|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$32.38
|
|
|
Service Code
|
NDC 67877012405
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$29.14 |
| Rate for Payer: Aetna Commercial |
$27.52
|
| Rate for Payer: BCBS Trust/PPO |
$26.74
|
| Rate for Payer: BCN Commercial |
$26.74
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cofinity Commercial |
$27.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$29.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.52
|
| Rate for Payer: Nomi Health Commercial |
$26.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.29
|
| Rate for Payer: PHP Commercial |
$27.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$28.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.49
|
| Rate for Payer: UHC Core |
$27.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.29
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$32.38
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$29.14 |
| Rate for Payer: Aetna Commercial |
$27.52
|
| Rate for Payer: BCBS Trust/PPO |
$26.74
|
| Rate for Payer: BCN Commercial |
$26.74
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cofinity Commercial |
$27.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$29.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.52
|
| Rate for Payer: Nomi Health Commercial |
$26.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.29
|
| Rate for Payer: PHP Commercial |
$27.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$28.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.49
|
| Rate for Payer: UHC Core |
$27.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.29
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$134.40
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.54 |
| Max. Negotiated Rate |
$120.96 |
| Rate for Payer: Aetna Commercial |
$114.24
|
| Rate for Payer: BCBS Trust/PPO |
$111.00
|
| Rate for Payer: BCN Commercial |
$111.00
|
| Rate for Payer: Cash Price |
$107.52
|
| Rate for Payer: Cofinity Commercial |
$115.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.52
|
| Rate for Payer: Healthscope Commercial |
$120.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.24
|
| Rate for Payer: Nomi Health Commercial |
$110.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.80
|
| Rate for Payer: PHP Commercial |
$114.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$116.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$118.27
|
| Rate for Payer: UHC Core |
$112.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.80
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 19903001023
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: BCBS Trust/PPO |
$20.35
|
| Rate for Payer: BCN Commercial |
$20.35
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Nomi Health Commercial |
$20.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.48
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$21.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.68
|
| Rate for Payer: UHC Core |
$20.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 09900000926
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.82
|
| Rate for Payer: BCBS Trust/PPO |
$0.80
|
| Rate for Payer: BCN Commercial |
$0.80
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cofinity Commercial |
$0.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.78
|
| Rate for Payer: Healthscope Commercial |
$0.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.82
|
| Rate for Payer: Nomi Health Commercial |
$0.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.73
|
| Rate for Payer: PHP Commercial |
$0.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$0.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.85
|
| Rate for Payer: UHC Core |
$0.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.73
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 09900000351
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: BCBS Trust/PPO |
$1.47
|
| Rate for Payer: BCN Commercial |
$1.47
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.42
|
| Rate for Payer: Healthscope Commercial |
$1.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.51
|
| Rate for Payer: Nomi Health Commercial |
$1.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.33
|
| Rate for Payer: PHP Commercial |
$1.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.57
|
| Rate for Payer: UHC Core |
$1.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.33
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 09900000351
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna Medicare |
$0.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.56
|
| Rate for Payer: BCBS Complete |
$0.33
|
| Rate for Payer: BCBS MAPPO |
$0.45
|
| Rate for Payer: BCBS Trust/PPO |
$1.46
|
| Rate for Payer: BCN Commercial |
$1.46
|
| Rate for Payer: BCN Medicare Advantage |
$0.45
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.45
|
| Rate for Payer: Healthscope Commercial |
$1.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.33
|
| Rate for Payer: Mclaren Medicaid |
$0.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.47
|
| Rate for Payer: Meridian Medicaid |
$0.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.51
|
| Rate for Payer: Nomi Health Commercial |
$1.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.33
|
| Rate for Payer: PACE Senior Care Partners |
$0.42
|
| Rate for Payer: PACE SWMI |
$0.45
|
| Rate for Payer: PHP Commercial |
$1.51
|
| Rate for Payer: PHP Medicare Advantage |
$0.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1.55
|
| Rate for Payer: Priority Health Medicare |
$0.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.24
|
| Rate for Payer: Railroad Medicare Medicare |
$0.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.57
|
| Rate for Payer: UHC Core |
$1.49
|
| Rate for Payer: UHC Exchange |
$0.45
|
| Rate for Payer: UHC Medicaid |
$0.31
|
| Rate for Payer: UHC Medicare Advantage |
$0.45
|
| Rate for Payer: UHCCP Medicaid |
$0.31
|
| Rate for Payer: VA VA |
$0.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.33
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 09900000926
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.82
|
| Rate for Payer: Aetna Medicare |
$0.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.30
|
| Rate for Payer: BCBS Complete |
$0.18
|
| Rate for Payer: BCBS MAPPO |
$0.24
|
| Rate for Payer: BCBS Trust/PPO |
$0.80
|
| Rate for Payer: BCN Commercial |
$0.80
|
| Rate for Payer: BCN Medicare Advantage |
$0.24
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cofinity Commercial |
$0.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.24
|
| Rate for Payer: Healthscope Commercial |
$0.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.73
|
| Rate for Payer: Mclaren Medicaid |
$0.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.25
|
| Rate for Payer: Meridian Medicaid |
$0.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.28
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.82
|
| Rate for Payer: Nomi Health Commercial |
$0.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.73
|
| Rate for Payer: PACE Senior Care Partners |
$0.23
|
| Rate for Payer: PACE SWMI |
$0.24
|
| Rate for Payer: PHP Commercial |
$0.82
|
| Rate for Payer: PHP Medicare Advantage |
$0.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$0.84
|
| Rate for Payer: Priority Health Medicare |
$0.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.68
|
| Rate for Payer: Railroad Medicare Medicare |
$0.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.85
|
| Rate for Payer: UHC Core |
$0.81
|
| Rate for Payer: UHC Exchange |
$0.24
|
| Rate for Payer: UHC Medicaid |
$0.17
|
| Rate for Payer: UHC Medicare Advantage |
$0.24
|
| Rate for Payer: UHCCP Medicaid |
$0.17
|
| Rate for Payer: VA VA |
$0.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.73
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$24.64
|
|
|
Service Code
|
NDC 19903001023
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.70
|
| Rate for Payer: BCBS Complete |
$4.56
|
| Rate for Payer: BCBS MAPPO |
$6.16
|
| Rate for Payer: BCBS Trust/PPO |
$20.26
|
| Rate for Payer: BCN Commercial |
$20.26
|
| Rate for Payer: BCN Medicare Advantage |
$6.16
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.16
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Mclaren Medicaid |
$4.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.47
|
| Rate for Payer: Meridian Medicaid |
$4.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.08
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Nomi Health Commercial |
$20.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.48
|
| Rate for Payer: PACE Senior Care Partners |
$5.85
|
| Rate for Payer: PACE SWMI |
$6.16
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: PHP Medicare Advantage |
$6.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$21.44
|
| Rate for Payer: Priority Health Medicare |
$6.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.15
|
| Rate for Payer: Railroad Medicare Medicare |
$6.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.68
|
| Rate for Payer: UHC Core |
$20.57
|
| Rate for Payer: UHC Exchange |
$6.16
|
| Rate for Payer: UHC Medicaid |
$4.34
|
| Rate for Payer: UHC Medicare Advantage |
$6.16
|
| Rate for Payer: UHCCP Medicaid |
$4.34
|
| Rate for Payer: VA VA |
$6.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$4.12
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna Medicare |
$1.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.29
|
| Rate for Payer: BCBS Complete |
$0.76
|
| Rate for Payer: BCBS MAPPO |
$1.03
|
| Rate for Payer: BCBS Trust/PPO |
$3.39
|
| Rate for Payer: BCN Commercial |
$3.39
|
| Rate for Payer: BCN Medicare Advantage |
$1.03
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.03
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.09
|
| Rate for Payer: Mclaren Medicaid |
$0.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.08
|
| Rate for Payer: Meridian Medicaid |
$0.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.18
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.50
|
| Rate for Payer: Nomi Health Commercial |
$3.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.09
|
| Rate for Payer: PACE Senior Care Partners |
$0.98
|
| Rate for Payer: PACE SWMI |
$1.03
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: PHP Medicare Advantage |
$1.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.58
|
| Rate for Payer: Priority Health Medicare |
$1.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.87
|
| Rate for Payer: Railroad Medicare Medicare |
$1.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.63
|
| Rate for Payer: UHC Core |
$3.44
|
| Rate for Payer: UHC Exchange |
$1.03
|
| Rate for Payer: UHC Medicaid |
$0.73
|
| Rate for Payer: UHC Medicare Advantage |
$1.03
|
| Rate for Payer: UHCCP Medicaid |
$0.73
|
| Rate for Payer: VA VA |
$1.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.09
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: BCBS Trust/PPO |
$3.40
|
| Rate for Payer: BCN Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.50
|
| Rate for Payer: Nomi Health Commercial |
$3.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.63
|
| Rate for Payer: UHC Core |
$3.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.09
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$411.25
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.50 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: Aetna Medicare |
$106.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$128.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$128.52
|
| Rate for Payer: BCBS Complete |
$76.12
|
| Rate for Payer: BCBS MAPPO |
$102.81
|
| Rate for Payer: BCBS Trust/PPO |
$338.09
|
| Rate for Payer: BCN Commercial |
$338.09
|
| Rate for Payer: BCN Medicare Advantage |
$102.81
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$102.81
|
| Rate for Payer: Healthscope Commercial |
$370.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.44
|
| Rate for Payer: Mclaren Medicaid |
$72.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$107.95
|
| Rate for Payer: Meridian Medicaid |
$76.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.23
|
| Rate for Payer: Molina Medicare/Medicaid |
$113.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.56
|
| Rate for Payer: Nomi Health Commercial |
$337.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$308.44
|
| Rate for Payer: PACE Senior Care Partners |
$97.67
|
| Rate for Payer: PACE SWMI |
$102.81
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: PHP Medicare Advantage |
$102.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$72.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$357.79
|
| Rate for Payer: Priority Health Medicare |
$103.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.23
|
| Rate for Payer: Railroad Medicare Medicare |
$102.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$361.90
|
| Rate for Payer: UHC Core |
$343.39
|
| Rate for Payer: UHC Exchange |
$102.81
|
| Rate for Payer: UHC Medicaid |
$72.50
|
| Rate for Payer: UHC Medicare Advantage |
$102.81
|
| Rate for Payer: UHCCP Medicaid |
$72.50
|
| Rate for Payer: VA VA |
$102.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.44
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$411.25
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.23 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: BCBS Trust/PPO |
$339.65
|
| Rate for Payer: BCN Commercial |
$339.65
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$370.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.56
|
| Rate for Payer: Nomi Health Commercial |
$337.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$308.44
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$357.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$361.90
|
| Rate for Payer: UHC Core |
$343.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.44
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$228.31
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.25 |
| Max. Negotiated Rate |
$205.48 |
| Rate for Payer: Aetna Commercial |
$194.06
|
| Rate for Payer: Aetna Commercial |
$384.64
|
| Rate for Payer: Aetna Medicare |
$117.66
|
| Rate for Payer: Aetna Medicare |
$59.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$141.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$71.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$71.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$141.41
|
| Rate for Payer: BCBS Complete |
$42.26
|
| Rate for Payer: BCBS Complete |
$83.76
|
| Rate for Payer: BCBS MAPPO |
$57.08
|
| Rate for Payer: BCBS MAPPO |
$113.13
|
| Rate for Payer: BCBS Trust/PPO |
$187.69
|
| Rate for Payer: BCBS Trust/PPO |
$372.02
|
| Rate for Payer: BCN Commercial |
$372.02
|
| Rate for Payer: BCN Commercial |
$187.69
|
| Rate for Payer: BCN Medicare Advantage |
$113.13
|
| Rate for Payer: BCN Medicare Advantage |
$57.08
|
| Rate for Payer: Cash Price |
$182.65
|
| Rate for Payer: Cash Price |
$362.02
|
| Rate for Payer: Cofinity Commercial |
$196.35
|
| Rate for Payer: Cofinity Commercial |
$389.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$362.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$113.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.08
|
| Rate for Payer: Healthscope Commercial |
$205.48
|
| Rate for Payer: Healthscope Commercial |
$407.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$171.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.39
|
| Rate for Payer: Mclaren Medicaid |
$79.78
|
| Rate for Payer: Mclaren Medicaid |
$40.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$118.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$59.93
|
| Rate for Payer: Meridian Medicaid |
$42.26
|
| Rate for Payer: Meridian Medicaid |
$83.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$130.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$124.44
|
| Rate for Payer: Molina Medicare/Medicaid |
$62.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$384.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.06
|
| Rate for Payer: Nomi Health Commercial |
$371.07
|
| Rate for Payer: Nomi Health Commercial |
$187.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$171.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$339.39
|
| Rate for Payer: PACE Senior Care Partners |
$107.47
|
| Rate for Payer: PACE Senior Care Partners |
$54.22
|
| Rate for Payer: PACE SWMI |
$113.13
|
| Rate for Payer: PACE SWMI |
$57.08
|
| Rate for Payer: PHP Commercial |
$194.06
|
| Rate for Payer: PHP Commercial |
$384.64
|
| Rate for Payer: PHP Medicare Advantage |
$57.08
|
| Rate for Payer: PHP Medicare Advantage |
$113.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$79.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$40.25
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$393.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$198.63
|
| Rate for Payer: Priority Health Medicare |
$114.26
|
| Rate for Payer: Priority Health Medicare |
$57.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$158.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$314.95
|
| Rate for Payer: Railroad Medicare Medicare |
$57.08
|
| Rate for Payer: Railroad Medicare Medicare |
$113.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$200.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$398.22
|
| Rate for Payer: UHC Core |
$377.85
|
| Rate for Payer: UHC Core |
$190.64
|
| Rate for Payer: UHC Exchange |
$113.13
|
| Rate for Payer: UHC Exchange |
$57.08
|
| Rate for Payer: UHC Medicaid |
$79.78
|
| Rate for Payer: UHC Medicaid |
$40.25
|
| Rate for Payer: UHC Medicare Advantage |
$57.08
|
| Rate for Payer: UHC Medicare Advantage |
$113.13
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
| Rate for Payer: UHCCP Medicaid |
$79.78
|
| Rate for Payer: VA VA |
$57.08
|
| Rate for Payer: VA VA |
$113.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$171.23
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$228.31
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.90 |
| Max. Negotiated Rate |
$205.48 |
| Rate for Payer: Aetna Commercial |
$194.06
|
| Rate for Payer: Aetna Commercial |
$384.64
|
| Rate for Payer: BCBS Trust/PPO |
$188.56
|
| Rate for Payer: BCBS Trust/PPO |
$373.74
|
| Rate for Payer: BCN Commercial |
$188.56
|
| Rate for Payer: BCN Commercial |
$373.74
|
| Rate for Payer: Cash Price |
$182.65
|
| Rate for Payer: Cash Price |
$362.02
|
| Rate for Payer: Cofinity Commercial |
$389.17
|
| Rate for Payer: Cofinity Commercial |
$196.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$362.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.65
|
| Rate for Payer: Healthscope Commercial |
$205.48
|
| Rate for Payer: Healthscope Commercial |
$407.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$171.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$384.64
|
| Rate for Payer: Nomi Health Commercial |
$187.21
|
| Rate for Payer: Nomi Health Commercial |
$371.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$171.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$339.39
|
| Rate for Payer: PHP Commercial |
$384.64
|
| Rate for Payer: PHP Commercial |
$194.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$393.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$198.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$158.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$314.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$200.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$398.22
|
| Rate for Payer: UHC Core |
$190.64
|
| Rate for Payer: UHC Core |
$377.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$171.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.39
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$14,444.82
|
|
|
Service Code
|
APR-DRG 3002
|
| Min. Negotiated Rate |
$13,756.98 |
| Max. Negotiated Rate |
$14,444.82 |
| Rate for Payer: BCBS Complete |
$14,444.82
|
| Rate for Payer: Mclaren Medicaid |
$13,756.98
|
| Rate for Payer: Meridian Medicaid |
$14,444.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,756.98
|
| Rate for Payer: UHC Medicaid |
$13,756.98
|
| Rate for Payer: UHCCP Medicaid |
$13,756.98
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$25,096.24
|
|
|
Service Code
|
APR-DRG 3004
|
| Min. Negotiated Rate |
$23,901.18 |
| Max. Negotiated Rate |
$25,096.24 |
| Rate for Payer: BCBS Complete |
$25,096.24
|
| Rate for Payer: Mclaren Medicaid |
$23,901.18
|
| Rate for Payer: Meridian Medicaid |
$25,096.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$23,901.18
|
| Rate for Payer: UHC Medicaid |
$23,901.18
|
| Rate for Payer: UHCCP Medicaid |
$23,901.18
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$19,141.63
|
|
|
Service Code
|
APR-DRG 3003
|
| Min. Negotiated Rate |
$18,230.12 |
| Max. Negotiated Rate |
$19,141.63 |
| Rate for Payer: BCBS Complete |
$19,141.63
|
| Rate for Payer: Mclaren Medicaid |
$18,230.12
|
| Rate for Payer: Meridian Medicaid |
$19,141.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$18,230.12
|
| Rate for Payer: UHC Medicaid |
$18,230.12
|
| Rate for Payer: UHCCP Medicaid |
$18,230.12
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$12,633.83
|
|
|
Service Code
|
APR-DRG 3001
|
| Min. Negotiated Rate |
$12,032.22 |
| Max. Negotiated Rate |
$12,633.83 |
| Rate for Payer: BCBS Complete |
$12,633.83
|
| Rate for Payer: Mclaren Medicaid |
$12,032.22
|
| Rate for Payer: Meridian Medicaid |
$12,633.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$12,032.22
|
| Rate for Payer: UHC Medicaid |
$12,032.22
|
| Rate for Payer: UHCCP Medicaid |
$12,032.22
|
|
|
SKIN CARE CONSULT
|
Professional
|
Both
|
$27.00
|
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: BCBS Complete |
$10.80
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.25
|
|
|
SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$35,205.51
|
|
|
Service Code
|
APR-DRG 3124
|
| Min. Negotiated Rate |
$33,529.06 |
| Max. Negotiated Rate |
$35,205.51 |
| Rate for Payer: BCBS Complete |
$35,205.51
|
| Rate for Payer: Mclaren Medicaid |
$33,529.06
|
| Rate for Payer: Meridian Medicaid |
$35,205.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$33,529.06
|
| Rate for Payer: UHC Medicaid |
$33,529.06
|
| Rate for Payer: UHCCP Medicaid |
$33,529.06
|
|
|
SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$9,769.06
|
|
|
Service Code
|
APR-DRG 3121
|
| Min. Negotiated Rate |
$9,303.86 |
| Max. Negotiated Rate |
$9,769.06 |
| Rate for Payer: BCBS Complete |
$9,769.06
|
| Rate for Payer: Mclaren Medicaid |
$9,303.86
|
| Rate for Payer: Meridian Medicaid |
$9,769.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,303.86
|
| Rate for Payer: UHC Medicaid |
$9,303.86
|
| Rate for Payer: UHCCP Medicaid |
$9,303.86
|
|
|
SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$18,608.43
|
|
|
Service Code
|
APR-DRG 3123
|
| Min. Negotiated Rate |
$17,722.31 |
| Max. Negotiated Rate |
$18,608.43 |
| Rate for Payer: BCBS Complete |
$18,608.43
|
| Rate for Payer: Mclaren Medicaid |
$17,722.31
|
| Rate for Payer: Meridian Medicaid |
$18,608.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$17,722.31
|
| Rate for Payer: UHC Medicaid |
$17,722.31
|
| Rate for Payer: UHCCP Medicaid |
$17,722.31
|
|
|
SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
|
IP
|
$14,152.46
|
|
|
Service Code
|
APR-DRG 3122
|
| Min. Negotiated Rate |
$13,478.53 |
| Max. Negotiated Rate |
$14,152.46 |
| Rate for Payer: BCBS Complete |
$14,152.46
|
| Rate for Payer: Mclaren Medicaid |
$13,478.53
|
| Rate for Payer: Meridian Medicaid |
$14,152.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,478.53
|
| Rate for Payer: UHC Medicaid |
$13,478.53
|
| Rate for Payer: UHCCP Medicaid |
$13,478.53
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
|
IP
|
$17,452.63
|
|
|
Service Code
|
APR-DRG 3613
|
| Min. Negotiated Rate |
$16,621.55 |
| Max. Negotiated Rate |
$17,452.63 |
| Rate for Payer: BCBS Complete |
$17,452.63
|
| Rate for Payer: Mclaren Medicaid |
$16,621.55
|
| Rate for Payer: Meridian Medicaid |
$17,452.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$16,621.55
|
| Rate for Payer: UHC Medicaid |
$16,621.55
|
| Rate for Payer: UHCCP Medicaid |
$16,621.55
|
|
