|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$91.39
|
|
|
Service Code
|
NDC 00409330101
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.61 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: BCBS Trust/PPO |
$75.48
|
| Rate for Payer: BCN Commercial |
$75.48
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Nomi Health Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.42
|
| Rate for Payer: UHC Core |
$76.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.54
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$91.39
|
|
|
Service Code
|
NDC 00409166022
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.61 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: BCBS Trust/PPO |
$75.48
|
| Rate for Payer: BCN Commercial |
$75.48
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Nomi Health Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.42
|
| Rate for Payer: UHC Core |
$76.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.54
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$75.62
|
|
|
Service Code
|
NDC 00781349380
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$68.06 |
| Rate for Payer: Aetna Commercial |
$64.28
|
| Rate for Payer: Aetna Medicare |
$19.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.63
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.63
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: BCBS MAPPO |
$18.91
|
| Rate for Payer: BCBS Trust/PPO |
$62.17
|
| Rate for Payer: BCN Commercial |
$62.17
|
| Rate for Payer: BCN Medicare Advantage |
$18.91
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cofinity Commercial |
$65.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.91
|
| Rate for Payer: Healthscope Commercial |
$68.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.72
|
| Rate for Payer: Mclaren Medicaid |
$13.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.85
|
| Rate for Payer: Meridian Medicaid |
$14.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.74
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$64.28
|
| Rate for Payer: Nomi Health Commercial |
$62.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.72
|
| Rate for Payer: PACE Senior Care Partners |
$17.96
|
| Rate for Payer: PACE SWMI |
$18.91
|
| Rate for Payer: PHP Commercial |
$64.28
|
| Rate for Payer: PHP Medicare Advantage |
$18.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$65.79
|
| Rate for Payer: Priority Health Medicare |
$19.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.63
|
| Rate for Payer: Railroad Medicare Medicare |
$18.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$66.55
|
| Rate for Payer: UHC Core |
$63.14
|
| Rate for Payer: UHC Exchange |
$18.91
|
| Rate for Payer: UHC Medicaid |
$13.33
|
| Rate for Payer: UHC Medicare Advantage |
$18.91
|
| Rate for Payer: UHCCP Medicaid |
$13.33
|
| Rate for Payer: VA VA |
$18.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.72
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$91.39
|
|
|
Service Code
|
NDC 00409330101
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.11 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Aetna Medicare |
$23.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.56
|
| Rate for Payer: BCBS Complete |
$16.92
|
| Rate for Payer: BCBS MAPPO |
$22.85
|
| Rate for Payer: BCBS Trust/PPO |
$75.13
|
| Rate for Payer: BCN Commercial |
$75.13
|
| Rate for Payer: BCN Medicare Advantage |
$22.85
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.85
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.54
|
| Rate for Payer: Mclaren Medicaid |
$16.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.99
|
| Rate for Payer: Meridian Medicaid |
$16.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.27
|
| Rate for Payer: Molina Medicare/Medicaid |
$25.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Nomi Health Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PACE Senior Care Partners |
$21.71
|
| Rate for Payer: PACE SWMI |
$22.85
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: PHP Medicare Advantage |
$22.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.51
|
| Rate for Payer: Priority Health Medicare |
$23.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.61
|
| Rate for Payer: Railroad Medicare Medicare |
$22.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.42
|
| Rate for Payer: UHC Core |
$76.31
|
| Rate for Payer: UHC Exchange |
$22.85
|
| Rate for Payer: UHC Medicaid |
$16.11
|
| Rate for Payer: UHC Medicare Advantage |
$22.85
|
| Rate for Payer: UHCCP Medicaid |
$16.11
|
| Rate for Payer: VA VA |
$22.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.54
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$91.39
|
|
|
Service Code
|
NDC 00409166020
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.61 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: BCBS Trust/PPO |
$75.48
|
| Rate for Payer: BCN Commercial |
$75.48
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Nomi Health Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.42
|
| Rate for Payer: UHC Core |
$76.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.54
|
|
|
DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$91.39
|
|
|
Service Code
|
NDC 00409166020
|
| Hospital Charge Code |
173991
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.11 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$77.68
|
| Rate for Payer: Aetna Medicare |
$23.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.56
|
| Rate for Payer: BCBS Complete |
$16.92
|
| Rate for Payer: BCBS MAPPO |
$22.85
|
| Rate for Payer: BCBS Trust/PPO |
$75.13
|
| Rate for Payer: BCN Commercial |
$75.13
|
| Rate for Payer: BCN Medicare Advantage |
$22.85
|
| Rate for Payer: Cash Price |
$73.11
|
| Rate for Payer: Cofinity Commercial |
$78.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.85
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.54
|
| Rate for Payer: Mclaren Medicaid |
$16.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.99
|
| Rate for Payer: Meridian Medicaid |
$16.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.27
|
| Rate for Payer: Molina Medicare/Medicaid |
$25.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.68
|
| Rate for Payer: Nomi Health Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.54
|
| Rate for Payer: PACE Senior Care Partners |
$21.71
|
| Rate for Payer: PACE SWMI |
$22.85
|
| Rate for Payer: PHP Commercial |
$77.68
|
| Rate for Payer: PHP Medicare Advantage |
$22.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.51
|
| Rate for Payer: Priority Health Medicare |
$23.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.61
|
| Rate for Payer: Railroad Medicare Medicare |
$22.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.42
|
| Rate for Payer: UHC Core |
$76.31
|
| Rate for Payer: UHC Exchange |
$22.85
|
| Rate for Payer: UHC Medicaid |
$16.11
|
| Rate for Payer: UHC Medicare Advantage |
$22.85
|
| Rate for Payer: UHCCP Medicaid |
$16.11
|
| Rate for Payer: VA VA |
$22.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.54
|
|
|
DEXTROMETHORPHAN 20 MG-QUINIDINE 10 MG CAPSULE
|
Facility
|
IP
|
$5,446.77
|
|
|
Service Code
|
NDC 64597030160
|
| Hospital Charge Code |
107672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,790.95 |
| Max. Negotiated Rate |
$4,902.09 |
| Rate for Payer: Aetna Commercial |
$4,629.75
|
| Rate for Payer: BCBS Trust/PPO |
$4,498.49
|
| Rate for Payer: BCN Commercial |
$4,498.49
|
| Rate for Payer: Cash Price |
$4,357.42
|
| Rate for Payer: Cofinity Commercial |
$4,684.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,357.42
|
| Rate for Payer: Healthscope Commercial |
$4,902.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,085.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,629.75
|
| Rate for Payer: Nomi Health Commercial |
$4,466.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,085.08
|
| Rate for Payer: PHP Commercial |
$4,629.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4,738.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3,790.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,793.16
|
| Rate for Payer: UHC Core |
$4,548.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,085.08
|
|
|
DEXTROMETHORPHAN 20 MG-QUINIDINE 10 MG CAPSULE
|
Facility
|
OP
|
$5,446.77
|
|
|
Service Code
|
NDC 64597030160
|
| Hospital Charge Code |
107672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$960.27 |
| Max. Negotiated Rate |
$4,902.09 |
| Rate for Payer: Aetna Commercial |
$4,629.75
|
| Rate for Payer: Aetna Medicare |
$1,416.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,702.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,702.12
|
| Rate for Payer: BCBS Complete |
$1,008.20
|
| Rate for Payer: BCBS MAPPO |
$1,361.69
|
| Rate for Payer: BCBS Trust/PPO |
$4,477.79
|
| Rate for Payer: BCN Commercial |
$4,477.79
|
| Rate for Payer: BCN Medicare Advantage |
$1,361.69
|
| Rate for Payer: Cash Price |
$4,357.42
|
| Rate for Payer: Cofinity Commercial |
$4,684.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,357.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,361.69
|
| Rate for Payer: Healthscope Commercial |
$4,902.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,085.08
|
| Rate for Payer: Mclaren Medicaid |
$960.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,429.78
|
| Rate for Payer: Meridian Medicaid |
$1,008.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,565.95
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,497.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,629.75
|
| Rate for Payer: Nomi Health Commercial |
$4,466.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,085.08
|
| Rate for Payer: PACE Senior Care Partners |
$1,293.61
|
| Rate for Payer: PACE SWMI |
$1,361.69
|
| Rate for Payer: PHP Commercial |
$4,629.75
|
| Rate for Payer: PHP Medicare Advantage |
$1,361.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4,738.69
|
| Rate for Payer: Priority Health Medicare |
$1,375.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3,790.95
|
| Rate for Payer: Railroad Medicare Medicare |
$1,361.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,793.16
|
| Rate for Payer: UHC Core |
$4,548.05
|
| Rate for Payer: UHC Exchange |
$1,361.69
|
| Rate for Payer: UHC Medicaid |
$960.27
|
| Rate for Payer: UHC Medicare Advantage |
$1,361.69
|
| Rate for Payer: UHCCP Medicaid |
$960.27
|
| Rate for Payer: VA VA |
$1,361.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,085.08
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
NDC 81033010351
|
| Hospital Charge Code |
108397
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: BCBS Trust/PPO |
$55.49
|
| Rate for Payer: BCN Commercial |
$55.49
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Nomi Health Commercial |
$55.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$58.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.13
|
| Rate for Payer: UHC Core |
$56.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.39
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
NDC 81033010351
|
| Hospital Charge Code |
108397
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Medicare |
$17.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.00
|
| Rate for Payer: BCBS Complete |
$12.44
|
| Rate for Payer: BCBS MAPPO |
$16.80
|
| Rate for Payer: BCBS Trust/PPO |
$55.24
|
| Rate for Payer: BCN Commercial |
$55.24
|
| Rate for Payer: BCN Medicare Advantage |
$16.80
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.80
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.39
|
| Rate for Payer: Mclaren Medicaid |
$11.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.64
|
| Rate for Payer: Meridian Medicaid |
$12.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.32
|
| Rate for Payer: Molina Medicare/Medicaid |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Nomi Health Commercial |
$55.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: PACE Senior Care Partners |
$15.96
|
| Rate for Payer: PACE SWMI |
$16.80
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Medicare Advantage |
$16.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$58.46
|
| Rate for Payer: Priority Health Medicare |
$16.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.76
|
| Rate for Payer: Railroad Medicare Medicare |
$16.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.13
|
| Rate for Payer: UHC Core |
$56.10
|
| Rate for Payer: UHC Exchange |
$16.80
|
| Rate for Payer: UHC Medicaid |
$11.85
|
| Rate for Payer: UHC Medicare Advantage |
$16.80
|
| Rate for Payer: UHCCP Medicaid |
$11.85
|
| Rate for Payer: VA VA |
$16.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.39
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
NDC 81033010310
|
| Hospital Charge Code |
108397
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Medicare |
$17.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.00
|
| Rate for Payer: BCBS Complete |
$12.44
|
| Rate for Payer: BCBS MAPPO |
$16.80
|
| Rate for Payer: BCBS Trust/PPO |
$55.24
|
| Rate for Payer: BCN Commercial |
$55.24
|
| Rate for Payer: BCN Medicare Advantage |
$16.80
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.80
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.39
|
| Rate for Payer: Mclaren Medicaid |
$11.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.64
|
| Rate for Payer: Meridian Medicaid |
$12.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.32
|
| Rate for Payer: Molina Medicare/Medicaid |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Nomi Health Commercial |
$55.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: PACE Senior Care Partners |
$15.96
|
| Rate for Payer: PACE SWMI |
$16.80
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Medicare Advantage |
$16.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$58.46
|
| Rate for Payer: Priority Health Medicare |
$16.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.76
|
| Rate for Payer: Railroad Medicare Medicare |
$16.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.13
|
| Rate for Payer: UHC Core |
$56.10
|
| Rate for Payer: UHC Exchange |
$16.80
|
| Rate for Payer: UHC Medicaid |
$11.85
|
| Rate for Payer: UHC Medicare Advantage |
$16.80
|
| Rate for Payer: UHCCP Medicaid |
$11.85
|
| Rate for Payer: VA VA |
$16.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.39
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
NDC 81033010310
|
| Hospital Charge Code |
108397
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: BCBS Trust/PPO |
$55.49
|
| Rate for Payer: BCN Commercial |
$55.49
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Nomi Health Commercial |
$55.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$58.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.13
|
| Rate for Payer: UHC Core |
$56.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.39
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$7.30
|
|
|
Service Code
|
NDC 00904751372
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: BCBS Trust/PPO |
$6.03
|
| Rate for Payer: BCN Commercial |
$6.03
|
| Rate for Payer: Cash Price |
$5.84
|
| Rate for Payer: Cofinity Commercial |
$6.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.84
|
| Rate for Payer: Healthscope Commercial |
$6.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.21
|
| Rate for Payer: Nomi Health Commercial |
$5.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.47
|
| Rate for Payer: PHP Commercial |
$6.21
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$6.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.42
|
| Rate for Payer: UHC Core |
$6.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.47
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
NDC 00121063800
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Aetna Commercial |
$5.41
|
| Rate for Payer: BCBS Trust/PPO |
$5.25
|
| Rate for Payer: BCN Commercial |
$5.25
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cofinity Commercial |
$5.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.09
|
| Rate for Payer: Healthscope Commercial |
$5.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.41
|
| Rate for Payer: Nomi Health Commercial |
$5.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.77
|
| Rate for Payer: PHP Commercial |
$5.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.60
|
| Rate for Payer: UHC Core |
$5.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.77
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.34
|
|
|
Service Code
|
NDC 69339014919
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Aetna Commercial |
$5.39
|
| Rate for Payer: Aetna Medicare |
$1.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.98
|
| Rate for Payer: BCBS Complete |
$1.17
|
| Rate for Payer: BCBS MAPPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$5.21
|
| Rate for Payer: BCN Commercial |
$5.21
|
| Rate for Payer: BCN Medicare Advantage |
$1.58
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cofinity Commercial |
$5.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.58
|
| Rate for Payer: Healthscope Commercial |
$5.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.75
|
| Rate for Payer: Mclaren Medicaid |
$1.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.66
|
| Rate for Payer: Meridian Medicaid |
$1.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.82
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.39
|
| Rate for Payer: Nomi Health Commercial |
$5.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.75
|
| Rate for Payer: PACE Senior Care Partners |
$1.51
|
| Rate for Payer: PACE SWMI |
$1.58
|
| Rate for Payer: PHP Commercial |
$5.39
|
| Rate for Payer: PHP Medicare Advantage |
$1.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.52
|
| Rate for Payer: Priority Health Medicare |
$1.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.41
|
| Rate for Payer: Railroad Medicare Medicare |
$1.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.58
|
| Rate for Payer: UHC Core |
$5.29
|
| Rate for Payer: UHC Exchange |
$1.58
|
| Rate for Payer: UHC Medicaid |
$1.12
|
| Rate for Payer: UHC Medicare Advantage |
$1.58
|
| Rate for Payer: UHCCP Medicaid |
$1.12
|
| Rate for Payer: VA VA |
$1.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.75
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.30
|
|
|
Service Code
|
NDC 00904751366
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: Aetna Medicare |
$1.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.28
|
| Rate for Payer: BCBS Complete |
$1.35
|
| Rate for Payer: BCBS MAPPO |
$1.82
|
| Rate for Payer: BCBS Trust/PPO |
$6.00
|
| Rate for Payer: BCN Commercial |
$6.00
|
| Rate for Payer: BCN Medicare Advantage |
$1.82
|
| Rate for Payer: Cash Price |
$5.84
|
| Rate for Payer: Cofinity Commercial |
$6.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.82
|
| Rate for Payer: Healthscope Commercial |
$6.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.47
|
| Rate for Payer: Mclaren Medicaid |
$1.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.92
|
| Rate for Payer: Meridian Medicaid |
$1.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$2.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.21
|
| Rate for Payer: Nomi Health Commercial |
$5.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.47
|
| Rate for Payer: PACE Senior Care Partners |
$1.73
|
| Rate for Payer: PACE SWMI |
$1.82
|
| Rate for Payer: PHP Commercial |
$6.21
|
| Rate for Payer: PHP Medicare Advantage |
$1.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$6.35
|
| Rate for Payer: Priority Health Medicare |
$1.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.08
|
| Rate for Payer: Railroad Medicare Medicare |
$1.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.42
|
| Rate for Payer: UHC Core |
$6.10
|
| Rate for Payer: UHC Exchange |
$1.82
|
| Rate for Payer: UHC Medicaid |
$1.29
|
| Rate for Payer: UHC Medicare Advantage |
$1.82
|
| Rate for Payer: UHCCP Medicaid |
$1.29
|
| Rate for Payer: VA VA |
$1.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.47
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.34
|
|
|
Service Code
|
NDC 69339014905
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Aetna Commercial |
$5.39
|
| Rate for Payer: BCBS Trust/PPO |
$5.24
|
| Rate for Payer: BCN Commercial |
$5.24
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cofinity Commercial |
$5.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.07
|
| Rate for Payer: Healthscope Commercial |
$5.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.39
|
| Rate for Payer: Nomi Health Commercial |
$5.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.75
|
| Rate for Payer: PHP Commercial |
$5.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.58
|
| Rate for Payer: UHC Core |
$5.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.75
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.34
|
|
|
Service Code
|
NDC 69339014905
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Aetna Commercial |
$5.39
|
| Rate for Payer: Aetna Medicare |
$1.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.98
|
| Rate for Payer: BCBS Complete |
$1.17
|
| Rate for Payer: BCBS MAPPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$5.21
|
| Rate for Payer: BCN Commercial |
$5.21
|
| Rate for Payer: BCN Medicare Advantage |
$1.58
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cofinity Commercial |
$5.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.58
|
| Rate for Payer: Healthscope Commercial |
$5.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.75
|
| Rate for Payer: Mclaren Medicaid |
$1.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.66
|
| Rate for Payer: Meridian Medicaid |
$1.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.82
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.39
|
| Rate for Payer: Nomi Health Commercial |
$5.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.75
|
| Rate for Payer: PACE Senior Care Partners |
$1.51
|
| Rate for Payer: PACE SWMI |
$1.58
|
| Rate for Payer: PHP Commercial |
$5.39
|
| Rate for Payer: PHP Medicare Advantage |
$1.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.52
|
| Rate for Payer: Priority Health Medicare |
$1.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.41
|
| Rate for Payer: Railroad Medicare Medicare |
$1.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.58
|
| Rate for Payer: UHC Core |
$5.29
|
| Rate for Payer: UHC Exchange |
$1.58
|
| Rate for Payer: UHC Medicaid |
$1.12
|
| Rate for Payer: UHC Medicare Advantage |
$1.58
|
| Rate for Payer: UHCCP Medicaid |
$1.12
|
| Rate for Payer: VA VA |
$1.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.75
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
NDC 00121063805
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Aetna Commercial |
$5.41
|
| Rate for Payer: Aetna Medicare |
$1.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.99
|
| Rate for Payer: BCBS Complete |
$1.18
|
| Rate for Payer: BCBS MAPPO |
$1.59
|
| Rate for Payer: BCBS Trust/PPO |
$5.23
|
| Rate for Payer: BCN Commercial |
$5.23
|
| Rate for Payer: BCN Medicare Advantage |
$1.59
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cofinity Commercial |
$5.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.59
|
| Rate for Payer: Healthscope Commercial |
$5.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.77
|
| Rate for Payer: Mclaren Medicaid |
$1.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.67
|
| Rate for Payer: Meridian Medicaid |
$1.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.41
|
| Rate for Payer: Nomi Health Commercial |
$5.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.77
|
| Rate for Payer: PACE Senior Care Partners |
$1.51
|
| Rate for Payer: PACE SWMI |
$1.59
|
| Rate for Payer: PHP Commercial |
$5.41
|
| Rate for Payer: PHP Medicare Advantage |
$1.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.53
|
| Rate for Payer: Priority Health Medicare |
$1.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.43
|
| Rate for Payer: Railroad Medicare Medicare |
$1.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.60
|
| Rate for Payer: UHC Core |
$5.31
|
| Rate for Payer: UHC Exchange |
$1.59
|
| Rate for Payer: UHC Medicaid |
$1.12
|
| Rate for Payer: UHC Medicare Advantage |
$1.59
|
| Rate for Payer: UHCCP Medicaid |
$1.12
|
| Rate for Payer: VA VA |
$1.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.77
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
NDC 00121063800
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Aetna Commercial |
$5.41
|
| Rate for Payer: Aetna Medicare |
$1.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.99
|
| Rate for Payer: BCBS Complete |
$1.18
|
| Rate for Payer: BCBS MAPPO |
$1.59
|
| Rate for Payer: BCBS Trust/PPO |
$5.23
|
| Rate for Payer: BCN Commercial |
$5.23
|
| Rate for Payer: BCN Medicare Advantage |
$1.59
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cofinity Commercial |
$5.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.59
|
| Rate for Payer: Healthscope Commercial |
$5.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.77
|
| Rate for Payer: Mclaren Medicaid |
$1.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.67
|
| Rate for Payer: Meridian Medicaid |
$1.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.41
|
| Rate for Payer: Nomi Health Commercial |
$5.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.77
|
| Rate for Payer: PACE Senior Care Partners |
$1.51
|
| Rate for Payer: PACE SWMI |
$1.59
|
| Rate for Payer: PHP Commercial |
$5.41
|
| Rate for Payer: PHP Medicare Advantage |
$1.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.53
|
| Rate for Payer: Priority Health Medicare |
$1.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.43
|
| Rate for Payer: Railroad Medicare Medicare |
$1.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.60
|
| Rate for Payer: UHC Core |
$5.31
|
| Rate for Payer: UHC Exchange |
$1.59
|
| Rate for Payer: UHC Medicaid |
$1.12
|
| Rate for Payer: UHC Medicare Advantage |
$1.59
|
| Rate for Payer: UHCCP Medicaid |
$1.12
|
| Rate for Payer: VA VA |
$1.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.77
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 09900000386
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: Aetna Medicare |
$0.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.18
|
| Rate for Payer: BCBS Complete |
$0.11
|
| Rate for Payer: BCBS MAPPO |
$0.15
|
| Rate for Payer: BCBS Trust/PPO |
$0.49
|
| Rate for Payer: BCN Commercial |
$0.49
|
| Rate for Payer: BCN Medicare Advantage |
$0.15
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cofinity Commercial |
$0.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.15
|
| Rate for Payer: Healthscope Commercial |
$0.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.44
|
| Rate for Payer: Mclaren Medicaid |
$0.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.15
|
| Rate for Payer: Meridian Medicaid |
$0.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.17
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.50
|
| Rate for Payer: Nomi Health Commercial |
$0.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.44
|
| Rate for Payer: PACE Senior Care Partners |
$0.14
|
| Rate for Payer: PACE SWMI |
$0.15
|
| Rate for Payer: PHP Commercial |
$0.50
|
| Rate for Payer: PHP Medicare Advantage |
$0.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$0.51
|
| Rate for Payer: Priority Health Medicare |
$0.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.41
|
| Rate for Payer: Railroad Medicare Medicare |
$0.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.52
|
| Rate for Payer: UHC Core |
$0.49
|
| Rate for Payer: UHC Exchange |
$0.15
|
| Rate for Payer: UHC Medicaid |
$0.10
|
| Rate for Payer: UHC Medicare Advantage |
$0.15
|
| Rate for Payer: UHCCP Medicaid |
$0.10
|
| Rate for Payer: VA VA |
$0.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.44
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.34
|
|
|
Service Code
|
NDC 69339014919
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Aetna Commercial |
$5.39
|
| Rate for Payer: BCBS Trust/PPO |
$5.24
|
| Rate for Payer: BCN Commercial |
$5.24
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cofinity Commercial |
$5.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.07
|
| Rate for Payer: Healthscope Commercial |
$5.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.39
|
| Rate for Payer: Nomi Health Commercial |
$5.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.75
|
| Rate for Payer: PHP Commercial |
$5.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.58
|
| Rate for Payer: UHC Core |
$5.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.75
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
NDC 00121063805
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Aetna Commercial |
$5.41
|
| Rate for Payer: BCBS Trust/PPO |
$5.25
|
| Rate for Payer: BCN Commercial |
$5.25
|
| Rate for Payer: Cash Price |
$5.09
|
| Rate for Payer: Cofinity Commercial |
$5.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.09
|
| Rate for Payer: Healthscope Commercial |
$5.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.41
|
| Rate for Payer: Nomi Health Commercial |
$5.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.77
|
| Rate for Payer: PHP Commercial |
$5.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.60
|
| Rate for Payer: UHC Core |
$5.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.77
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.30
|
|
|
Service Code
|
NDC 00904751372
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: Aetna Medicare |
$1.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.28
|
| Rate for Payer: BCBS Complete |
$1.35
|
| Rate for Payer: BCBS MAPPO |
$1.82
|
| Rate for Payer: BCBS Trust/PPO |
$6.00
|
| Rate for Payer: BCN Commercial |
$6.00
|
| Rate for Payer: BCN Medicare Advantage |
$1.82
|
| Rate for Payer: Cash Price |
$5.84
|
| Rate for Payer: Cofinity Commercial |
$6.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.82
|
| Rate for Payer: Healthscope Commercial |
$6.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.47
|
| Rate for Payer: Mclaren Medicaid |
$1.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.92
|
| Rate for Payer: Meridian Medicaid |
$1.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$2.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.21
|
| Rate for Payer: Nomi Health Commercial |
$5.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.47
|
| Rate for Payer: PACE Senior Care Partners |
$1.73
|
| Rate for Payer: PACE SWMI |
$1.82
|
| Rate for Payer: PHP Commercial |
$6.21
|
| Rate for Payer: PHP Medicare Advantage |
$1.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$6.35
|
| Rate for Payer: Priority Health Medicare |
$1.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.08
|
| Rate for Payer: Railroad Medicare Medicare |
$1.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.42
|
| Rate for Payer: UHC Core |
$6.10
|
| Rate for Payer: UHC Exchange |
$1.82
|
| Rate for Payer: UHC Medicaid |
$1.29
|
| Rate for Payer: UHC Medicare Advantage |
$1.82
|
| Rate for Payer: UHCCP Medicaid |
$1.29
|
| Rate for Payer: VA VA |
$1.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.47
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 09900000386
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna Commercial |
$0.50
|
| Rate for Payer: BCBS Trust/PPO |
$0.49
|
| Rate for Payer: BCN Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cofinity Commercial |
$0.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.47
|
| Rate for Payer: Healthscope Commercial |
$0.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.50
|
| Rate for Payer: Nomi Health Commercial |
$0.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.44
|
| Rate for Payer: PHP Commercial |
$0.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$0.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.52
|
| Rate for Payer: UHC Core |
$0.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.44
|
|
