|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$254.40
|
|
|
Service Code
|
NDC 68084085501
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.94 |
| Max. Negotiated Rate |
$228.96 |
| Rate for Payer: Aetna American Axle |
$165.36
|
| Rate for Payer: Aetna Commercial |
$216.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.36
|
| Rate for Payer: Cash Price |
$203.52
|
| Rate for Payer: Cofinity Commercial |
$178.08
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.52
|
| Rate for Payer: Healthscope Commercial |
$228.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.24
|
| Rate for Payer: PHP Commercial |
$216.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.36
|
| Rate for Payer: Priority Health SBD |
$160.27
|
| Rate for Payer: UMR Bronson Commercial |
$111.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.80
|
|
|
BACLOFEN 20,000 MCG/20 ML (1,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$1,245.42
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
160111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.13 |
| Max. Negotiated Rate |
$1,120.88 |
| Rate for Payer: Aetna American Axle |
$809.52
|
| Rate for Payer: Aetna Commercial |
$1,058.61
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$809.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: Cash Price |
$996.34
|
| Rate for Payer: Cash Price |
$996.34
|
| Rate for Payer: Cofinity Commercial |
$871.79
|
| Rate for Payer: Cofinity Commercial |
$1,071.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$871.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$996.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Healthscope Commercial |
$1,120.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$871.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$934.07
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,058.61
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PHP Commercial |
$1,058.61
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$809.52
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health SBD |
$784.61
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UMR Bronson Commercial |
$460.81
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$934.07
|
|
|
BACLOFEN 20,000 MCG/20 ML (1,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$1,245.42
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
160111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$547.98 |
| Max. Negotiated Rate |
$1,120.88 |
| Rate for Payer: Aetna American Axle |
$809.52
|
| Rate for Payer: Aetna Commercial |
$1,058.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$809.52
|
| Rate for Payer: Cash Price |
$996.34
|
| Rate for Payer: Cofinity Commercial |
$1,071.06
|
| Rate for Payer: Cofinity Commercial |
$871.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$871.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$996.34
|
| Rate for Payer: Healthscope Commercial |
$1,120.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$871.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$934.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,058.61
|
| Rate for Payer: PHP Commercial |
$1,058.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$809.52
|
| Rate for Payer: Priority Health SBD |
$784.61
|
| Rate for Payer: UMR Bronson Commercial |
$547.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$934.07
|
|
|
BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
IP
|
$3,497.02
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,538.69 |
| Max. Negotiated Rate |
$3,147.32 |
| Rate for Payer: Aetna American Axle |
$2,273.06
|
| Rate for Payer: Aetna Commercial |
$2,972.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,273.06
|
| Rate for Payer: Cash Price |
$2,797.62
|
| Rate for Payer: Cofinity Commercial |
$2,447.91
|
| Rate for Payer: Cofinity Commercial |
$3,007.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,447.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,797.62
|
| Rate for Payer: Healthscope Commercial |
$3,147.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,447.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,622.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,972.47
|
| Rate for Payer: PHP Commercial |
$2,972.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,273.06
|
| Rate for Payer: Priority Health SBD |
$2,203.12
|
| Rate for Payer: UMR Bronson Commercial |
$1,538.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,622.76
|
|
|
BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
OP
|
$3,497.02
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.13 |
| Max. Negotiated Rate |
$3,147.32 |
| Rate for Payer: Aetna American Axle |
$2,273.06
|
| Rate for Payer: Aetna Commercial |
$2,972.47
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,273.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: Cash Price |
$2,797.62
|
| Rate for Payer: Cash Price |
$2,797.62
|
| Rate for Payer: Cofinity Commercial |
$3,007.44
|
| Rate for Payer: Cofinity Commercial |
$2,447.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,447.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,797.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Healthscope Commercial |
$3,147.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,447.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,622.76
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,972.47
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PHP Commercial |
$2,972.47
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,273.06
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health SBD |
$2,203.12
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UMR Bronson Commercial |
$1,293.90
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,622.76
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 68084086811
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna American Axle |
$2.73
|
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.73
|
| Rate for Payer: Cash Price |
$3.36
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.36
|
| Rate for Payer: Healthscope Commercial |
$3.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.57
|
| Rate for Payer: PHP Commercial |
$3.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.73
|
| Rate for Payer: Priority Health SBD |
$2.65
|
| Rate for Payer: UMR Bronson Commercial |
$1.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.15
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 68084086811
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna American Axle |
$2.73
|
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Aetna Medicare |
$2.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.73
|
| Rate for Payer: BCBS Complete |
$1.68
|
| Rate for Payer: Cash Price |
$3.36
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.36
|
| Rate for Payer: Healthscope Commercial |
$3.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.57
|
| Rate for Payer: PHP Commercial |
$3.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.73
|
| Rate for Payer: Priority Health SBD |
$2.65
|
| Rate for Payer: UMR Bronson Commercial |
$1.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.15
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
OP
|
$230.30
|
|
|
Service Code
|
NDC 00172409760
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.21 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.69
|
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna Medicare |
$115.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.69
|
| Rate for Payer: BCBS Complete |
$92.12
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$85.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$246.72
|
|
|
Service Code
|
NDC 00904647661
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.56 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna American Axle |
$160.37
|
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
| Rate for Payer: UMR Bronson Commercial |
$108.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.04
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
NDC 68084086801
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.80 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: Aetna American Axle |
$273.00
|
| Rate for Payer: Aetna Commercial |
$357.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cofinity Commercial |
$294.00
|
| Rate for Payer: Cofinity Commercial |
$361.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.00
|
| Rate for Payer: Healthscope Commercial |
$378.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.00
|
| Rate for Payer: PHP Commercial |
$357.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.00
|
| Rate for Payer: Priority Health SBD |
$264.60
|
| Rate for Payer: UMR Bronson Commercial |
$184.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.00
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
OP
|
$271.68
|
|
|
Service Code
|
NDC 63739048010
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.52 |
| Max. Negotiated Rate |
$244.51 |
| Rate for Payer: Aetna American Axle |
$176.59
|
| Rate for Payer: Aetna Commercial |
$230.93
|
| Rate for Payer: Aetna Medicare |
$135.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.59
|
| Rate for Payer: BCBS Complete |
$108.67
|
| Rate for Payer: Cash Price |
$217.34
|
| Rate for Payer: Cofinity Commercial |
$190.18
|
| Rate for Payer: Cofinity Commercial |
$233.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$190.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.34
|
| Rate for Payer: Healthscope Commercial |
$244.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.93
|
| Rate for Payer: PHP Commercial |
$230.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.59
|
| Rate for Payer: Priority Health SBD |
$171.16
|
| Rate for Payer: UMR Bronson Commercial |
$100.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.76
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$271.68
|
|
|
Service Code
|
NDC 63739048010
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.54 |
| Max. Negotiated Rate |
$244.51 |
| Rate for Payer: Aetna American Axle |
$176.59
|
| Rate for Payer: Aetna Commercial |
$230.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.59
|
| Rate for Payer: Cash Price |
$217.34
|
| Rate for Payer: Cofinity Commercial |
$190.18
|
| Rate for Payer: Cofinity Commercial |
$233.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$190.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.34
|
| Rate for Payer: Healthscope Commercial |
$244.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.93
|
| Rate for Payer: PHP Commercial |
$230.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.59
|
| Rate for Payer: Priority Health SBD |
$171.16
|
| Rate for Payer: UMR Bronson Commercial |
$119.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.76
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
OP
|
$246.72
|
|
|
Service Code
|
NDC 00904647661
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.29 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna American Axle |
$160.37
|
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna Medicare |
$123.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: BCBS Complete |
$98.69
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
| Rate for Payer: UMR Bronson Commercial |
$91.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.04
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
NDC 68084086801
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.40 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: Aetna American Axle |
$273.00
|
| Rate for Payer: Aetna Commercial |
$357.00
|
| Rate for Payer: Aetna Medicare |
$210.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.00
|
| Rate for Payer: BCBS Complete |
$168.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cofinity Commercial |
$294.00
|
| Rate for Payer: Cofinity Commercial |
$361.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.00
|
| Rate for Payer: Healthscope Commercial |
$378.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.00
|
| Rate for Payer: PHP Commercial |
$357.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.00
|
| Rate for Payer: Priority Health SBD |
$264.60
|
| Rate for Payer: UMR Bronson Commercial |
$155.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.00
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 00172409760
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.33 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.69
|
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.69
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$101.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$2,053.06
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
107800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.13 |
| Max. Negotiated Rate |
$1,847.75 |
| Rate for Payer: Aetna American Axle |
$1,334.49
|
| Rate for Payer: Aetna American Axle |
$1,435.75
|
| Rate for Payer: Aetna American Axle |
$613.75
|
| Rate for Payer: Aetna American Axle |
$479.09
|
| Rate for Payer: Aetna Commercial |
$802.60
|
| Rate for Payer: Aetna Commercial |
$1,745.10
|
| Rate for Payer: Aetna Commercial |
$1,877.51
|
| Rate for Payer: Aetna Commercial |
$626.50
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,334.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: Cash Price |
$589.65
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cash Price |
$589.65
|
| Rate for Payer: Cash Price |
$1,767.07
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cash Price |
$1,767.07
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cofinity Commercial |
$1,899.60
|
| Rate for Payer: Cofinity Commercial |
$1,437.14
|
| Rate for Payer: Cofinity Commercial |
$1,765.63
|
| Rate for Payer: Cofinity Commercial |
$1,546.19
|
| Rate for Payer: Cofinity Commercial |
$812.04
|
| Rate for Payer: Cofinity Commercial |
$660.96
|
| Rate for Payer: Cofinity Commercial |
$515.94
|
| Rate for Payer: Cofinity Commercial |
$633.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,437.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$515.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$660.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,642.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Healthscope Commercial |
$1,847.75
|
| Rate for Payer: Healthscope Commercial |
$1,987.96
|
| Rate for Payer: Healthscope Commercial |
$849.81
|
| Rate for Payer: Healthscope Commercial |
$663.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$660.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$515.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,437.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,539.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$552.79
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,745.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$802.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.50
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PHP Commercial |
$626.50
|
| Rate for Payer: PHP Commercial |
$1,745.10
|
| Rate for Payer: PHP Commercial |
$1,877.51
|
| Rate for Payer: PHP Commercial |
$802.60
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$613.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,334.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,435.75
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health SBD |
$1,391.57
|
| Rate for Payer: Priority Health SBD |
$464.35
|
| Rate for Payer: Priority Health SBD |
$1,293.43
|
| Rate for Payer: Priority Health SBD |
$594.86
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UMR Bronson Commercial |
$272.71
|
| Rate for Payer: UMR Bronson Commercial |
$817.27
|
| Rate for Payer: UMR Bronson Commercial |
$759.63
|
| Rate for Payer: UMR Bronson Commercial |
$349.37
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,539.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$552.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.17
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$737.06
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
107800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$324.31 |
| Max. Negotiated Rate |
$663.35 |
| Rate for Payer: Aetna American Axle |
$479.09
|
| Rate for Payer: Aetna American Axle |
$1,435.75
|
| Rate for Payer: Aetna American Axle |
$1,334.49
|
| Rate for Payer: Aetna American Axle |
$613.75
|
| Rate for Payer: Aetna Commercial |
$626.50
|
| Rate for Payer: Aetna Commercial |
$802.60
|
| Rate for Payer: Aetna Commercial |
$1,877.51
|
| Rate for Payer: Aetna Commercial |
$1,745.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,334.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.09
|
| Rate for Payer: Cash Price |
$1,767.07
|
| Rate for Payer: Cash Price |
$589.65
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cofinity Commercial |
$1,437.14
|
| Rate for Payer: Cofinity Commercial |
$812.04
|
| Rate for Payer: Cofinity Commercial |
$660.96
|
| Rate for Payer: Cofinity Commercial |
$515.94
|
| Rate for Payer: Cofinity Commercial |
$1,546.19
|
| Rate for Payer: Cofinity Commercial |
$1,899.60
|
| Rate for Payer: Cofinity Commercial |
$633.87
|
| Rate for Payer: Cofinity Commercial |
$1,765.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$515.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$660.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,437.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,642.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.07
|
| Rate for Payer: Healthscope Commercial |
$663.35
|
| Rate for Payer: Healthscope Commercial |
$1,847.75
|
| Rate for Payer: Healthscope Commercial |
$1,987.96
|
| Rate for Payer: Healthscope Commercial |
$849.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,437.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$660.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$515.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,539.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$552.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$802.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,745.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.50
|
| Rate for Payer: PHP Commercial |
$626.50
|
| Rate for Payer: PHP Commercial |
$802.60
|
| Rate for Payer: PHP Commercial |
$1,745.10
|
| Rate for Payer: PHP Commercial |
$1,877.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$613.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,435.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,334.49
|
| Rate for Payer: Priority Health SBD |
$594.86
|
| Rate for Payer: Priority Health SBD |
$1,293.43
|
| Rate for Payer: Priority Health SBD |
$1,391.57
|
| Rate for Payer: Priority Health SBD |
$464.35
|
| Rate for Payer: UMR Bronson Commercial |
$324.31
|
| Rate for Payer: UMR Bronson Commercial |
$415.46
|
| Rate for Payer: UMR Bronson Commercial |
$971.89
|
| Rate for Payer: UMR Bronson Commercial |
$903.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,539.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$552.79
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
IP
|
$838.80
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$369.07 |
| Max. Negotiated Rate |
$754.92 |
| Rate for Payer: Aetna American Axle |
$545.22
|
| Rate for Payer: Aetna American Axle |
$545.27
|
| Rate for Payer: Aetna Commercial |
$712.98
|
| Rate for Payer: Aetna Commercial |
$713.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.27
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cofinity Commercial |
$721.43
|
| Rate for Payer: Cofinity Commercial |
$587.21
|
| Rate for Payer: Cofinity Commercial |
$587.16
|
| Rate for Payer: Cofinity Commercial |
$721.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.10
|
| Rate for Payer: Healthscope Commercial |
$754.92
|
| Rate for Payer: Healthscope Commercial |
$754.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$713.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$712.98
|
| Rate for Payer: PHP Commercial |
$713.04
|
| Rate for Payer: PHP Commercial |
$712.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.27
|
| Rate for Payer: Priority Health SBD |
$528.44
|
| Rate for Payer: Priority Health SBD |
$528.49
|
| Rate for Payer: UMR Bronson Commercial |
$369.07
|
| Rate for Payer: UMR Bronson Commercial |
$369.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.15
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
OP
|
$838.87
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.13 |
| Max. Negotiated Rate |
$754.98 |
| Rate for Payer: Aetna American Axle |
$545.27
|
| Rate for Payer: Aetna American Axle |
$545.22
|
| Rate for Payer: Aetna Commercial |
$712.98
|
| Rate for Payer: Aetna Commercial |
$713.04
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna Medicare |
$188.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.53
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS Complete |
$101.99
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCBS MAPPO |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: BCN Medicare Advantage |
$181.22
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cofinity Commercial |
$587.16
|
| Rate for Payer: Cofinity Commercial |
$721.37
|
| Rate for Payer: Cofinity Commercial |
$587.21
|
| Rate for Payer: Cofinity Commercial |
$721.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.22
|
| Rate for Payer: Healthscope Commercial |
$754.98
|
| Rate for Payer: Healthscope Commercial |
$754.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.15
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicaid |
$97.13
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Mclaren Medicare |
$181.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.28
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: Meridian Medicaid |
$101.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$713.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$712.98
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE Medicare |
$172.16
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PACE SWMI |
$181.22
|
| Rate for Payer: PHP Commercial |
$712.98
|
| Rate for Payer: PHP Commercial |
$713.04
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: PHP Medicare Advantage |
$181.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.27
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health Medicare |
$181.22
|
| Rate for Payer: Priority Health SBD |
$528.44
|
| Rate for Payer: Priority Health SBD |
$528.49
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: Railroad Medicare Medicare |
$181.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$510.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.22
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Exchange |
$346.33
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHC Medicare Advantage |
$181.22
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UHCCP Medicaid |
$97.13
|
| Rate for Payer: UMR Bronson Commercial |
$310.36
|
| Rate for Payer: UMR Bronson Commercial |
$310.38
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: VA VA |
$181.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.10
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$5.24
|
|
|
Service Code
|
NDC 50268010511
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna American Axle |
$3.41
|
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Aetna Medicare |
$2.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.41
|
| Rate for Payer: BCBS Complete |
$2.10
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Cofinity Commercial |
$4.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.19
|
| Rate for Payer: Healthscope Commercial |
$4.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.45
|
| Rate for Payer: PHP Commercial |
$4.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.41
|
| Rate for Payer: Priority Health SBD |
$3.30
|
| Rate for Payer: UMR Bronson Commercial |
$1.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.93
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$211.50
|
|
|
Service Code
|
NDC 72888000901
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.06 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna American Axle |
$137.47
|
| Rate for Payer: Aetna Commercial |
$179.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.47
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cofinity Commercial |
$148.05
|
| Rate for Payer: Cofinity Commercial |
$181.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.20
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.78
|
| Rate for Payer: PHP Commercial |
$179.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.47
|
| Rate for Payer: Priority Health SBD |
$133.25
|
| Rate for Payer: UMR Bronson Commercial |
$93.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.62
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$284.16
|
|
|
Service Code
|
NDC 71930006612
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.03 |
| Max. Negotiated Rate |
$255.74 |
| Rate for Payer: Aetna American Axle |
$184.70
|
| Rate for Payer: Aetna Commercial |
$241.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.70
|
| Rate for Payer: Cash Price |
$227.33
|
| Rate for Payer: Cofinity Commercial |
$198.91
|
| Rate for Payer: Cofinity Commercial |
$244.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.33
|
| Rate for Payer: Healthscope Commercial |
$255.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.54
|
| Rate for Payer: PHP Commercial |
$241.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.70
|
| Rate for Payer: Priority Health SBD |
$179.02
|
| Rate for Payer: UMR Bronson Commercial |
$125.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.12
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$284.16
|
|
|
Service Code
|
NDC 71930006612
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.14 |
| Max. Negotiated Rate |
$255.74 |
| Rate for Payer: Aetna American Axle |
$184.70
|
| Rate for Payer: Aetna Commercial |
$241.54
|
| Rate for Payer: Aetna Medicare |
$142.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.70
|
| Rate for Payer: BCBS Complete |
$113.66
|
| Rate for Payer: Cash Price |
$227.33
|
| Rate for Payer: Cofinity Commercial |
$198.91
|
| Rate for Payer: Cofinity Commercial |
$244.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.33
|
| Rate for Payer: Healthscope Commercial |
$255.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.54
|
| Rate for Payer: PHP Commercial |
$241.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.70
|
| Rate for Payer: Priority Health SBD |
$179.02
|
| Rate for Payer: UMR Bronson Commercial |
$105.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.12
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$261.84
|
|
|
Service Code
|
NDC 50268010515
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.88 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna American Axle |
$170.20
|
| Rate for Payer: Aetna Commercial |
$222.56
|
| Rate for Payer: Aetna Medicare |
$130.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.20
|
| Rate for Payer: BCBS Complete |
$104.74
|
| Rate for Payer: Cash Price |
$209.47
|
| Rate for Payer: Cofinity Commercial |
$183.29
|
| Rate for Payer: Cofinity Commercial |
$225.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.47
|
| Rate for Payer: Healthscope Commercial |
$235.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.56
|
| Rate for Payer: PHP Commercial |
$222.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.20
|
| Rate for Payer: Priority Health SBD |
$164.96
|
| Rate for Payer: UMR Bronson Commercial |
$96.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.38
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$211.50
|
|
|
Service Code
|
NDC 72888000901
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.25 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna American Axle |
$137.47
|
| Rate for Payer: Aetna Commercial |
$179.78
|
| Rate for Payer: Aetna Medicare |
$105.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.47
|
| Rate for Payer: BCBS Complete |
$84.60
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cofinity Commercial |
$148.05
|
| Rate for Payer: Cofinity Commercial |
$181.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.20
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.78
|
| Rate for Payer: PHP Commercial |
$179.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.47
|
| Rate for Payer: Priority Health SBD |
$133.25
|
| Rate for Payer: UMR Bronson Commercial |
$78.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.62
|
|
