|
ALTEPLASE 100 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,687.84 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna American Axle |
$18,743.40
|
| Rate for Payer: Aetna American Axle |
$187.43
|
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna Commercial |
$245.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cash Price |
$230.69
|
| Rate for Payer: Cofinity Commercial |
$247.99
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Commercial |
$201.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$230.69
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Healthscope Commercial |
$259.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$201.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,185.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21,627.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,510.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$245.11
|
| Rate for Payer: PHP Commercial |
$245.11
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,185.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.85
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: Priority Health SBD |
$181.67
|
| Rate for Payer: UMR Bronson Commercial |
$126.88
|
| Rate for Payer: UMR Bronson Commercial |
$12,687.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21,627.00
|
|
|
ALTEPLASE 100 MG IV INFUSION FOR STROKE
|
Facility
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150807
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,687.84 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna American Axle |
$18,743.40
|
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,185.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21,627.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,185.20
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: UMR Bronson Commercial |
$12,687.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21,627.00
|
|
|
ALTEPLASE 100MG IV SOLUTION FOR PE
|
Facility
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,687.84 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna American Axle |
$18,743.40
|
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,185.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21,627.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,185.20
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: UMR Bronson Commercial |
$12,687.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21,627.00
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION
|
Facility
OP
|
$582.24
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.67 |
| Max. Negotiated Rate |
$524.02 |
| Rate for Payer: Aetna American Axle |
$378.46
|
| Rate for Payer: Aetna Commercial |
$494.90
|
| Rate for Payer: Aetna Medicare |
$92.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$378.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$111.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$111.22
|
| Rate for Payer: BCBS Complete |
$51.11
|
| Rate for Payer: BCBS MAPPO |
$88.97
|
| Rate for Payer: BCBS Trust/PPO |
$287.51
|
| Rate for Payer: BCN Medicare Advantage |
$88.97
|
| Rate for Payer: Cash Price |
$465.79
|
| Rate for Payer: Cash Price |
$465.79
|
| Rate for Payer: Cofinity Commercial |
$407.57
|
| Rate for Payer: Cofinity Commercial |
$500.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$465.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$88.97
|
| Rate for Payer: Healthscope Commercial |
$524.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$407.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$436.68
|
| Rate for Payer: Mclaren Medicaid |
$48.67
|
| Rate for Payer: Mclaren Medicare |
$88.97
|
| Rate for Payer: Meridian Medicaid |
$51.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$93.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$494.90
|
| Rate for Payer: PACE Medicare |
$84.53
|
| Rate for Payer: PACE SWMI |
$88.97
|
| Rate for Payer: PHP Commercial |
$494.90
|
| Rate for Payer: PHP Medicare Advantage |
$88.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$48.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$407.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$261.87
|
| Rate for Payer: Priority Health Medicare |
$88.97
|
| Rate for Payer: Priority Health Narrow Network |
$209.50
|
| Rate for Payer: Priority Health SBD |
$366.81
|
| Rate for Payer: Railroad Medicare Medicare |
$88.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$88.97
|
| Rate for Payer: UHC Medicare Advantage |
$91.64
|
| Rate for Payer: UMR Bronson Commercial |
$215.43
|
| Rate for Payer: VA VA |
$88.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$436.68
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION
|
Facility
IP
|
$582.24
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$256.19 |
| Max. Negotiated Rate |
$524.02 |
| Rate for Payer: Aetna American Axle |
$378.46
|
| Rate for Payer: Aetna Commercial |
$494.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$378.46
|
| Rate for Payer: Cash Price |
$465.79
|
| Rate for Payer: Cofinity Commercial |
$407.57
|
| Rate for Payer: Cofinity Commercial |
$500.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$465.79
|
| Rate for Payer: Healthscope Commercial |
$524.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$407.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$436.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$494.90
|
| Rate for Payer: PHP Commercial |
$494.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$407.57
|
| Rate for Payer: Priority Health SBD |
$366.81
|
| Rate for Payer: UMR Bronson Commercial |
$256.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$436.68
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,343.92 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna American Axle |
$9,371.70
|
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,371.70
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$10,092.60
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,092.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,255.30
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,092.60
|
| Rate for Payer: Priority Health SBD |
$9,083.34
|
| Rate for Payer: UMR Bronson Commercial |
$6,343.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALTEPLASE 50 MG IV INFUSION FOR STROKE
|
Facility
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
301291
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,343.92 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna American Axle |
$9,371.70
|
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,371.70
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$10,092.60
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,092.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,255.30
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,092.60
|
| Rate for Payer: Priority Health SBD |
$9,083.34
|
| Rate for Payer: UMR Bronson Commercial |
$6,343.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALTEPLASE INFUSION FOR CARDIAC ARREST
|
Facility
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
300766
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,343.92 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna American Axle |
$9,371.70
|
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,371.70
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$10,092.60
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,092.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,255.30
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,092.60
|
| Rate for Payer: Priority Health SBD |
$9,083.34
|
| Rate for Payer: UMR Bronson Commercial |
$6,343.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALUM, AMMONIUM (BULK) POWDER
|
Facility
IP
|
$327.59
|
|
|
Service Code
|
NDC 395004912
|
| Hospital Charge Code |
345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$294.83 |
| Rate for Payer: Aetna American Axle |
$212.93
|
| Rate for Payer: Aetna Commercial |
$278.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.93
|
| Rate for Payer: Cash Price |
$262.07
|
| Rate for Payer: Cofinity Commercial |
$229.31
|
| Rate for Payer: Cofinity Commercial |
$281.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.07
|
| Rate for Payer: Healthscope Commercial |
$294.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.45
|
| Rate for Payer: PHP Commercial |
$278.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.31
|
| Rate for Payer: Priority Health SBD |
$206.38
|
| Rate for Payer: UMR Bronson Commercial |
$144.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.69
|
|
|
ALUM, AMMONIUM (BULK) POWDER
|
Facility
IP
|
$135.83
|
|
|
Service Code
|
NDC 395004996
|
| Hospital Charge Code |
345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.77 |
| Max. Negotiated Rate |
$122.25 |
| Rate for Payer: Aetna American Axle |
$88.29
|
| Rate for Payer: Aetna Commercial |
$115.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.29
|
| Rate for Payer: Cash Price |
$108.66
|
| Rate for Payer: Cofinity Commercial |
$116.81
|
| Rate for Payer: Cofinity Commercial |
$95.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.66
|
| Rate for Payer: Healthscope Commercial |
$122.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.46
|
| Rate for Payer: PHP Commercial |
$115.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.08
|
| Rate for Payer: Priority Health SBD |
$85.57
|
| Rate for Payer: UMR Bronson Commercial |
$59.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.87
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$111.63
|
|
|
Service Code
|
NDC 0536-0091-85
|
| Hospital Charge Code |
353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.12 |
| Max. Negotiated Rate |
$100.47 |
| Rate for Payer: Aetna American Axle |
$72.56
|
| Rate for Payer: Aetna Commercial |
$94.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.56
|
| Rate for Payer: Cash Price |
$89.30
|
| Rate for Payer: Cofinity Commercial |
$78.14
|
| Rate for Payer: Cofinity Commercial |
$96.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.30
|
| Rate for Payer: Healthscope Commercial |
$100.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$94.89
|
| Rate for Payer: PHP Commercial |
$94.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.14
|
| Rate for Payer: Priority Health SBD |
$70.33
|
| Rate for Payer: UMR Bronson Commercial |
$49.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.72
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$10.26
|
|
|
Service Code
|
NDC 0904-6838-73
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$13.23
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna American Axle |
$8.60
|
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.60
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$11.38
|
| Rate for Payer: Cofinity Commercial |
$9.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.58
|
| Rate for Payer: Healthscope Commercial |
$11.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.25
|
| Rate for Payer: PHP Commercial |
$11.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.26
|
| Rate for Payer: Priority Health SBD |
$8.33
|
| Rate for Payer: UMR Bronson Commercial |
$5.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.92
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$10.88
|
|
|
Service Code
|
NDC 9900-0001-91
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna American Axle |
$7.07
|
| Rate for Payer: Aetna Commercial |
$9.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.07
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cofinity Commercial |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$9.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.70
|
| Rate for Payer: Healthscope Commercial |
$9.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.25
|
| Rate for Payer: PHP Commercial |
$9.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.62
|
| Rate for Payer: Priority Health SBD |
$6.85
|
| Rate for Payer: UMR Bronson Commercial |
$4.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.16
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$14.38
|
|
|
Service Code
|
NDC 57896-629-12
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Aetna American Axle |
$9.35
|
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.35
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Cofinity Commercial |
$12.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.50
|
| Rate for Payer: Healthscope Commercial |
$12.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.22
|
| Rate for Payer: PHP Commercial |
$12.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.07
|
| Rate for Payer: Priority Health SBD |
$9.06
|
| Rate for Payer: UMR Bronson Commercial |
$6.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.78
|
|
|
ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)
|
Facility
OP
|
$9,009.23
|
|
|
Service Code
|
CPT 41874
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$240.34 |
| Max. Negotiated Rate |
$9,009.23 |
| Rate for Payer: Aetna Medicare |
$2,976.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,577.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,577.30
|
| Rate for Payer: BCBS Complete |
$1,643.84
|
| Rate for Payer: BCBS MAPPO |
$2,861.84
|
| Rate for Payer: BCBS Trust/PPO |
$330.98
|
| Rate for Payer: BCN Medicare Advantage |
$2,861.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,861.84
|
| Rate for Payer: Mclaren Medicaid |
$1,565.43
|
| Rate for Payer: Mclaren Medicare |
$2,861.84
|
| Rate for Payer: Meridian Medicaid |
$1,643.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,004.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,291.12
|
| Rate for Payer: PACE Medicare |
$2,718.75
|
| Rate for Payer: PACE SWMI |
$2,861.84
|
| Rate for Payer: PHP Medicare Advantage |
$2,861.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,565.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,009.23
|
| Rate for Payer: Priority Health Medicare |
$2,861.84
|
| Rate for Payer: Priority Health Narrow Network |
$7,207.38
|
| Rate for Payer: Railroad Medicare Medicare |
$2,861.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.37
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,861.84
|
| Rate for Payer: UHC Exchange |
$240.34
|
| Rate for Payer: UHC Medicare Advantage |
$2,947.70
|
| Rate for Payer: VA VA |
$2,861.84
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
IP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8,881.07 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna American Axle |
$13,119.76
|
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,119.76
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$14,128.97
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,128.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,138.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17,156.60
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14,128.97
|
| Rate for Payer: Priority Health SBD |
$12,716.07
|
| Rate for Payer: UMR Bronson Commercial |
$8,881.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,138.18
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
IP
|
$359.52
|
|
|
Service Code
|
NDC 0832-1015-00
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.19 |
| Max. Negotiated Rate |
$323.57 |
| Rate for Payer: Aetna American Axle |
$233.69
|
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.69
|
| Rate for Payer: Cash Price |
$287.62
|
| Rate for Payer: Cofinity Commercial |
$251.66
|
| Rate for Payer: Cofinity Commercial |
$309.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.62
|
| Rate for Payer: Healthscope Commercial |
$323.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$305.59
|
| Rate for Payer: PHP Commercial |
$305.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.66
|
| Rate for Payer: Priority Health SBD |
$226.50
|
| Rate for Payer: UMR Bronson Commercial |
$158.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.64
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
IP
|
$725.76
|
|
|
Service Code
|
NDC 0781-2048-01
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$319.33 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna American Axle |
$471.74
|
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$471.74
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$508.03
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$508.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$544.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$616.90
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$508.03
|
| Rate for Payer: Priority Health SBD |
$457.23
|
| Rate for Payer: UMR Bronson Commercial |
$319.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$544.32
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION
|
Facility
IP
|
$133.39
|
|
|
Service Code
|
NDC 50383-807-16
|
| Hospital Charge Code |
365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.69 |
| Max. Negotiated Rate |
$120.05 |
| Rate for Payer: Aetna American Axle |
$86.70
|
| Rate for Payer: Aetna Commercial |
$113.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.70
|
| Rate for Payer: Cash Price |
$106.71
|
| Rate for Payer: Cofinity Commercial |
$114.72
|
| Rate for Payer: Cofinity Commercial |
$93.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.71
|
| Rate for Payer: Healthscope Commercial |
$120.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.38
|
| Rate for Payer: PHP Commercial |
$113.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.37
|
| Rate for Payer: Priority Health SBD |
$84.04
|
| Rate for Payer: UMR Bronson Commercial |
$58.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.04
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION
|
Facility
IP
|
$366.82
|
|
|
Service Code
|
NDC 0121-0646-16
|
| Hospital Charge Code |
365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.40 |
| Max. Negotiated Rate |
$330.14 |
| Rate for Payer: Aetna American Axle |
$238.43
|
| Rate for Payer: Aetna Commercial |
$311.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.43
|
| Rate for Payer: Cash Price |
$293.46
|
| Rate for Payer: Cofinity Commercial |
$256.77
|
| Rate for Payer: Cofinity Commercial |
$315.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.46
|
| Rate for Payer: Healthscope Commercial |
$330.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$275.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$311.80
|
| Rate for Payer: PHP Commercial |
$311.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.77
|
| Rate for Payer: Priority Health SBD |
$231.10
|
| Rate for Payer: UMR Bronson Commercial |
$161.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$275.12
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION
|
Facility
IP
|
$400.16
|
|
|
Service Code
|
NDC 60432-093-16
|
| Hospital Charge Code |
365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.07 |
| Max. Negotiated Rate |
$360.14 |
| Rate for Payer: Aetna American Axle |
$260.10
|
| Rate for Payer: Aetna Commercial |
$340.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.10
|
| Rate for Payer: Cash Price |
$320.13
|
| Rate for Payer: Cofinity Commercial |
$280.11
|
| Rate for Payer: Cofinity Commercial |
$344.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.13
|
| Rate for Payer: Healthscope Commercial |
$360.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$280.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$340.14
|
| Rate for Payer: PHP Commercial |
$340.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.11
|
| Rate for Payer: Priority Health SBD |
$252.10
|
| Rate for Payer: UMR Bronson Commercial |
$176.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.12
|
|
|
AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$3,188.51
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
20803
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,402.94 |
| Max. Negotiated Rate |
$2,869.66 |
| Rate for Payer: Aetna American Axle |
$2,072.53
|
| Rate for Payer: Aetna Commercial |
$2,710.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,072.53
|
| Rate for Payer: Cash Price |
$2,550.81
|
| Rate for Payer: Cofinity Commercial |
$2,231.96
|
| Rate for Payer: Cofinity Commercial |
$2,742.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,550.81
|
| Rate for Payer: Healthscope Commercial |
$2,869.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,231.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,391.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,710.23
|
| Rate for Payer: PHP Commercial |
$2,710.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,231.96
|
| Rate for Payer: Priority Health SBD |
$2,008.76
|
| Rate for Payer: UMR Bronson Commercial |
$1,402.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,391.38
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION
|
Facility
OP
|
$29.07
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
119785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$26.16 |
| Rate for Payer: Aetna American Axle |
$18.90
|
| Rate for Payer: Aetna American Axle |
$32.97
|
| Rate for Payer: Aetna Commercial |
$43.12
|
| Rate for Payer: Aetna Commercial |
$24.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.97
|
| Rate for Payer: BCBS Complete |
$11.63
|
| Rate for Payer: BCBS Complete |
$20.29
|
| Rate for Payer: BCBS Trust/PPO |
$2.66
|
| Rate for Payer: BCBS Trust/PPO |
$2.66
|
| Rate for Payer: Cash Price |
$23.26
|
| Rate for Payer: Cash Price |
$23.26
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cofinity Commercial |
$25.00
|
| Rate for Payer: Cofinity Commercial |
$43.63
|
| Rate for Payer: Cofinity Commercial |
$20.35
|
| Rate for Payer: Cofinity Commercial |
$35.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.58
|
| Rate for Payer: Healthscope Commercial |
$26.16
|
| Rate for Payer: Healthscope Commercial |
$45.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.12
|
| Rate for Payer: PHP Commercial |
$24.71
|
| Rate for Payer: PHP Commercial |
$43.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.35
|
| Rate for Payer: Priority Health SBD |
$18.31
|
| Rate for Payer: Priority Health SBD |
$31.96
|
| Rate for Payer: UMR Bronson Commercial |
$10.76
|
| Rate for Payer: UMR Bronson Commercial |
$18.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.80
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION
|
Facility
IP
|
$16.36
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
119785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.72 |
| Rate for Payer: Aetna American Axle |
$10.63
|
| Rate for Payer: Aetna American Axle |
$32.97
|
| Rate for Payer: Aetna American Axle |
$31.32
|
| Rate for Payer: Aetna Commercial |
$40.95
|
| Rate for Payer: Aetna Commercial |
$13.91
|
| Rate for Payer: Aetna Commercial |
$43.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.32
|
| Rate for Payer: Cash Price |
$38.54
|
| Rate for Payer: Cash Price |
$40.58
|
| Rate for Payer: Cash Price |
$13.09
|
| Rate for Payer: Cofinity Commercial |
$14.07
|
| Rate for Payer: Cofinity Commercial |
$11.45
|
| Rate for Payer: Cofinity Commercial |
$43.63
|
| Rate for Payer: Cofinity Commercial |
$35.51
|
| Rate for Payer: Cofinity Commercial |
$33.73
|
| Rate for Payer: Cofinity Commercial |
$41.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.58
|
| Rate for Payer: Healthscope Commercial |
$14.72
|
| Rate for Payer: Healthscope Commercial |
$43.36
|
| Rate for Payer: Healthscope Commercial |
$45.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.95
|
| Rate for Payer: PHP Commercial |
$13.91
|
| Rate for Payer: PHP Commercial |
$40.95
|
| Rate for Payer: PHP Commercial |
$43.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.51
|
| Rate for Payer: Priority Health SBD |
$10.31
|
| Rate for Payer: Priority Health SBD |
$30.35
|
| Rate for Payer: Priority Health SBD |
$31.96
|
| Rate for Payer: UMR Bronson Commercial |
$21.20
|
| Rate for Payer: UMR Bronson Commercial |
$22.32
|
| Rate for Payer: UMR Bronson Commercial |
$7.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.14
|
|
