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.42
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$193.80
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.88 |
| Max. Negotiated Rate |
$174.42 |
| Rate for Payer: Aetna Commercial |
$164.73
|
| Rate for Payer: BCBS Trust/PPO |
$160.06
|
| Rate for Payer: BCN Commercial |
$160.06
|
| Rate for Payer: Cash Price |
$155.04
|
| Rate for Payer: Cofinity Commercial |
$166.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.04
|
| Rate for Payer: Healthscope Commercial |
$174.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$164.73
|
| Rate for Payer: Nomi Health Commercial |
$158.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$145.35
|
| Rate for Payer: PHP Commercial |
$164.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$168.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.54
|
| Rate for Payer: UHC Core |
$161.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.35
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Aetna Commercial |
$1.81
|
| Rate for Payer: BCBS Trust/PPO |
$1.76
|
| Rate for Payer: BCN Commercial |
$1.76
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.70
|
| Rate for Payer: Healthscope Commercial |
$1.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.81
|
| Rate for Payer: Nomi Health Commercial |
$1.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.60
|
| Rate for Payer: PHP Commercial |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.87
|
| Rate for Payer: UHC Core |
$1.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.60
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$276.36
|
|
|
Service Code
|
NDC 00904687045
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.35 |
| Max. Negotiated Rate |
$248.72 |
| Rate for Payer: Aetna Commercial |
$234.91
|
| Rate for Payer: BCBS Trust/PPO |
$228.25
|
| Rate for Payer: BCN Commercial |
$228.25
|
| Rate for Payer: Cash Price |
$221.09
|
| Rate for Payer: Cofinity Commercial |
$237.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.09
|
| Rate for Payer: Healthscope Commercial |
$248.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.91
|
| Rate for Payer: Nomi Health Commercial |
$226.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.27
|
| Rate for Payer: PHP Commercial |
$234.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$240.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$192.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.20
|
| Rate for Payer: UHC Core |
$230.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.27
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Aetna Commercial |
$1.81
|
| Rate for Payer: Aetna Medicare |
$0.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.67
|
| Rate for Payer: BCBS Complete |
$0.39
|
| Rate for Payer: BCBS MAPPO |
$0.53
|
| Rate for Payer: BCBS Trust/PPO |
$1.75
|
| Rate for Payer: BCN Commercial |
$1.75
|
| Rate for Payer: BCN Medicare Advantage |
$0.53
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.53
|
| Rate for Payer: Healthscope Commercial |
$1.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.60
|
| Rate for Payer: Mclaren Medicaid |
$0.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.56
|
| Rate for Payer: Meridian Medicaid |
$0.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.61
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.81
|
| Rate for Payer: Nomi Health Commercial |
$1.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.60
|
| Rate for Payer: PACE Senior Care Partners |
$0.51
|
| Rate for Payer: PACE SWMI |
$0.53
|
| Rate for Payer: PHP Commercial |
$1.81
|
| Rate for Payer: PHP Medicare Advantage |
$0.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1.85
|
| Rate for Payer: Priority Health Medicare |
$0.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.48
|
| Rate for Payer: Railroad Medicare Medicare |
$0.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.87
|
| Rate for Payer: UHC Core |
$1.78
|
| Rate for Payer: UHC Exchange |
$0.53
|
| Rate for Payer: UHC Medicaid |
$0.38
|
| Rate for Payer: UHC Medicare Advantage |
$0.53
|
| Rate for Payer: UHCCP Medicaid |
$0.38
|
| Rate for Payer: VA VA |
$0.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.60
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
IP
|
$270.72
|
|
|
Service Code
|
NDC 00904567661
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.42 |
| Max. Negotiated Rate |
$243.65 |
| Rate for Payer: Aetna Commercial |
$230.11
|
| Rate for Payer: BCBS Trust/PPO |
$223.59
|
| Rate for Payer: BCN Commercial |
$223.59
|
| Rate for Payer: Cash Price |
$216.58
|
| Rate for Payer: Cofinity Commercial |
$232.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.58
|
| Rate for Payer: Healthscope Commercial |
$243.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.11
|
| Rate for Payer: Nomi Health Commercial |
$221.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.04
|
| Rate for Payer: PHP Commercial |
$230.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$235.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$188.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.23
|
| Rate for Payer: UHC Core |
$226.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.04
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$270.72
|
|
|
Service Code
|
NDC 00904567661
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.73 |
| Max. Negotiated Rate |
$243.65 |
| Rate for Payer: Aetna Commercial |
$230.11
|
| Rate for Payer: Aetna Medicare |
$70.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$84.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$84.60
|
| Rate for Payer: BCBS Complete |
$50.11
|
| Rate for Payer: BCBS MAPPO |
$67.68
|
| Rate for Payer: BCBS Trust/PPO |
$222.56
|
| Rate for Payer: BCN Commercial |
$222.56
|
| Rate for Payer: BCN Medicare Advantage |
$67.68
|
| Rate for Payer: Cash Price |
$216.58
|
| Rate for Payer: Cofinity Commercial |
$232.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$243.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.04
|
| Rate for Payer: Mclaren Medicaid |
$47.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$71.06
|
| Rate for Payer: Meridian Medicaid |
$50.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$74.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.11
|
| Rate for Payer: Nomi Health Commercial |
$221.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.04
|
| Rate for Payer: PACE Senior Care Partners |
$64.30
|
| Rate for Payer: PACE SWMI |
$67.68
|
| Rate for Payer: PHP Commercial |
$230.11
|
| Rate for Payer: PHP Medicare Advantage |
$67.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$47.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$235.53
|
| Rate for Payer: Priority Health Medicare |
$68.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$188.42
|
| Rate for Payer: Railroad Medicare Medicare |
$67.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.23
|
| Rate for Payer: UHC Core |
$226.05
|
| Rate for Payer: UHC Exchange |
$67.68
|
| Rate for Payer: UHC Medicaid |
$47.73
|
| Rate for Payer: UHC Medicare Advantage |
$67.68
|
| Rate for Payer: UHCCP Medicaid |
$47.73
|
| Rate for Payer: VA VA |
$67.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.04
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$74.73
|
|
|
Service Code
|
NDC 00378700193
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.17 |
| Max. Negotiated Rate |
$67.26 |
| Rate for Payer: Aetna Commercial |
$63.52
|
| Rate for Payer: Aetna Medicare |
$19.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.35
|
| Rate for Payer: BCBS Complete |
$13.83
|
| Rate for Payer: BCBS MAPPO |
$18.68
|
| Rate for Payer: BCBS Trust/PPO |
$61.44
|
| Rate for Payer: BCN Commercial |
$61.44
|
| Rate for Payer: BCN Medicare Advantage |
$18.68
|
| Rate for Payer: Cash Price |
$59.78
|
| Rate for Payer: Cofinity Commercial |
$64.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.68
|
| Rate for Payer: Healthscope Commercial |
$67.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.05
|
| Rate for Payer: Mclaren Medicaid |
$13.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.62
|
| Rate for Payer: Meridian Medicaid |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.48
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.52
|
| Rate for Payer: Nomi Health Commercial |
$61.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.05
|
| Rate for Payer: PACE Senior Care Partners |
$17.75
|
| Rate for Payer: PACE SWMI |
$18.68
|
| Rate for Payer: PHP Commercial |
$63.52
|
| Rate for Payer: PHP Medicare Advantage |
$18.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$65.02
|
| Rate for Payer: Priority Health Medicare |
$18.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.01
|
| Rate for Payer: Railroad Medicare Medicare |
$18.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.76
|
| Rate for Payer: UHC Core |
$62.40
|
| Rate for Payer: UHC Exchange |
$18.68
|
| Rate for Payer: UHC Medicaid |
$13.17
|
| Rate for Payer: UHC Medicare Advantage |
$18.68
|
| Rate for Payer: UHCCP Medicaid |
$13.17
|
| Rate for Payer: VA VA |
$18.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.05
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
IP
|
$74.73
|
|
|
Service Code
|
NDC 00378700193
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.01 |
| Max. Negotiated Rate |
$67.26 |
| Rate for Payer: Aetna Commercial |
$63.52
|
| Rate for Payer: BCBS Trust/PPO |
$61.72
|
| Rate for Payer: BCN Commercial |
$61.72
|
| Rate for Payer: Cash Price |
$59.78
|
| Rate for Payer: Cofinity Commercial |
$64.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.78
|
| Rate for Payer: Healthscope Commercial |
$67.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.52
|
| Rate for Payer: Nomi Health Commercial |
$61.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.05
|
| Rate for Payer: PHP Commercial |
$63.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$65.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.76
|
| Rate for Payer: UHC Core |
$62.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.05
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$7,387.00
|
|
|
Service Code
|
APR-DRG 8443
|
| Min. Negotiated Rate |
$7,035.24 |
| Max. Negotiated Rate |
$7,387.00 |
| Rate for Payer: BCBS Complete |
$7,387.00
|
| Rate for Payer: Mclaren Medicaid |
$7,035.24
|
| Rate for Payer: Meridian Medicaid |
$7,387.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$7,035.24
|
| Rate for Payer: UHC Medicaid |
$7,035.24
|
| Rate for Payer: UHCCP Medicaid |
$7,035.24
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$11,947.61
|
|
|
Service Code
|
APR-DRG 8444
|
| Min. Negotiated Rate |
$11,378.68 |
| Max. Negotiated Rate |
$11,947.61 |
| Rate for Payer: BCBS Complete |
$11,947.61
|
| Rate for Payer: Mclaren Medicaid |
$11,378.68
|
| Rate for Payer: Meridian Medicaid |
$11,947.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$11,378.68
|
| Rate for Payer: UHC Medicaid |
$11,378.68
|
| Rate for Payer: UHCCP Medicaid |
$11,378.68
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$5,304.67
|
|
|
Service Code
|
APR-DRG 8442
|
| Min. Negotiated Rate |
$5,052.07 |
| Max. Negotiated Rate |
$5,304.67 |
| Rate for Payer: BCBS Complete |
$5,304.67
|
| Rate for Payer: Mclaren Medicaid |
$5,052.07
|
| Rate for Payer: Meridian Medicaid |
$5,304.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,052.07
|
| Rate for Payer: UHC Medicaid |
$5,052.07
|
| Rate for Payer: UHCCP Medicaid |
$5,052.07
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$2,931.56
|
|
|
Service Code
|
APR-DRG 8441
|
| Min. Negotiated Rate |
$2,791.96 |
| Max. Negotiated Rate |
$2,931.56 |
| Rate for Payer: BCBS Complete |
$2,931.56
|
| Rate for Payer: Mclaren Medicaid |
$2,791.96
|
| Rate for Payer: Meridian Medicaid |
$2,931.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,791.96
|
| Rate for Payer: UHC Medicaid |
$2,791.96
|
| Rate for Payer: UHCCP Medicaid |
$2,791.96
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
IP
|
$1,411.79
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$982.61 |
| Max. Negotiated Rate |
$1,270.61 |
| Rate for Payer: Aetna Commercial |
$1,200.02
|
| Rate for Payer: BCBS Trust/PPO |
$1,166.00
|
| Rate for Payer: BCN Commercial |
$1,166.00
|
| Rate for Payer: Cash Price |
$1,129.43
|
| Rate for Payer: Cofinity Commercial |
$1,214.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,129.43
|
| Rate for Payer: Healthscope Commercial |
$1,270.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,058.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,200.02
|
| Rate for Payer: Nomi Health Commercial |
$1,157.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,058.84
|
| Rate for Payer: PHP Commercial |
$1,200.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,228.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$982.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,242.38
|
| Rate for Payer: UHC Core |
$1,178.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,058.84
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
OP
|
$1,411.79
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$248.90 |
| Max. Negotiated Rate |
$1,270.61 |
| Rate for Payer: Aetna Commercial |
$1,200.02
|
| Rate for Payer: Aetna Medicare |
$367.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$441.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$441.18
|
| Rate for Payer: BCBS Complete |
$261.32
|
| Rate for Payer: BCBS MAPPO |
$352.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,160.63
|
| Rate for Payer: BCN Commercial |
$1,160.63
|
| Rate for Payer: BCN Medicare Advantage |
$352.95
|
| Rate for Payer: Cash Price |
$1,129.43
|
| Rate for Payer: Cofinity Commercial |
$1,214.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,129.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$352.95
|
| Rate for Payer: Healthscope Commercial |
$1,270.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,058.84
|
| Rate for Payer: Mclaren Medicaid |
$248.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$370.59
|
| Rate for Payer: Meridian Medicaid |
$261.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$405.89
|
| Rate for Payer: Molina Medicare/Medicaid |
$388.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,200.02
|
| Rate for Payer: Nomi Health Commercial |
$1,157.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,058.84
|
| Rate for Payer: PACE Senior Care Partners |
$335.30
|
| Rate for Payer: PACE SWMI |
$352.95
|
| Rate for Payer: PHP Commercial |
$1,200.02
|
| Rate for Payer: PHP Medicare Advantage |
$352.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$248.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,228.26
|
| Rate for Payer: Priority Health Medicare |
$356.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$982.61
|
| Rate for Payer: Railroad Medicare Medicare |
$352.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,242.38
|
| Rate for Payer: UHC Core |
$1,178.84
|
| Rate for Payer: UHC Exchange |
$352.95
|
| Rate for Payer: UHC Medicaid |
$248.90
|
| Rate for Payer: UHC Medicare Advantage |
$352.95
|
| Rate for Payer: UHCCP Medicaid |
$248.90
|
| Rate for Payer: VA VA |
$352.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,058.84
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.98 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: BCBS Trust/PPO |
$46.25
|
| Rate for Payer: BCN Commercial |
$46.25
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.00
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$48.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.28
|
| Rate for Payer: UHC Core |
$46.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: Aetna Medicare |
$14.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.50
|
| Rate for Payer: BCBS Complete |
$10.37
|
| Rate for Payer: BCBS MAPPO |
$14.00
|
| Rate for Payer: BCBS Trust/PPO |
$46.04
|
| Rate for Payer: BCN Commercial |
$46.04
|
| Rate for Payer: BCN Medicare Advantage |
$14.00
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.00
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Mclaren Medicaid |
$9.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.70
|
| Rate for Payer: Meridian Medicaid |
$10.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$15.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.00
|
| Rate for Payer: PACE Senior Care Partners |
$13.30
|
| Rate for Payer: PACE SWMI |
$14.00
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: PHP Medicare Advantage |
$14.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$48.72
|
| Rate for Payer: Priority Health Medicare |
$14.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.98
|
| Rate for Payer: Railroad Medicare Medicare |
$14.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.28
|
| Rate for Payer: UHC Core |
$46.76
|
| Rate for Payer: UHC Exchange |
$14.00
|
| Rate for Payer: UHC Medicaid |
$9.87
|
| Rate for Payer: UHC Medicare Advantage |
$14.00
|
| Rate for Payer: UHCCP Medicaid |
$9.87
|
| Rate for Payer: VA VA |
$14.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS
|
Facility
|
OP
|
$11.41
|
|
|
Service Code
|
NDC 96295013764
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$10.27 |
| Rate for Payer: Aetna Commercial |
$9.70
|
| Rate for Payer: Aetna Medicare |
$2.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.57
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.57
|
| Rate for Payer: BCBS Complete |
$2.11
|
| Rate for Payer: BCBS MAPPO |
$2.85
|
| Rate for Payer: BCBS Trust/PPO |
$9.38
|
| Rate for Payer: BCN Commercial |
$9.38
|
| Rate for Payer: BCN Medicare Advantage |
$2.85
|
| Rate for Payer: Cash Price |
$9.13
|
| Rate for Payer: Cofinity Commercial |
$9.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.85
|
| Rate for Payer: Healthscope Commercial |
$10.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.56
|
| Rate for Payer: Mclaren Medicaid |
$2.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.00
|
| Rate for Payer: Meridian Medicaid |
$2.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.28
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.70
|
| Rate for Payer: Nomi Health Commercial |
$9.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.56
|
| Rate for Payer: PACE Senior Care Partners |
$2.71
|
| Rate for Payer: PACE SWMI |
$2.85
|
| Rate for Payer: PHP Commercial |
$9.70
|
| Rate for Payer: PHP Medicare Advantage |
$2.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$9.93
|
| Rate for Payer: Priority Health Medicare |
$2.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.94
|
| Rate for Payer: Railroad Medicare Medicare |
$2.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.04
|
| Rate for Payer: UHC Core |
$9.53
|
| Rate for Payer: UHC Exchange |
$2.85
|
| Rate for Payer: UHC Medicaid |
$2.01
|
| Rate for Payer: UHC Medicare Advantage |
$2.85
|
| Rate for Payer: UHCCP Medicaid |
$2.01
|
| Rate for Payer: VA VA |
$2.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.56
|
|
