|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 9900-0009-76
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna American Axle |
$3.35
|
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.35
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.39
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: Priority Health SBD |
$3.25
|
| Rate for Payer: UMR Bronson Commercial |
$2.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.87
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 61570-131-50
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.40
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.09
|
| Rate for Payer: Priority Health SBD |
$18.08
|
| Rate for Payer: UMR Bronson Commercial |
$12.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$67.20
|
|
|
Service Code
|
NDC 67877-124-40
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.57 |
| Max. Negotiated Rate |
$60.48 |
| Rate for Payer: Aetna American Axle |
$43.68
|
| Rate for Payer: Aetna Commercial |
$57.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.68
|
| Rate for Payer: Cash Price |
$53.76
|
| Rate for Payer: Cofinity Commercial |
$47.04
|
| Rate for Payer: Cofinity Commercial |
$57.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.76
|
| Rate for Payer: Healthscope Commercial |
$60.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.12
|
| Rate for Payer: PHP Commercial |
$57.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.04
|
| Rate for Payer: Priority Health SBD |
$42.34
|
| Rate for Payer: UMR Bronson Commercial |
$29.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.40
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$165.20
|
|
|
Service Code
|
NDC 61570-131-40
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.69 |
| Max. Negotiated Rate |
$148.68 |
| Rate for Payer: Aetna American Axle |
$107.38
|
| Rate for Payer: Aetna Commercial |
$140.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.38
|
| Rate for Payer: Cash Price |
$132.16
|
| Rate for Payer: Cofinity Commercial |
$115.64
|
| Rate for Payer: Cofinity Commercial |
$142.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.16
|
| Rate for Payer: Healthscope Commercial |
$148.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$140.42
|
| Rate for Payer: PHP Commercial |
$140.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.64
|
| Rate for Payer: Priority Health SBD |
$104.08
|
| Rate for Payer: UMR Bronson Commercial |
$72.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.90
|
|
|
SIMETHICONE 125 MG CHEWABLE TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 0536-1223-08
|
| Hospital Charge Code |
7226
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 0904-5894-30
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$15.39
|
|
|
Service Code
|
NDC 70000-0051-1
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: Aetna American Axle |
$10.00
|
| Rate for Payer: Aetna Commercial |
$13.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.00
|
| Rate for Payer: Cash Price |
$12.31
|
| Rate for Payer: Cofinity Commercial |
$10.77
|
| Rate for Payer: Cofinity Commercial |
$13.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.31
|
| Rate for Payer: Healthscope Commercial |
$13.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.08
|
| Rate for Payer: PHP Commercial |
$13.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.77
|
| Rate for Payer: Priority Health SBD |
$9.70
|
| Rate for Payer: UMR Bronson Commercial |
$6.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.54
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$9.86
|
|
|
Service Code
|
NDC 96295-13553
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$8.87 |
| Rate for Payer: Aetna American Axle |
$6.41
|
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.41
|
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Cofinity Commercial |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.89
|
| Rate for Payer: Healthscope Commercial |
$8.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.38
|
| Rate for Payer: PHP Commercial |
$8.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.90
|
| Rate for Payer: Priority Health SBD |
$6.21
|
| Rate for Payer: UMR Bronson Commercial |
$4.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.40
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 1990301023
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.94
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.25
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UMR Bronson Commercial |
$10.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 62372-630-15
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.39
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: UMR Bronson Commercial |
$10.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 1990301021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.94
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.25
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UMR Bronson Commercial |
$10.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$10.98
|
|
|
Service Code
|
NDC 0536-2220-75
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna American Axle |
$7.14
|
| Rate for Payer: Aetna Commercial |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.14
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cofinity Commercial |
$7.69
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.78
|
| Rate for Payer: Healthscope Commercial |
$9.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.33
|
| Rate for Payer: PHP Commercial |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.69
|
| Rate for Payer: Priority Health SBD |
$6.92
|
| Rate for Payer: UMR Bronson Commercial |
$4.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.24
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$39.95
|
|
|
Service Code
|
NDC 0904-5068-60
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Aetna American Axle |
$25.97
|
| Rate for Payer: Aetna Commercial |
$33.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.97
|
| Rate for Payer: Cash Price |
$31.96
|
| Rate for Payer: Cofinity Commercial |
$27.96
|
| Rate for Payer: Cofinity Commercial |
$34.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.96
|
| Rate for Payer: Healthscope Commercial |
$35.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.96
|
| Rate for Payer: PHP Commercial |
$33.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.96
|
| Rate for Payer: Priority Health SBD |
$25.17
|
| Rate for Payer: UMR Bronson Commercial |
$17.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.96
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 70000-0434-1
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$65.80
|
|
|
Service Code
|
NDC 69618-033-01
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.95 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna American Axle |
$42.77
|
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.06
|
| Rate for Payer: Priority Health SBD |
$41.45
|
| Rate for Payer: UMR Bronson Commercial |
$28.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.35
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$56.40
|
|
|
Service Code
|
NDC 57896-791-01
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.66
|
| Rate for Payer: Cash Price |
$45.12
|
| Rate for Payer: Cofinity Commercial |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.12
|
| Rate for Payer: Healthscope Commercial |
$50.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.94
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.48
|
| Rate for Payer: Priority Health SBD |
$35.53
|
| Rate for Payer: UMR Bronson Commercial |
$24.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$72.85
|
|
|
Service Code
|
NDC 96295-13606
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.05 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna American Axle |
$47.35
|
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Commercial |
$51.00
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$61.92
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.00
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UMR Bronson Commercial |
$32.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.64
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$51.70
|
|
|
Service Code
|
NDC 0904-7206-60
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$46.53 |
| Rate for Payer: Aetna American Axle |
$33.60
|
| Rate for Payer: Aetna Commercial |
$43.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.60
|
| Rate for Payer: Cash Price |
$41.36
|
| Rate for Payer: Cofinity Commercial |
$36.19
|
| Rate for Payer: Cofinity Commercial |
$44.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.36
|
| Rate for Payer: Healthscope Commercial |
$46.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.94
|
| Rate for Payer: PHP Commercial |
$43.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.19
|
| Rate for Payer: Priority Health SBD |
$32.57
|
| Rate for Payer: UMR Bronson Commercial |
$22.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.78
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 63739-225-10
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna American Axle |
$67.21
|
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.21
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.89
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.38
|
| Rate for Payer: Priority Health SBD |
$65.14
|
| Rate for Payer: UMR Bronson Commercial |
$45.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$12,541.84
|
|
|
Service Code
|
MS-DRG 194
|
| Min. Negotiated Rate |
$6,505.85 |
| Max. Negotiated Rate |
$12,541.84 |
| Rate for Payer: Aetna Medicare |
$7,122.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,560.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,560.32
|
| Rate for Payer: BCBS MAPPO |
$6,848.26
|
| Rate for Payer: BCBS Trust/PPO |
$12,300.65
|
| Rate for Payer: BCN Medicare Advantage |
$6,848.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,848.26
|
| Rate for Payer: Mclaren Medicare |
$6,848.26
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,190.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,875.50
|
| Rate for Payer: PACE Medicare |
$6,505.85
|
| Rate for Payer: PACE SWMI |
$6,848.26
|
| Rate for Payer: PHP Medicare Advantage |
$6,848.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,798.50
|
| Rate for Payer: Priority Health Medicare |
$6,848.26
|
| Rate for Payer: Priority Health Narrow Network |
$9,438.80
|
| Rate for Payer: Railroad Medicare Medicare |
$6,848.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,541.84
|
| Rate for Payer: UHC Core |
$10,284.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,848.26
|
| Rate for Payer: UHC Exchange |
$8,175.96
|
| Rate for Payer: UHC Medicare Advantage |
$7,053.71
|
| Rate for Payer: VA VA |
$6,848.26
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$20,235.96
|
|
|
Service Code
|
MS-DRG 193
|
| Min. Negotiated Rate |
$10,198.42 |
| Max. Negotiated Rate |
$20,235.96 |
| Rate for Payer: Aetna Medicare |
$11,164.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,418.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,418.98
|
| Rate for Payer: BCBS MAPPO |
$10,735.18
|
| Rate for Payer: BCBS Trust/PPO |
$19,301.58
|
| Rate for Payer: BCN Medicare Advantage |
$10,735.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,735.18
|
| Rate for Payer: Mclaren Medicare |
$10,735.18
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,271.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,345.46
|
| Rate for Payer: PACE Medicare |
$10,198.42
|
| Rate for Payer: PACE SWMI |
$10,735.18
|
| Rate for Payer: PHP Medicare Advantage |
$10,735.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,036.60
|
| Rate for Payer: Priority Health Medicare |
$10,735.18
|
| Rate for Payer: Priority Health Narrow Network |
$15,229.28
|
| Rate for Payer: Railroad Medicare Medicare |
$10,735.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20,235.96
|
| Rate for Payer: UHC Core |
$16,593.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,735.18
|
| Rate for Payer: UHC Exchange |
$13,191.71
|
| Rate for Payer: UHC Medicare Advantage |
$11,057.24
|
| Rate for Payer: VA VA |
$10,735.18
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$9,542.90
|
|
|
Service Code
|
MS-DRG 195
|
| Min. Negotiated Rate |
$5,066.58 |
| Max. Negotiated Rate |
$9,542.90 |
| Rate for Payer: Aetna Medicare |
$5,546.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,666.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,666.55
|
| Rate for Payer: BCBS MAPPO |
$5,333.24
|
| Rate for Payer: BCBS Trust/PPO |
$8,345.34
|
| Rate for Payer: BCN Medicare Advantage |
$5,333.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,333.24
|
| Rate for Payer: Mclaren Medicare |
$5,333.24
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,599.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,133.23
|
| Rate for Payer: PACE Medicare |
$5,066.58
|
| Rate for Payer: PACE SWMI |
$5,333.24
|
| Rate for Payer: PHP Medicare Advantage |
$5,333.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,977.31
|
| Rate for Payer: Priority Health Medicare |
$5,333.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,181.85
|
| Rate for Payer: Railroad Medicare Medicare |
$5,333.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,542.90
|
| Rate for Payer: UHC Core |
$7,825.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,333.24
|
| Rate for Payer: UHC Exchange |
$6,220.97
|
| Rate for Payer: UHC Medicare Advantage |
$5,493.24
|
| Rate for Payer: VA VA |
$5,333.24
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM
|
Facility
|
OP
|
$1,115.78
|
|
|
Service Code
|
CPT 12016
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$122.88 |
| Max. Negotiated Rate |
$1,115.78 |
| Rate for Payer: Aetna Medicare |
$368.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$443.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$443.04
|
| Rate for Payer: BCBS Complete |
$203.58
|
| Rate for Payer: BCBS MAPPO |
$354.43
|
| Rate for Payer: BCBS Trust/PPO |
$122.88
|
| Rate for Payer: BCN Medicare Advantage |
$354.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$354.43
|
| Rate for Payer: Mclaren Medicaid |
$193.87
|
| Rate for Payer: Mclaren Medicare |
$354.43
|
| Rate for Payer: Meridian Medicaid |
$203.58
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$372.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$407.59
|
| Rate for Payer: PACE Medicare |
$336.71
|
| Rate for Payer: PACE SWMI |
$354.43
|
| Rate for Payer: PHP Medicare Advantage |
$354.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$193.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,115.78
|
| Rate for Payer: Priority Health Medicare |
$354.43
|
| Rate for Payer: Priority Health Narrow Network |
$892.62
|
| Rate for Payer: Railroad Medicare Medicare |
$354.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.24
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$354.43
|
| Rate for Payer: UHC Exchange |
$124.76
|
| Rate for Payer: UHC Medicare Advantage |
$365.06
|
| Rate for Payer: VA VA |
$354.43
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 12011
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$54.36 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$185.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.44
|
| Rate for Payer: BCBS Complete |
$102.21
|
| Rate for Payer: BCBS MAPPO |
$177.95
|
| Rate for Payer: BCBS Trust/PPO |
$136.72
|
| Rate for Payer: BCN Medicare Advantage |
$177.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$177.95
|
| Rate for Payer: Mclaren Medicaid |
$97.34
|
| Rate for Payer: Mclaren Medicare |
$177.95
|
| Rate for Payer: Meridian Medicaid |
$102.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$186.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.64
|
| Rate for Payer: PACE Medicare |
$169.05
|
| Rate for Payer: PACE SWMI |
$177.95
|
| Rate for Payer: PHP Medicare Advantage |
$177.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$560.20
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$448.16
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.80
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$177.95
|
| Rate for Payer: UHC Exchange |
$54.36
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 12011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$54.36 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$185.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.44
|
| Rate for Payer: BCBS Complete |
$102.21
|
| Rate for Payer: BCBS MAPPO |
$177.95
|
| Rate for Payer: BCBS Trust/PPO |
$136.72
|
| Rate for Payer: BCN Medicare Advantage |
$177.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$177.95
|
| Rate for Payer: Mclaren Medicaid |
$97.34
|
| Rate for Payer: Mclaren Medicare |
$177.95
|
| Rate for Payer: Meridian Medicaid |
$102.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$186.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.64
|
| Rate for Payer: PACE Medicare |
$169.05
|
| Rate for Payer: PACE SWMI |
$177.95
|
| Rate for Payer: PHP Medicare Advantage |
$177.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$560.20
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$448.16
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.80
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$177.95
|
| Rate for Payer: UHC Exchange |
$54.36
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
