|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$212.25
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$191.02 |
| Rate for Payer: Aetna American Axle |
$137.96
|
| Rate for Payer: Aetna American Axle |
$99.40
|
| Rate for Payer: Aetna American Axle |
$154.04
|
| Rate for Payer: Aetna Commercial |
$180.41
|
| Rate for Payer: Aetna Commercial |
$201.43
|
| Rate for Payer: Aetna Commercial |
$129.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.04
|
| Rate for Payer: BCBS Complete |
$84.90
|
| Rate for Payer: BCBS Complete |
$61.17
|
| Rate for Payer: BCBS Complete |
$94.79
|
| Rate for Payer: BCBS Trust/PPO |
$3.14
|
| Rate for Payer: BCBS Trust/PPO |
$3.14
|
| Rate for Payer: BCBS Trust/PPO |
$3.14
|
| Rate for Payer: Cash Price |
$122.34
|
| Rate for Payer: Cash Price |
$189.58
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$122.34
|
| Rate for Payer: Cash Price |
$189.58
|
| Rate for Payer: Cofinity Commercial |
$165.89
|
| Rate for Payer: Cofinity Commercial |
$107.05
|
| Rate for Payer: Cofinity Commercial |
$131.52
|
| Rate for Payer: Cofinity Commercial |
$148.58
|
| Rate for Payer: Cofinity Commercial |
$182.54
|
| Rate for Payer: Cofinity Commercial |
$203.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.80
|
| Rate for Payer: Healthscope Commercial |
$137.64
|
| Rate for Payer: Healthscope Commercial |
$191.02
|
| Rate for Payer: Healthscope Commercial |
$213.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.99
|
| Rate for Payer: PHP Commercial |
$180.41
|
| Rate for Payer: PHP Commercial |
$129.99
|
| Rate for Payer: PHP Commercial |
$201.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.58
|
| Rate for Payer: Priority Health SBD |
$149.30
|
| Rate for Payer: Priority Health SBD |
$133.72
|
| Rate for Payer: Priority Health SBD |
$96.35
|
| Rate for Payer: UMR Bronson Commercial |
$78.53
|
| Rate for Payer: UMR Bronson Commercial |
$56.58
|
| Rate for Payer: UMR Bronson Commercial |
$87.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.19
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$236.98
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.27 |
| Max. Negotiated Rate |
$213.28 |
| Rate for Payer: Aetna American Axle |
$154.04
|
| Rate for Payer: Aetna American Axle |
$137.96
|
| Rate for Payer: Aetna Commercial |
$180.41
|
| Rate for Payer: Aetna Commercial |
$201.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.04
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$189.58
|
| Rate for Payer: Cofinity Commercial |
$148.58
|
| Rate for Payer: Cofinity Commercial |
$182.54
|
| Rate for Payer: Cofinity Commercial |
$165.89
|
| Rate for Payer: Cofinity Commercial |
$203.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.58
|
| Rate for Payer: Healthscope Commercial |
$213.28
|
| Rate for Payer: Healthscope Commercial |
$191.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.41
|
| Rate for Payer: PHP Commercial |
$180.41
|
| Rate for Payer: PHP Commercial |
$201.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.89
|
| Rate for Payer: Priority Health SBD |
$149.30
|
| Rate for Payer: Priority Health SBD |
$133.72
|
| Rate for Payer: UMR Bronson Commercial |
$104.27
|
| Rate for Payer: UMR Bronson Commercial |
$93.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.74
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,527.46
|
|
|
Service Code
|
HCPCS J0850
|
| Hospital Charge Code |
14634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$988.91 |
| Max. Negotiated Rate |
$5,842.21 |
| Rate for Payer: Aetna American Axle |
$3,592.85
|
| Rate for Payer: Aetna Commercial |
$4,698.34
|
| Rate for Payer: Aetna Medicare |
$1,880.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,592.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,259.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,259.84
|
| Rate for Payer: BCBS Complete |
$1,038.44
|
| Rate for Payer: BCBS MAPPO |
$1,807.87
|
| Rate for Payer: BCBS Trust/PPO |
$5,842.21
|
| Rate for Payer: BCN Medicare Advantage |
$1,807.87
|
| Rate for Payer: Cash Price |
$4,421.97
|
| Rate for Payer: Cash Price |
$4,421.97
|
| Rate for Payer: Cofinity Commercial |
$4,753.62
|
| Rate for Payer: Cofinity Commercial |
$3,869.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,421.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,807.87
|
| Rate for Payer: Healthscope Commercial |
$4,974.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,869.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,145.60
|
| Rate for Payer: Mclaren Medicaid |
$988.91
|
| Rate for Payer: Mclaren Medicare |
$1,807.87
|
| Rate for Payer: Meridian Medicaid |
$1,038.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,898.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,079.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,698.34
|
| Rate for Payer: PACE Medicare |
$1,717.48
|
| Rate for Payer: PACE SWMI |
$1,807.87
|
| Rate for Payer: PHP Commercial |
$4,698.34
|
| Rate for Payer: PHP Medicare Advantage |
$1,807.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$988.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,869.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,897.50
|
| Rate for Payer: Priority Health Medicare |
$1,807.87
|
| Rate for Payer: Priority Health Narrow Network |
$3,918.00
|
| Rate for Payer: Priority Health SBD |
$3,482.30
|
| Rate for Payer: Railroad Medicare Medicare |
$1,807.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,807.87
|
| Rate for Payer: UHC Medicare Advantage |
$1,862.11
|
| Rate for Payer: UMR Bronson Commercial |
$2,045.16
|
| Rate for Payer: VA VA |
$1,807.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,145.60
|
|
|
CYTOMEGALOVIRUS IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,527.46
|
|
|
Service Code
|
HCPCS J0850
|
| Hospital Charge Code |
14634
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,432.08 |
| Max. Negotiated Rate |
$4,974.71 |
| Rate for Payer: Aetna American Axle |
$3,592.85
|
| Rate for Payer: Aetna Commercial |
$4,698.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,592.85
|
| Rate for Payer: Cash Price |
$4,421.97
|
| Rate for Payer: Cofinity Commercial |
$3,869.22
|
| Rate for Payer: Cofinity Commercial |
$4,753.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,421.97
|
| Rate for Payer: Healthscope Commercial |
$4,974.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,869.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,145.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,698.34
|
| Rate for Payer: PHP Commercial |
$4,698.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,869.22
|
| Rate for Payer: Priority Health SBD |
$3,482.30
|
| Rate for Payer: UMR Bronson Commercial |
$2,432.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,145.60
|
|
|
DABIGATRAN ETEXILATE 150 MG CAPSULE
|
Facility
|
IP
|
$648.69
|
|
|
Service Code
|
NDC 0597-0360-82
|
| Hospital Charge Code |
106491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.42 |
| Max. Negotiated Rate |
$583.82 |
| Rate for Payer: Aetna American Axle |
$421.65
|
| Rate for Payer: Aetna Commercial |
$551.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$421.65
|
| Rate for Payer: Cash Price |
$518.95
|
| Rate for Payer: Cofinity Commercial |
$454.08
|
| Rate for Payer: Cofinity Commercial |
$557.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$518.95
|
| Rate for Payer: Healthscope Commercial |
$583.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$454.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$486.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$551.39
|
| Rate for Payer: PHP Commercial |
$551.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$454.08
|
| Rate for Payer: Priority Health SBD |
$408.67
|
| Rate for Payer: UMR Bronson Commercial |
$285.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$486.52
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$648.69
|
|
|
Service Code
|
NDC 0597-0355-56
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.42 |
| Max. Negotiated Rate |
$583.82 |
| Rate for Payer: Aetna American Axle |
$421.65
|
| Rate for Payer: Aetna Commercial |
$551.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$421.65
|
| Rate for Payer: Cash Price |
$518.95
|
| Rate for Payer: Cofinity Commercial |
$454.08
|
| Rate for Payer: Cofinity Commercial |
$557.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$518.95
|
| Rate for Payer: Healthscope Commercial |
$583.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$454.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$486.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$551.39
|
| Rate for Payer: PHP Commercial |
$551.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$454.08
|
| Rate for Payer: Priority Health SBD |
$408.67
|
| Rate for Payer: UMR Bronson Commercial |
$285.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$486.52
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$233.75
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.85 |
| Max. Negotiated Rate |
$210.38 |
| Rate for Payer: Aetna American Axle |
$151.94
|
| Rate for Payer: Aetna Commercial |
$198.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.94
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cofinity Commercial |
$163.62
|
| Rate for Payer: Cofinity Commercial |
$201.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.00
|
| Rate for Payer: Healthscope Commercial |
$210.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$163.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$198.69
|
| Rate for Payer: PHP Commercial |
$198.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.62
|
| Rate for Payer: Priority Health SBD |
$147.26
|
| Rate for Payer: UMR Bronson Commercial |
$102.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.31
|
|
|
DACARBAZINE 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$233.75
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$210.38 |
| Rate for Payer: Aetna American Axle |
$151.94
|
| Rate for Payer: Aetna Commercial |
$198.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.94
|
| Rate for Payer: BCBS Complete |
$93.50
|
| Rate for Payer: BCBS Trust/PPO |
$12.05
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cofinity Commercial |
$163.62
|
| Rate for Payer: Cofinity Commercial |
$201.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.00
|
| Rate for Payer: Healthscope Commercial |
$210.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$163.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$198.69
|
| Rate for Payer: PHP Commercial |
$198.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.62
|
| Rate for Payer: Priority Health SBD |
$147.26
|
| Rate for Payer: UMR Bronson Commercial |
$86.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.31
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$66.86
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.42 |
| Max. Negotiated Rate |
$60.17 |
| Rate for Payer: Aetna American Axle |
$43.46
|
| Rate for Payer: Aetna American Axle |
$123.99
|
| Rate for Payer: Aetna Commercial |
$162.14
|
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.46
|
| Rate for Payer: Cash Price |
$53.49
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: Cofinity Commercial |
$133.52
|
| Rate for Payer: Cofinity Commercial |
$57.50
|
| Rate for Payer: Cofinity Commercial |
$46.80
|
| Rate for Payer: Cofinity Commercial |
$164.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.49
|
| Rate for Payer: Healthscope Commercial |
$171.68
|
| Rate for Payer: Healthscope Commercial |
$60.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$162.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.83
|
| Rate for Payer: PHP Commercial |
$56.83
|
| Rate for Payer: PHP Commercial |
$162.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.80
|
| Rate for Payer: Priority Health SBD |
$42.12
|
| Rate for Payer: Priority Health SBD |
$120.17
|
| Rate for Payer: UMR Bronson Commercial |
$29.42
|
| Rate for Payer: UMR Bronson Commercial |
$83.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.06
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$66.86
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$60.17 |
| Rate for Payer: Aetna American Axle |
$43.46
|
| Rate for Payer: Aetna American Axle |
$133.84
|
| Rate for Payer: Aetna American Axle |
$123.99
|
| Rate for Payer: Aetna Commercial |
$175.02
|
| Rate for Payer: Aetna Commercial |
$162.14
|
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.46
|
| Rate for Payer: BCBS Complete |
$76.30
|
| Rate for Payer: BCBS Complete |
$26.74
|
| Rate for Payer: BCBS Complete |
$82.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.05
|
| Rate for Payer: BCBS Trust/PPO |
$12.05
|
| Rate for Payer: BCBS Trust/PPO |
$12.05
|
| Rate for Payer: Cash Price |
$164.73
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: Cash Price |
$164.73
|
| Rate for Payer: Cash Price |
$53.49
|
| Rate for Payer: Cash Price |
$53.49
|
| Rate for Payer: Cofinity Commercial |
$46.80
|
| Rate for Payer: Cofinity Commercial |
$57.50
|
| Rate for Payer: Cofinity Commercial |
$164.04
|
| Rate for Payer: Cofinity Commercial |
$144.14
|
| Rate for Payer: Cofinity Commercial |
$177.08
|
| Rate for Payer: Cofinity Commercial |
$133.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.60
|
| Rate for Payer: Healthscope Commercial |
$185.32
|
| Rate for Payer: Healthscope Commercial |
$60.17
|
| Rate for Payer: Healthscope Commercial |
$171.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$162.14
|
| Rate for Payer: PHP Commercial |
$175.02
|
| Rate for Payer: PHP Commercial |
$162.14
|
| Rate for Payer: PHP Commercial |
$56.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.80
|
| Rate for Payer: Priority Health SBD |
$120.17
|
| Rate for Payer: Priority Health SBD |
$42.12
|
| Rate for Payer: Priority Health SBD |
$129.72
|
| Rate for Payer: UMR Bronson Commercial |
$24.74
|
| Rate for Payer: UMR Bronson Commercial |
$76.19
|
| Rate for Payer: UMR Bronson Commercial |
$70.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.14
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,546.13
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
28912
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$680.30 |
| Max. Negotiated Rate |
$1,391.52 |
| Rate for Payer: Aetna American Axle |
$1,004.98
|
| Rate for Payer: Aetna American Axle |
$7,904.88
|
| Rate for Payer: Aetna American Axle |
$1,085.38
|
| Rate for Payer: Aetna American Axle |
$1,335.33
|
| Rate for Payer: Aetna American Axle |
$1,926.94
|
| Rate for Payer: Aetna Commercial |
$1,746.21
|
| Rate for Payer: Aetna Commercial |
$1,314.21
|
| Rate for Payer: Aetna Commercial |
$10,337.15
|
| Rate for Payer: Aetna Commercial |
$2,519.85
|
| Rate for Payer: Aetna Commercial |
$1,419.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,085.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,904.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,926.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,004.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,335.33
|
| Rate for Payer: Cash Price |
$1,335.86
|
| Rate for Payer: Cash Price |
$9,729.08
|
| Rate for Payer: Cash Price |
$2,371.62
|
| Rate for Payer: Cash Price |
$1,236.90
|
| Rate for Payer: Cash Price |
$1,643.49
|
| Rate for Payer: Cofinity Commercial |
$1,766.75
|
| Rate for Payer: Cofinity Commercial |
$1,438.05
|
| Rate for Payer: Cofinity Commercial |
$2,075.17
|
| Rate for Payer: Cofinity Commercial |
$1,168.87
|
| Rate for Payer: Cofinity Commercial |
$10,458.76
|
| Rate for Payer: Cofinity Commercial |
$1,082.29
|
| Rate for Payer: Cofinity Commercial |
$1,329.67
|
| Rate for Payer: Cofinity Commercial |
$1,436.05
|
| Rate for Payer: Cofinity Commercial |
$8,512.94
|
| Rate for Payer: Cofinity Commercial |
$2,549.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,335.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,371.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,643.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,236.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,729.08
|
| Rate for Payer: Healthscope Commercial |
$1,391.52
|
| Rate for Payer: Healthscope Commercial |
$10,945.22
|
| Rate for Payer: Healthscope Commercial |
$1,502.84
|
| Rate for Payer: Healthscope Commercial |
$1,848.92
|
| Rate for Payer: Healthscope Commercial |
$2,668.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,512.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,075.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,438.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,168.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,082.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,540.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,223.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,121.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,159.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,252.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10,337.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,314.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,746.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,419.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,519.85
|
| Rate for Payer: PHP Commercial |
$1,419.35
|
| Rate for Payer: PHP Commercial |
$2,519.85
|
| Rate for Payer: PHP Commercial |
$10,337.15
|
| Rate for Payer: PHP Commercial |
$1,314.21
|
| Rate for Payer: PHP Commercial |
$1,746.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,075.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,512.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,438.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,168.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,082.29
|
| Rate for Payer: Priority Health SBD |
$1,051.99
|
| Rate for Payer: Priority Health SBD |
$7,661.65
|
| Rate for Payer: Priority Health SBD |
$1,867.65
|
| Rate for Payer: Priority Health SBD |
$1,294.25
|
| Rate for Payer: Priority Health SBD |
$974.06
|
| Rate for Payer: UMR Bronson Commercial |
$734.72
|
| Rate for Payer: UMR Bronson Commercial |
$680.30
|
| Rate for Payer: UMR Bronson Commercial |
$903.92
|
| Rate for Payer: UMR Bronson Commercial |
$5,350.99
|
| Rate for Payer: UMR Bronson Commercial |
$1,304.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,540.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,159.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,252.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,223.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,121.01
|
|
|
DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12,161.35
|
|
|
Service Code
|
HCPCS J9120
|
| Hospital Charge Code |
28912
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$365.89 |
| Max. Negotiated Rate |
$10,945.22 |
| Rate for Payer: Aetna American Axle |
$7,904.88
|
| Rate for Payer: Aetna American Axle |
$1,085.38
|
| Rate for Payer: Aetna Commercial |
$1,419.35
|
| Rate for Payer: Aetna Commercial |
$10,337.15
|
| Rate for Payer: Aetna Medicare |
$695.66
|
| Rate for Payer: Aetna Medicare |
$695.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,904.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,085.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$836.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$836.13
|
| Rate for Payer: Amish Plain Church Group Commercial |
$836.13
|
| Rate for Payer: Amish Plain Church Group Commercial |
$836.13
|
| Rate for Payer: BCBS Complete |
$384.22
|
| Rate for Payer: BCBS Complete |
$384.22
|
| Rate for Payer: BCBS MAPPO |
$668.90
|
| Rate for Payer: BCBS MAPPO |
$668.90
|
| Rate for Payer: BCBS Trust/PPO |
$2,161.58
|
| Rate for Payer: BCBS Trust/PPO |
$2,161.58
|
| Rate for Payer: BCN Medicare Advantage |
$668.90
|
| Rate for Payer: BCN Medicare Advantage |
$668.90
|
| Rate for Payer: Cash Price |
$1,335.86
|
| Rate for Payer: Cash Price |
$9,729.08
|
| Rate for Payer: Cash Price |
$1,335.86
|
| Rate for Payer: Cash Price |
$9,729.08
|
| Rate for Payer: Cofinity Commercial |
$1,168.87
|
| Rate for Payer: Cofinity Commercial |
$1,436.05
|
| Rate for Payer: Cofinity Commercial |
$10,458.76
|
| Rate for Payer: Cofinity Commercial |
$8,512.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,335.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,729.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$668.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$668.90
|
| Rate for Payer: Healthscope Commercial |
$10,945.22
|
| Rate for Payer: Healthscope Commercial |
$1,502.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,168.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,512.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,121.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,252.36
|
| Rate for Payer: Mclaren Medicaid |
$365.89
|
| Rate for Payer: Mclaren Medicaid |
$365.89
|
| Rate for Payer: Mclaren Medicare |
$668.90
|
| Rate for Payer: Mclaren Medicare |
$668.90
|
| Rate for Payer: Meridian Medicaid |
$384.22
|
| Rate for Payer: Meridian Medicaid |
$384.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$702.35
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$702.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$769.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$769.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,419.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10,337.15
|
| Rate for Payer: PACE Medicare |
$635.46
|
| Rate for Payer: PACE Medicare |
$635.46
|
| Rate for Payer: PACE SWMI |
$668.90
|
| Rate for Payer: PACE SWMI |
$668.90
|
| Rate for Payer: PHP Commercial |
$10,337.15
|
| Rate for Payer: PHP Commercial |
$1,419.35
|
| Rate for Payer: PHP Medicare Advantage |
$668.90
|
| Rate for Payer: PHP Medicare Advantage |
$668.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$365.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$365.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,168.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,512.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,462.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,462.47
|
| Rate for Payer: Priority Health Medicare |
$668.90
|
| Rate for Payer: Priority Health Medicare |
$668.90
|
| Rate for Payer: Priority Health Narrow Network |
$1,969.98
|
| Rate for Payer: Priority Health Narrow Network |
$1,969.98
|
| Rate for Payer: Priority Health SBD |
$1,051.99
|
| Rate for Payer: Priority Health SBD |
$7,661.65
|
| Rate for Payer: Railroad Medicare Medicare |
$668.90
|
| Rate for Payer: Railroad Medicare Medicare |
$668.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$668.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$668.90
|
| Rate for Payer: UHC Medicare Advantage |
$688.97
|
| Rate for Payer: UHC Medicare Advantage |
$688.97
|
| Rate for Payer: UMR Bronson Commercial |
$617.83
|
| Rate for Payer: UMR Bronson Commercial |
$4,499.70
|
| Rate for Payer: VA VA |
$668.90
|
| Rate for Payer: VA VA |
$668.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,121.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,252.36
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,976.00
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,309.44 |
| Max. Negotiated Rate |
$2,678.40 |
| Rate for Payer: Aetna American Axle |
$1,934.40
|
| Rate for Payer: Aetna Commercial |
$2,529.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,934.40
|
| Rate for Payer: Cash Price |
$2,380.80
|
| Rate for Payer: Cofinity Commercial |
$2,083.20
|
| Rate for Payer: Cofinity Commercial |
$2,559.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,380.80
|
| Rate for Payer: Healthscope Commercial |
$2,678.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,083.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,232.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,529.60
|
| Rate for Payer: PHP Commercial |
$2,529.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,083.20
|
| Rate for Payer: Priority Health SBD |
$1,874.88
|
| Rate for Payer: UMR Bronson Commercial |
$1,309.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,232.00
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,976.00
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$2,678.40 |
| Rate for Payer: Aetna American Axle |
$1,934.40
|
| Rate for Payer: Aetna Commercial |
$2,529.60
|
| Rate for Payer: Aetna Medicare |
$15.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,934.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.12
|
| Rate for Payer: BCBS Complete |
$8.78
|
| Rate for Payer: BCBS MAPPO |
$15.29
|
| Rate for Payer: BCBS Trust/PPO |
$49.42
|
| Rate for Payer: BCN Medicare Advantage |
$15.29
|
| Rate for Payer: Cash Price |
$2,380.80
|
| Rate for Payer: Cash Price |
$2,380.80
|
| Rate for Payer: Cofinity Commercial |
$2,083.20
|
| Rate for Payer: Cofinity Commercial |
$2,559.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,380.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.29
|
| Rate for Payer: Healthscope Commercial |
$2,678.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,083.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,232.00
|
| Rate for Payer: Mclaren Medicaid |
$8.37
|
| Rate for Payer: Mclaren Medicare |
$15.29
|
| Rate for Payer: Meridian Medicaid |
$8.78
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,529.60
|
| Rate for Payer: PACE Medicare |
$14.53
|
| Rate for Payer: PACE SWMI |
$15.29
|
| Rate for Payer: PHP Commercial |
$2,529.60
|
| Rate for Payer: PHP Medicare Advantage |
$15.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,083.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$44.68
|
| Rate for Payer: Priority Health Medicare |
$15.29
|
| Rate for Payer: Priority Health Narrow Network |
$35.74
|
| Rate for Payer: Priority Health SBD |
$1,874.88
|
| Rate for Payer: Railroad Medicare Medicare |
$15.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.29
|
| Rate for Payer: UHC Medicare Advantage |
$15.75
|
| Rate for Payer: UMR Bronson Commercial |
$1,101.12
|
| Rate for Payer: VA VA |
$15.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,232.00
|
|
|
DANAZOL 50 MG CAPSULE
|
Facility
|
IP
|
$873.20
|
|
|
Service Code
|
NDC 0555-0633-02
|
| Hospital Charge Code |
9715
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$384.21 |
| Max. Negotiated Rate |
$785.88 |
| Rate for Payer: Aetna American Axle |
$567.58
|
| Rate for Payer: Aetna Commercial |
$742.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$567.58
|
| Rate for Payer: Cash Price |
$698.56
|
| Rate for Payer: Cofinity Commercial |
$611.24
|
| Rate for Payer: Cofinity Commercial |
$750.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$698.56
|
| Rate for Payer: Healthscope Commercial |
$785.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$611.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$654.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$742.22
|
| Rate for Payer: PHP Commercial |
$742.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$611.24
|
| Rate for Payer: Priority Health SBD |
$550.12
|
| Rate for Payer: UMR Bronson Commercial |
$384.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$654.90
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$187.30
|
|
|
Service Code
|
NDC 0143-9297-01
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.41 |
| Max. Negotiated Rate |
$168.57 |
| Rate for Payer: Aetna American Axle |
$121.74
|
| Rate for Payer: Aetna Commercial |
$159.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.74
|
| Rate for Payer: Cash Price |
$149.84
|
| Rate for Payer: Cofinity Commercial |
$131.11
|
| Rate for Payer: Cofinity Commercial |
$161.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$149.84
|
| Rate for Payer: Healthscope Commercial |
$168.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$140.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.20
|
| Rate for Payer: PHP Commercial |
$159.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.11
|
| Rate for Payer: Priority Health SBD |
$118.00
|
| Rate for Payer: UMR Bronson Commercial |
$82.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$140.48
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$292.65
|
|
|
Service Code
|
NDC 42023-123-06
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.77 |
| Max. Negotiated Rate |
$263.38 |
| Rate for Payer: Aetna American Axle |
$190.22
|
| Rate for Payer: Aetna Commercial |
$248.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.22
|
| Rate for Payer: Cash Price |
$234.12
|
| Rate for Payer: Cofinity Commercial |
$204.86
|
| Rate for Payer: Cofinity Commercial |
$251.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.12
|
| Rate for Payer: Healthscope Commercial |
$263.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$248.75
|
| Rate for Payer: PHP Commercial |
$248.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.86
|
| Rate for Payer: Priority Health SBD |
$184.37
|
| Rate for Payer: UMR Bronson Commercial |
$128.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.49
|
|
|
DANTROLENE 25 MG CAPSULE
|
Facility
|
IP
|
$311.60
|
|
|
Service Code
|
NDC 0115-4411-01
|
| Hospital Charge Code |
9718
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.10 |
| Max. Negotiated Rate |
$280.44 |
| Rate for Payer: Aetna American Axle |
$202.54
|
| Rate for Payer: Aetna Commercial |
$264.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.54
|
| Rate for Payer: Cash Price |
$249.28
|
| Rate for Payer: Cofinity Commercial |
$218.12
|
| Rate for Payer: Cofinity Commercial |
$267.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.28
|
| Rate for Payer: Healthscope Commercial |
$280.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$264.86
|
| Rate for Payer: PHP Commercial |
$264.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.12
|
| Rate for Payer: Priority Health SBD |
$196.31
|
| Rate for Payer: UMR Bronson Commercial |
$137.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.70
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET
|
Facility
|
IP
|
$1,359.42
|
|
|
Service Code
|
NDC 0310-6210-30
|
| Hospital Charge Code |
169524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$598.14 |
| Max. Negotiated Rate |
$1,223.48 |
| Rate for Payer: Aetna American Axle |
$883.62
|
| Rate for Payer: Aetna Commercial |
$1,155.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$883.62
|
| Rate for Payer: Cash Price |
$1,087.54
|
| Rate for Payer: Cofinity Commercial |
$1,169.10
|
| Rate for Payer: Cofinity Commercial |
$951.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,087.54
|
| Rate for Payer: Healthscope Commercial |
$1,223.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$951.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,019.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,155.51
|
| Rate for Payer: PHP Commercial |
$1,155.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$951.59
|
| Rate for Payer: Priority Health SBD |
$856.43
|
| Rate for Payer: UMR Bronson Commercial |
$598.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,019.56
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET
|
Facility
|
IP
|
$300.70
|
|
|
Service Code
|
NDC 0310-6210-95
|
| Hospital Charge Code |
169524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.31 |
| Max. Negotiated Rate |
$270.63 |
| Rate for Payer: Aetna American Axle |
$195.46
|
| Rate for Payer: Aetna Commercial |
$255.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.46
|
| Rate for Payer: Cash Price |
$240.56
|
| Rate for Payer: Cofinity Commercial |
$210.49
|
| Rate for Payer: Cofinity Commercial |
$258.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.56
|
| Rate for Payer: Healthscope Commercial |
$270.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.60
|
| Rate for Payer: PHP Commercial |
$255.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.49
|
| Rate for Payer: Priority Health SBD |
$189.44
|
| Rate for Payer: UMR Bronson Commercial |
$132.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.52
|
|
|
DAPSONE 100 MG TABLET
|
Facility
|
IP
|
$289.05
|
|
|
Service Code
|
NDC 49938-101-30
|
| Hospital Charge Code |
2131
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.18 |
| Max. Negotiated Rate |
$260.14 |
| Rate for Payer: Aetna American Axle |
$187.88
|
| Rate for Payer: Aetna Commercial |
$245.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.88
|
| Rate for Payer: Cash Price |
$231.24
|
| Rate for Payer: Cofinity Commercial |
$202.34
|
| Rate for Payer: Cofinity Commercial |
$248.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.24
|
| Rate for Payer: Healthscope Commercial |
$260.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$245.69
|
| Rate for Payer: PHP Commercial |
$245.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.34
|
| Rate for Payer: Priority Health SBD |
$182.10
|
| Rate for Payer: UMR Bronson Commercial |
$127.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.79
|
|
|
DAPSONE 100 MG TABLET
|
Facility
|
IP
|
$127.88
|
|
|
Service Code
|
NDC 70954-136-10
|
| Hospital Charge Code |
2131
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.27 |
| Max. Negotiated Rate |
$115.09 |
| Rate for Payer: Aetna American Axle |
$83.12
|
| Rate for Payer: Aetna Commercial |
$108.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.12
|
| Rate for Payer: Cash Price |
$102.30
|
| Rate for Payer: Cofinity Commercial |
$109.98
|
| Rate for Payer: Cofinity Commercial |
$89.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.30
|
| Rate for Payer: Healthscope Commercial |
$115.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$89.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$108.70
|
| Rate for Payer: PHP Commercial |
$108.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.52
|
| Rate for Payer: Priority Health SBD |
$80.56
|
| Rate for Payer: UMR Bronson Commercial |
$56.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.91
|
|
|
DAPSONE 100 MG TABLET
|
Facility
|
IP
|
$250.98
|
|
|
Service Code
|
NDC 47781-334-31
|
| Hospital Charge Code |
2131
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.43 |
| Max. Negotiated Rate |
$225.88 |
| Rate for Payer: Aetna American Axle |
$163.14
|
| Rate for Payer: Aetna Commercial |
$213.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.14
|
| Rate for Payer: Cash Price |
$200.78
|
| Rate for Payer: Cofinity Commercial |
$175.69
|
| Rate for Payer: Cofinity Commercial |
$215.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.78
|
| Rate for Payer: Healthscope Commercial |
$225.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.33
|
| Rate for Payer: PHP Commercial |
$213.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.69
|
| Rate for Payer: Priority Health SBD |
$158.12
|
| Rate for Payer: UMR Bronson Commercial |
$110.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.24
|
|
|
DAPSONE 25 MG TABLET
|
Facility
|
IP
|
$235.55
|
|
|
Service Code
|
NDC 49938-102-30
|
| Hospital Charge Code |
2132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna American Axle |
$153.11
|
| Rate for Payer: Aetna Commercial |
$200.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.11
|
| Rate for Payer: Cash Price |
$188.44
|
| Rate for Payer: Cofinity Commercial |
$164.88
|
| Rate for Payer: Cofinity Commercial |
$202.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.44
|
| Rate for Payer: Healthscope Commercial |
$212.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$176.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$200.22
|
| Rate for Payer: PHP Commercial |
$200.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.88
|
| Rate for Payer: Priority Health SBD |
$148.40
|
| Rate for Payer: UMR Bronson Commercial |
$103.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$176.66
|
|
|
DAPSONE 25 MG TABLET
|
Facility
|
IP
|
$264.10
|
|
|
Service Code
|
NDC 13925-504-30
|
| Hospital Charge Code |
2132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna American Axle |
$171.66
|
| Rate for Payer: Aetna Commercial |
$224.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Commercial |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.48
|
| Rate for Payer: PHP Commercial |
$224.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.87
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UMR Bronson Commercial |
$116.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.08
|
|
