|
ROSUVASTATIN 20 MG TABLET
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 0781-5402-92
|
| Hospital Charge Code |
35135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.81 |
| Max. Negotiated Rate |
$200.07 |
| Rate for Payer: Aetna American Axle |
$144.50
|
| Rate for Payer: Aetna Commercial |
$188.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.50
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$155.61
|
| Rate for Payer: Cofinity Commercial |
$191.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$200.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$155.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$188.96
|
| Rate for Payer: PHP Commercial |
$188.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.61
|
| Rate for Payer: Priority Health SBD |
$140.05
|
| Rate for Payer: UMR Bronson Commercial |
$97.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.72
|
|
|
ROSUVASTATIN 40 MG TABLET
|
Facility
|
IP
|
$556.80
|
|
|
Service Code
|
NDC 0904-6781-61
|
| Hospital Charge Code |
35136
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$244.99 |
| Max. Negotiated Rate |
$501.12 |
| Rate for Payer: Aetna American Axle |
$361.92
|
| Rate for Payer: Aetna Commercial |
$473.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$361.92
|
| Rate for Payer: Cash Price |
$445.44
|
| Rate for Payer: Cofinity Commercial |
$389.76
|
| Rate for Payer: Cofinity Commercial |
$478.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$445.44
|
| Rate for Payer: Healthscope Commercial |
$501.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$389.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$417.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$473.28
|
| Rate for Payer: PHP Commercial |
$473.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.76
|
| Rate for Payer: Priority Health SBD |
$350.78
|
| Rate for Payer: UMR Bronson Commercial |
$244.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$417.60
|
|
|
ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION
|
Facility
|
IP
|
$284.53
|
|
|
Service Code
|
NDC 0006-4047-41
|
| Hospital Charge Code |
70476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.19 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Aetna American Axle |
$184.94
|
| Rate for Payer: Aetna Commercial |
$241.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.94
|
| Rate for Payer: Cash Price |
$227.62
|
| Rate for Payer: Cofinity Commercial |
$199.17
|
| Rate for Payer: Cofinity Commercial |
$244.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.62
|
| Rate for Payer: Healthscope Commercial |
$256.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.85
|
| Rate for Payer: PHP Commercial |
$241.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.17
|
| Rate for Payer: Priority Health SBD |
$179.25
|
| Rate for Payer: UMR Bronson Commercial |
$125.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.40
|
|
|
RUFINAMIDE 200 MG TABLET
|
Facility
|
IP
|
$5,450.55
|
|
|
Service Code
|
NDC 62856-582-52
|
| Hospital Charge Code |
95691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,398.24 |
| Max. Negotiated Rate |
$4,905.50 |
| Rate for Payer: Aetna American Axle |
$3,542.86
|
| Rate for Payer: Aetna Commercial |
$4,632.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,542.86
|
| Rate for Payer: Cash Price |
$4,360.44
|
| Rate for Payer: Cofinity Commercial |
$3,815.38
|
| Rate for Payer: Cofinity Commercial |
$4,687.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,360.44
|
| Rate for Payer: Healthscope Commercial |
$4,905.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,815.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,087.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,632.97
|
| Rate for Payer: PHP Commercial |
$4,632.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,815.38
|
| Rate for Payer: Priority Health SBD |
$3,433.85
|
| Rate for Payer: UMR Bronson Commercial |
$2,398.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,087.91
|
|
|
RUFINAMIDE 400 MG TABLET
|
Facility
|
IP
|
$1,602.40
|
|
|
Service Code
|
NDC 59651-617-08
|
| Hospital Charge Code |
95692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$705.06 |
| Max. Negotiated Rate |
$1,442.16 |
| Rate for Payer: Aetna American Axle |
$1,041.56
|
| Rate for Payer: Aetna Commercial |
$1,362.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,041.56
|
| Rate for Payer: Cash Price |
$1,281.92
|
| Rate for Payer: Cofinity Commercial |
$1,121.68
|
| Rate for Payer: Cofinity Commercial |
$1,378.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,281.92
|
| Rate for Payer: Healthscope Commercial |
$1,442.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,121.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,201.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,362.04
|
| Rate for Payer: PHP Commercial |
$1,362.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,121.68
|
| Rate for Payer: Priority Health SBD |
$1,009.51
|
| Rate for Payer: UMR Bronson Commercial |
$705.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,201.80
|
|
|
RUFINAMIDE 400 MG TABLET
|
Facility
|
IP
|
$10,901.09
|
|
|
Service Code
|
NDC 62856-583-52
|
| Hospital Charge Code |
95692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,796.48 |
| Max. Negotiated Rate |
$9,810.98 |
| Rate for Payer: Aetna American Axle |
$7,085.71
|
| Rate for Payer: Aetna Commercial |
$9,265.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,085.71
|
| Rate for Payer: Cash Price |
$8,720.87
|
| Rate for Payer: Cofinity Commercial |
$7,630.76
|
| Rate for Payer: Cofinity Commercial |
$9,374.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,720.87
|
| Rate for Payer: Healthscope Commercial |
$9,810.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,630.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,175.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,265.93
|
| Rate for Payer: PHP Commercial |
$9,265.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,630.76
|
| Rate for Payer: Priority Health SBD |
$6,867.69
|
| Rate for Payer: UMR Bronson Commercial |
$4,796.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,175.82
|
|
|
RUFINAMIDE 400 MG TABLET
|
Facility
|
IP
|
$2,536.13
|
|
|
Service Code
|
NDC 0054-0426-23
|
| Hospital Charge Code |
95692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,115.90 |
| Max. Negotiated Rate |
$2,282.52 |
| Rate for Payer: Aetna American Axle |
$1,648.48
|
| Rate for Payer: Aetna Commercial |
$2,155.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,648.48
|
| Rate for Payer: Cash Price |
$2,028.90
|
| Rate for Payer: Cofinity Commercial |
$1,775.29
|
| Rate for Payer: Cofinity Commercial |
$2,181.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,028.90
|
| Rate for Payer: Healthscope Commercial |
$2,282.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,775.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,902.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,155.71
|
| Rate for Payer: PHP Commercial |
$2,155.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,775.29
|
| Rate for Payer: Priority Health SBD |
$1,597.76
|
| Rate for Payer: UMR Bronson Commercial |
$1,115.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,902.10
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$10,793.34
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,749.07 |
| Max. Negotiated Rate |
$9,714.01 |
| Rate for Payer: Aetna American Axle |
$7,015.67
|
| Rate for Payer: Aetna Commercial |
$9,174.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,015.67
|
| Rate for Payer: Cash Price |
$8,634.67
|
| Rate for Payer: Cofinity Commercial |
$7,555.34
|
| Rate for Payer: Cofinity Commercial |
$9,282.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,634.67
|
| Rate for Payer: Healthscope Commercial |
$9,714.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,555.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,095.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,174.34
|
| Rate for Payer: PHP Commercial |
$9,174.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,555.34
|
| Rate for Payer: Priority Health SBD |
$6,799.80
|
| Rate for Payer: UMR Bronson Commercial |
$4,749.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,095.00
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$10,793.34
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$9,714.01 |
| Rate for Payer: Aetna American Axle |
$7,015.67
|
| Rate for Payer: Aetna Commercial |
$9,174.34
|
| Rate for Payer: Aetna Medicare |
$35.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,015.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.60
|
| Rate for Payer: BCBS Complete |
$19.57
|
| Rate for Payer: BCBS MAPPO |
$34.08
|
| Rate for Payer: BCBS Trust/PPO |
$110.09
|
| Rate for Payer: BCN Medicare Advantage |
$34.08
|
| Rate for Payer: Cash Price |
$8,634.67
|
| Rate for Payer: Cash Price |
$8,634.67
|
| Rate for Payer: Cofinity Commercial |
$7,555.34
|
| Rate for Payer: Cofinity Commercial |
$9,282.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,634.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.08
|
| Rate for Payer: Healthscope Commercial |
$9,714.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,555.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,095.00
|
| Rate for Payer: Mclaren Medicaid |
$18.64
|
| Rate for Payer: Mclaren Medicare |
$34.08
|
| Rate for Payer: Meridian Medicaid |
$19.57
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$35.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,174.34
|
| Rate for Payer: PACE Medicare |
$32.37
|
| Rate for Payer: PACE SWMI |
$34.08
|
| Rate for Payer: PHP Commercial |
$9,174.34
|
| Rate for Payer: PHP Medicare Advantage |
$34.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$18.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,555.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$97.67
|
| Rate for Payer: Priority Health Medicare |
$34.08
|
| Rate for Payer: Priority Health Narrow Network |
$78.14
|
| Rate for Payer: Priority Health SBD |
$6,799.80
|
| Rate for Payer: Railroad Medicare Medicare |
$34.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.08
|
| Rate for Payer: UHC Medicare Advantage |
$35.10
|
| Rate for Payer: UMR Bronson Commercial |
$3,993.54
|
| Rate for Payer: VA VA |
$34.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,095.00
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0659-20
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,001.22 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna American Axle |
$1,479.08
|
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,479.08
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,592.85
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,820.40
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,592.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,706.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health SBD |
$1,433.56
|
| Rate for Payer: UMR Bronson Commercial |
$1,001.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,706.62
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$6,826.50
|
|
|
Service Code
|
NDC 0078-0659-67
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,003.66 |
| Max. Negotiated Rate |
$6,143.85 |
| Rate for Payer: Aetna American Axle |
$4,437.22
|
| Rate for Payer: Aetna Commercial |
$5,802.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,437.22
|
| Rate for Payer: Cash Price |
$5,461.20
|
| Rate for Payer: Cofinity Commercial |
$4,778.55
|
| Rate for Payer: Cofinity Commercial |
$5,870.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,461.20
|
| Rate for Payer: Healthscope Commercial |
$6,143.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,778.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,119.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,802.52
|
| Rate for Payer: PHP Commercial |
$5,802.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,778.55
|
| Rate for Payer: Priority Health SBD |
$4,300.70
|
| Rate for Payer: UMR Bronson Commercial |
$3,003.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,119.88
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,001.22 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna American Axle |
$1,479.08
|
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,479.08
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,592.85
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,820.40
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,592.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,706.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health SBD |
$1,433.56
|
| Rate for Payer: UMR Bronson Commercial |
$1,001.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,706.62
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0696-20
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,001.22 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna American Axle |
$1,479.08
|
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,479.08
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,592.85
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,820.40
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,592.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,706.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health SBD |
$1,433.56
|
| Rate for Payer: UMR Bronson Commercial |
$1,001.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,706.62
|
|
|
SALIVARY GLAND PROCEDURES
|
Facility
|
IP
|
$24,463.08
|
|
|
Service Code
|
MS-DRG 139
|
| Min. Negotiated Rate |
$9,181.56 |
| Max. Negotiated Rate |
$24,463.08 |
| Rate for Payer: Aetna Medicare |
$10,051.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,081.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,081.00
|
| Rate for Payer: BCBS MAPPO |
$9,664.80
|
| Rate for Payer: BCBS Trust/PPO |
$24,463.08
|
| Rate for Payer: BCN Medicare Advantage |
$9,664.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,664.80
|
| Rate for Payer: Mclaren Medicare |
$9,664.80
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,148.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,114.52
|
| Rate for Payer: PACE Medicare |
$9,181.56
|
| Rate for Payer: PACE SWMI |
$9,664.80
|
| Rate for Payer: PHP Medicare Advantage |
$9,664.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,043.40
|
| Rate for Payer: Priority Health Medicare |
$9,664.80
|
| Rate for Payer: Priority Health Narrow Network |
$13,634.72
|
| Rate for Payer: Railroad Medicare Medicare |
$9,664.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18,117.18
|
| Rate for Payer: UHC Core |
$14,855.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,664.80
|
| Rate for Payer: UHC Exchange |
$11,810.49
|
| Rate for Payer: UHC Medicare Advantage |
$9,954.74
|
| Rate for Payer: VA VA |
$9,664.80
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
IP
|
$24.97
|
|
|
Service Code
|
NDC 4858200155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna American Axle |
$16.23
|
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.48
|
| Rate for Payer: Priority Health SBD |
$15.73
|
| Rate for Payer: UMR Bronson Commercial |
$10.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.73
|
|
|
SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$787.26
|
|
|
Service Code
|
NDC 0173-0520-00
|
| Hospital Charge Code |
28246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.39 |
| Max. Negotiated Rate |
$708.53 |
| Rate for Payer: Aetna American Axle |
$511.72
|
| Rate for Payer: Aetna Commercial |
$669.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$511.72
|
| Rate for Payer: Cash Price |
$629.81
|
| Rate for Payer: Cofinity Commercial |
$551.08
|
| Rate for Payer: Cofinity Commercial |
$677.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$629.81
|
| Rate for Payer: Healthscope Commercial |
$708.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$590.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$669.17
|
| Rate for Payer: PHP Commercial |
$669.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$551.08
|
| Rate for Payer: Priority Health SBD |
$495.97
|
| Rate for Payer: UMR Bronson Commercial |
$346.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$590.44
|
|
|
SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$1,378.37
|
|
|
Service Code
|
NDC 0173-0521-00
|
| Hospital Charge Code |
28246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$606.48 |
| Max. Negotiated Rate |
$1,240.53 |
| Rate for Payer: Aetna American Axle |
$895.94
|
| Rate for Payer: Aetna Commercial |
$1,171.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$895.94
|
| Rate for Payer: Cash Price |
$1,102.70
|
| Rate for Payer: Cofinity Commercial |
$1,185.40
|
| Rate for Payer: Cofinity Commercial |
$964.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,102.70
|
| Rate for Payer: Healthscope Commercial |
$1,240.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$964.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,033.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,171.61
|
| Rate for Payer: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$964.86
|
| Rate for Payer: Priority Health SBD |
$868.37
|
| Rate for Payer: UMR Bronson Commercial |
$606.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,033.78
|
|
|
SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$6,395.00
|
|
|
Service Code
|
CPT 58720
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$751.81 |
| Max. Negotiated Rate |
$6,395.00 |
| Rate for Payer: BCBS Trust/PPO |
$2,528.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$826.99
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Exchange |
$751.81
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$444.60
|
|
|
Service Code
|
NDC 13273-209-03
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.62 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna American Axle |
$288.99
|
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$311.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$311.22
|
| Rate for Payer: Priority Health SBD |
$280.10
|
| Rate for Payer: UMR Bronson Commercial |
$195.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.45
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$265.05
|
|
|
Service Code
|
NDC 65162-512-10
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna American Axle |
$172.28
|
| Rate for Payer: Aetna Commercial |
$225.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.28
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cofinity Commercial |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$227.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.04
|
| Rate for Payer: Healthscope Commercial |
$238.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$225.29
|
| Rate for Payer: PHP Commercial |
$225.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.54
|
| Rate for Payer: Priority Health SBD |
$166.98
|
| Rate for Payer: UMR Bronson Commercial |
$116.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.79
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 69367-160-04
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.70
|
| Rate for Payer: Aetna Commercial |
$327.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.70
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$327.84
|
| Rate for Payer: PHP Commercial |
$327.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.99
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$169.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.28
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
IP
|
$379.05
|
|
|
Service Code
|
NDC 69367-161-04
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.78 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$265.34
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$322.19
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.34
|
| Rate for Payer: Priority Health SBD |
$238.80
|
| Rate for Payer: UMR Bronson Commercial |
$166.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
IP
|
$291.84
|
|
|
Service Code
|
NDC 13273-210-03
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.41 |
| Max. Negotiated Rate |
$262.66 |
| Rate for Payer: Aetna American Axle |
$189.70
|
| Rate for Payer: Aetna Commercial |
$248.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: Cash Price |
$233.47
|
| Rate for Payer: Cofinity Commercial |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$250.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.47
|
| Rate for Payer: Healthscope Commercial |
$262.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$248.06
|
| Rate for Payer: PHP Commercial |
$248.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.29
|
| Rate for Payer: Priority Health SBD |
$183.86
|
| Rate for Payer: UMR Bronson Commercial |
$128.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.88
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$1,046.30
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
11338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$460.37 |
| Max. Negotiated Rate |
$941.67 |
| Rate for Payer: Aetna American Axle |
$680.10
|
| Rate for Payer: Aetna American Axle |
$607.37
|
| Rate for Payer: Aetna Commercial |
$794.25
|
| Rate for Payer: Aetna Commercial |
$889.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$680.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$607.37
|
| Rate for Payer: Cash Price |
$837.04
|
| Rate for Payer: Cash Price |
$747.53
|
| Rate for Payer: Cofinity Commercial |
$899.82
|
| Rate for Payer: Cofinity Commercial |
$803.59
|
| Rate for Payer: Cofinity Commercial |
$654.09
|
| Rate for Payer: Cofinity Commercial |
$732.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$837.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$747.53
|
| Rate for Payer: Healthscope Commercial |
$840.97
|
| Rate for Payer: Healthscope Commercial |
$941.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$732.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$654.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$784.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$700.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$889.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$794.25
|
| Rate for Payer: PHP Commercial |
$794.25
|
| Rate for Payer: PHP Commercial |
$889.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$732.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$654.09
|
| Rate for Payer: Priority Health SBD |
$588.68
|
| Rate for Payer: Priority Health SBD |
$659.17
|
| Rate for Payer: UMR Bronson Commercial |
$460.37
|
| Rate for Payer: UMR Bronson Commercial |
$411.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$784.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$700.81
|
|
|
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT
|
Facility
|
OP
|
$11,377.15
|
|
|
Service Code
|
CPT 67255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$671.58 |
| Max. Negotiated Rate |
$11,377.15 |
| Rate for Payer: Aetna Medicare |
$3,758.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,517.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,517.55
|
| Rate for Payer: BCBS Complete |
$2,075.90
|
| Rate for Payer: BCBS MAPPO |
$3,614.04
|
| Rate for Payer: BCBS Trust/PPO |
$1,693.81
|
| Rate for Payer: BCN Medicare Advantage |
$3,614.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,614.04
|
| Rate for Payer: Mclaren Medicaid |
$1,976.88
|
| Rate for Payer: Mclaren Medicare |
$3,614.04
|
| Rate for Payer: Meridian Medicaid |
$2,075.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,794.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,156.15
|
| Rate for Payer: PACE Medicare |
$3,433.34
|
| Rate for Payer: PACE SWMI |
$3,614.04
|
| Rate for Payer: PHP Medicare Advantage |
$3,614.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,976.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,377.15
|
| Rate for Payer: Priority Health Medicare |
$3,614.04
|
| Rate for Payer: Priority Health Narrow Network |
$9,101.72
|
| Rate for Payer: Railroad Medicare Medicare |
$3,614.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$738.74
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,614.04
|
| Rate for Payer: UHC Exchange |
$671.58
|
| Rate for Payer: UHC Medicare Advantage |
$3,722.46
|
| Rate for Payer: VA VA |
$3,614.04
|
|
