|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$63.07
|
|
|
Service Code
|
NDC 16729-239-30
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$56.76 |
| Rate for Payer: Aetna American Axle |
$41.00
|
| Rate for Payer: Aetna Commercial |
$53.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.00
|
| Rate for Payer: Cash Price |
$50.46
|
| Rate for Payer: Cofinity Commercial |
$44.15
|
| Rate for Payer: Cofinity Commercial |
$54.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.46
|
| Rate for Payer: Healthscope Commercial |
$56.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.61
|
| Rate for Payer: PHP Commercial |
$53.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.15
|
| Rate for Payer: Priority Health SBD |
$39.73
|
| Rate for Payer: UMR Bronson Commercial |
$27.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.30
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$70.27
|
|
|
Service Code
|
NDC 70860-605-02
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.92 |
| Max. Negotiated Rate |
$63.24 |
| Rate for Payer: Aetna American Axle |
$45.68
|
| Rate for Payer: Aetna Commercial |
$59.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.68
|
| Rate for Payer: Cash Price |
$56.22
|
| Rate for Payer: Cofinity Commercial |
$49.19
|
| Rate for Payer: Cofinity Commercial |
$60.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.22
|
| Rate for Payer: Healthscope Commercial |
$63.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.73
|
| Rate for Payer: PHP Commercial |
$59.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.19
|
| Rate for Payer: Priority Health SBD |
$44.27
|
| Rate for Payer: UMR Bronson Commercial |
$30.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.70
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$82.05
|
|
|
Service Code
|
NDC 0781-3297-72
|
| Hospital Charge Code |
27103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.10 |
| Max. Negotiated Rate |
$73.84 |
| Rate for Payer: Aetna American Axle |
$53.33
|
| Rate for Payer: Aetna Commercial |
$69.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.33
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cofinity Commercial |
$57.44
|
| Rate for Payer: Cofinity Commercial |
$70.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.64
|
| Rate for Payer: Healthscope Commercial |
$73.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.74
|
| Rate for Payer: PHP Commercial |
$69.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.44
|
| Rate for Payer: Priority Health SBD |
$51.69
|
| Rate for Payer: UMR Bronson Commercial |
$36.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.54
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$113.23
|
|
|
Service Code
|
NDC 0409-1660-10
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.82 |
| Max. Negotiated Rate |
$101.91 |
| Rate for Payer: Aetna American Axle |
$73.60
|
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.60
|
| Rate for Payer: Cash Price |
$90.58
|
| Rate for Payer: Cofinity Commercial |
$79.26
|
| Rate for Payer: Cofinity Commercial |
$97.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.58
|
| Rate for Payer: Healthscope Commercial |
$101.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$96.25
|
| Rate for Payer: PHP Commercial |
$96.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.26
|
| Rate for Payer: Priority Health SBD |
$71.33
|
| Rate for Payer: UMR Bronson Commercial |
$49.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.92
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$111.20
|
|
|
Service Code
|
NDC 0338-9557-12
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.93 |
| Max. Negotiated Rate |
$100.08 |
| Rate for Payer: Aetna American Axle |
$72.28
|
| Rate for Payer: Aetna Commercial |
$94.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.28
|
| Rate for Payer: Cash Price |
$88.96
|
| Rate for Payer: Cofinity Commercial |
$77.84
|
| Rate for Payer: Cofinity Commercial |
$95.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.96
|
| Rate for Payer: Healthscope Commercial |
$100.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$94.52
|
| Rate for Payer: PHP Commercial |
$94.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.84
|
| Rate for Payer: Priority Health SBD |
$70.06
|
| Rate for Payer: UMR Bronson Commercial |
$48.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.40
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$151.73
|
|
|
Service Code
|
NDC 9900-0010-03
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.76 |
| Max. Negotiated Rate |
$136.56 |
| Rate for Payer: Aetna American Axle |
$98.62
|
| Rate for Payer: Aetna Commercial |
$128.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.62
|
| Rate for Payer: Cash Price |
$121.38
|
| Rate for Payer: Cofinity Commercial |
$106.21
|
| Rate for Payer: Cofinity Commercial |
$130.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.38
|
| Rate for Payer: Healthscope Commercial |
$136.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$113.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$128.97
|
| Rate for Payer: PHP Commercial |
$128.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.21
|
| Rate for Payer: Priority Health SBD |
$95.59
|
| Rate for Payer: UMR Bronson Commercial |
$66.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$113.80
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$103.74
|
|
|
Service Code
|
NDC 55150-297-10
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.65 |
| Max. Negotiated Rate |
$93.37 |
| Rate for Payer: Aetna American Axle |
$67.43
|
| Rate for Payer: Aetna Commercial |
$88.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.43
|
| Rate for Payer: Cash Price |
$82.99
|
| Rate for Payer: Cofinity Commercial |
$72.62
|
| Rate for Payer: Cofinity Commercial |
$89.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.99
|
| Rate for Payer: Healthscope Commercial |
$93.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.18
|
| Rate for Payer: PHP Commercial |
$88.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.62
|
| Rate for Payer: Priority Health SBD |
$65.36
|
| Rate for Payer: UMR Bronson Commercial |
$45.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.80
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$103.74
|
|
|
Service Code
|
NDC 55150-297-01
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.65 |
| Max. Negotiated Rate |
$93.37 |
| Rate for Payer: Aetna American Axle |
$67.43
|
| Rate for Payer: Aetna Commercial |
$88.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.43
|
| Rate for Payer: Cash Price |
$82.99
|
| Rate for Payer: Cofinity Commercial |
$72.62
|
| Rate for Payer: Cofinity Commercial |
$89.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.99
|
| Rate for Payer: Healthscope Commercial |
$93.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.18
|
| Rate for Payer: PHP Commercial |
$88.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.62
|
| Rate for Payer: Priority Health SBD |
$65.36
|
| Rate for Payer: UMR Bronson Commercial |
$45.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.80
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$124.36
|
|
|
Service Code
|
NDC 0143-9525-10
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.72 |
| Max. Negotiated Rate |
$111.92 |
| Rate for Payer: Aetna American Axle |
$80.83
|
| Rate for Payer: Aetna Commercial |
$105.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.83
|
| Rate for Payer: Cash Price |
$99.49
|
| Rate for Payer: Cofinity Commercial |
$106.95
|
| Rate for Payer: Cofinity Commercial |
$87.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.49
|
| Rate for Payer: Healthscope Commercial |
$111.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$105.71
|
| Rate for Payer: PHP Commercial |
$105.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.05
|
| Rate for Payer: Priority Health SBD |
$78.35
|
| Rate for Payer: UMR Bronson Commercial |
$54.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.27
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$113.23
|
|
|
Service Code
|
NDC 0409-1660-35
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.82 |
| Max. Negotiated Rate |
$101.91 |
| Rate for Payer: Aetna American Axle |
$73.60
|
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.60
|
| Rate for Payer: Cash Price |
$90.58
|
| Rate for Payer: Cofinity Commercial |
$79.26
|
| Rate for Payer: Cofinity Commercial |
$97.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.58
|
| Rate for Payer: Healthscope Commercial |
$101.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$96.25
|
| Rate for Payer: PHP Commercial |
$96.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.26
|
| Rate for Payer: Priority Health SBD |
$71.33
|
| Rate for Payer: UMR Bronson Commercial |
$49.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.92
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$124.36
|
|
|
Service Code
|
NDC 0143-9525-01
|
| Hospital Charge Code |
166083
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.72 |
| Max. Negotiated Rate |
$111.92 |
| Rate for Payer: Aetna American Axle |
$80.83
|
| Rate for Payer: Aetna Commercial |
$105.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.83
|
| Rate for Payer: Cash Price |
$99.49
|
| Rate for Payer: Cofinity Commercial |
$106.95
|
| Rate for Payer: Cofinity Commercial |
$87.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.49
|
| Rate for Payer: Healthscope Commercial |
$111.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$105.71
|
| Rate for Payer: PHP Commercial |
$105.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.05
|
| Rate for Payer: Priority Health SBD |
$78.35
|
| Rate for Payer: UMR Bronson Commercial |
$54.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.27
|
|
|
DEXMEDETOMIDINE 4 MCG/ML IV PUSH SOLUTION
|
Facility
|
IP
|
$59.63
|
|
|
Service Code
|
NDC 9900-0001-85
|
| Hospital Charge Code |
300091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$53.67 |
| Rate for Payer: Aetna American Axle |
$38.76
|
| Rate for Payer: Aetna Commercial |
$50.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.76
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cofinity Commercial |
$41.74
|
| Rate for Payer: Cofinity Commercial |
$51.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.70
|
| Rate for Payer: Healthscope Commercial |
$53.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.69
|
| Rate for Payer: PHP Commercial |
$50.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.74
|
| Rate for Payer: Priority Health SBD |
$37.57
|
| Rate for Payer: UMR Bronson Commercial |
$26.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.72
|
|
|
DEXMETHYLPHENIDATE 5 MG TABLET
|
Facility
|
IP
|
$162.75
|
|
|
Service Code
|
NDC 67877-656-01
|
| Hospital Charge Code |
31846
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.61 |
| Max. Negotiated Rate |
$146.48 |
| Rate for Payer: Aetna American Axle |
$105.79
|
| Rate for Payer: Aetna Commercial |
$138.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.79
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cofinity Commercial |
$113.92
|
| Rate for Payer: Cofinity Commercial |
$139.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.20
|
| Rate for Payer: Healthscope Commercial |
$146.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$138.34
|
| Rate for Payer: PHP Commercial |
$138.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.92
|
| Rate for Payer: Priority Health SBD |
$102.53
|
| Rate for Payer: UMR Bronson Commercial |
$71.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.06
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
IP
|
$423.50
|
|
|
Service Code
|
NDC 31722-229-01
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.34 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: Aetna American Axle |
$275.28
|
| Rate for Payer: Aetna Commercial |
$359.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.28
|
| Rate for Payer: Cash Price |
$338.80
|
| Rate for Payer: Cofinity Commercial |
$296.45
|
| Rate for Payer: Cofinity Commercial |
$364.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.80
|
| Rate for Payer: Healthscope Commercial |
$381.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.98
|
| Rate for Payer: PHP Commercial |
$359.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.45
|
| Rate for Payer: Priority Health SBD |
$266.80
|
| Rate for Payer: UMR Bronson Commercial |
$186.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.62
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
IP
|
$817.83
|
|
|
Service Code
|
NDC 0115-9918-01
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$359.85 |
| Max. Negotiated Rate |
$736.05 |
| Rate for Payer: Aetna American Axle |
$531.59
|
| Rate for Payer: Aetna Commercial |
$695.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$531.59
|
| Rate for Payer: Cash Price |
$654.26
|
| Rate for Payer: Cofinity Commercial |
$572.48
|
| Rate for Payer: Cofinity Commercial |
$703.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$654.26
|
| Rate for Payer: Healthscope Commercial |
$736.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$572.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$613.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$695.16
|
| Rate for Payer: PHP Commercial |
$695.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$572.48
|
| Rate for Payer: Priority Health SBD |
$515.23
|
| Rate for Payer: UMR Bronson Commercial |
$359.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$613.37
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
IP
|
$4,169.22
|
|
|
Service Code
|
NDC 0078-0430-05
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,834.46 |
| Max. Negotiated Rate |
$3,752.30 |
| Rate for Payer: Aetna American Axle |
$2,709.99
|
| Rate for Payer: Aetna Commercial |
$3,543.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,709.99
|
| Rate for Payer: Cash Price |
$3,335.38
|
| Rate for Payer: Cofinity Commercial |
$3,585.53
|
| Rate for Payer: Cofinity Commercial |
$2,918.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,335.38
|
| Rate for Payer: Healthscope Commercial |
$3,752.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,918.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,126.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,543.84
|
| Rate for Payer: PHP Commercial |
$3,543.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,918.45
|
| Rate for Payer: Priority Health SBD |
$2,626.61
|
| Rate for Payer: UMR Bronson Commercial |
$1,834.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,126.92
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$257.66
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.37 |
| Max. Negotiated Rate |
$231.89 |
| Rate for Payer: Aetna American Axle |
$167.48
|
| Rate for Payer: Aetna Commercial |
$219.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.48
|
| Rate for Payer: Cash Price |
$206.13
|
| Rate for Payer: Cofinity Commercial |
$221.59
|
| Rate for Payer: Cofinity Commercial |
$180.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.13
|
| Rate for Payer: Healthscope Commercial |
$231.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$219.01
|
| Rate for Payer: PHP Commercial |
$219.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.36
|
| Rate for Payer: Priority Health SBD |
$162.33
|
| Rate for Payer: UMR Bronson Commercial |
$113.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.24
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$418.69
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$184.22 |
| Max. Negotiated Rate |
$376.82 |
| Rate for Payer: Aetna American Axle |
$272.15
|
| Rate for Payer: Aetna American Axle |
$639.32
|
| Rate for Payer: Aetna American Axle |
$306.00
|
| Rate for Payer: Aetna American Axle |
$333.16
|
| Rate for Payer: Aetna American Axle |
$306.76
|
| Rate for Payer: Aetna Commercial |
$435.67
|
| Rate for Payer: Aetna Commercial |
$401.15
|
| Rate for Payer: Aetna Commercial |
$355.89
|
| Rate for Payer: Aetna Commercial |
$836.03
|
| Rate for Payer: Aetna Commercial |
$400.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$272.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$333.16
|
| Rate for Payer: Cash Price |
$377.55
|
| Rate for Payer: Cash Price |
$376.62
|
| Rate for Payer: Cash Price |
$334.95
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cash Price |
$410.04
|
| Rate for Payer: Cofinity Commercial |
$360.07
|
| Rate for Payer: Cofinity Commercial |
$293.08
|
| Rate for Payer: Cofinity Commercial |
$405.87
|
| Rate for Payer: Cofinity Commercial |
$330.36
|
| Rate for Payer: Cofinity Commercial |
$440.79
|
| Rate for Payer: Cofinity Commercial |
$358.78
|
| Rate for Payer: Cofinity Commercial |
$688.50
|
| Rate for Payer: Cofinity Commercial |
$329.54
|
| Rate for Payer: Cofinity Commercial |
$404.86
|
| Rate for Payer: Cofinity Commercial |
$845.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$410.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.86
|
| Rate for Payer: Healthscope Commercial |
$376.82
|
| Rate for Payer: Healthscope Commercial |
$423.69
|
| Rate for Payer: Healthscope Commercial |
$461.30
|
| Rate for Payer: Healthscope Commercial |
$885.21
|
| Rate for Payer: Healthscope Commercial |
$424.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$358.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$688.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$737.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$384.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$314.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$400.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$355.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$401.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$836.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$435.67
|
| Rate for Payer: PHP Commercial |
$401.15
|
| Rate for Payer: PHP Commercial |
$836.03
|
| Rate for Payer: PHP Commercial |
$355.89
|
| Rate for Payer: PHP Commercial |
$435.67
|
| Rate for Payer: PHP Commercial |
$400.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$330.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$358.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$688.50
|
| Rate for Payer: Priority Health SBD |
$619.65
|
| Rate for Payer: Priority Health SBD |
$263.77
|
| Rate for Payer: Priority Health SBD |
$322.91
|
| Rate for Payer: Priority Health SBD |
$296.59
|
| Rate for Payer: Priority Health SBD |
$297.32
|
| Rate for Payer: UMR Bronson Commercial |
$225.52
|
| Rate for Payer: UMR Bronson Commercial |
$184.22
|
| Rate for Payer: UMR Bronson Commercial |
$207.14
|
| Rate for Payer: UMR Bronson Commercial |
$432.77
|
| Rate for Payer: UMR Bronson Commercial |
$207.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$314.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$384.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$737.68
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$983.57
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.08 |
| Max. Negotiated Rate |
$885.21 |
| Rate for Payer: Aetna American Axle |
$639.32
|
| Rate for Payer: Aetna Commercial |
$836.03
|
| Rate for Payer: Aetna Medicare |
$112.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$135.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$135.01
|
| Rate for Payer: BCBS Complete |
$62.04
|
| Rate for Payer: BCBS MAPPO |
$108.01
|
| Rate for Payer: BCBS Trust/PPO |
$349.01
|
| Rate for Payer: BCN Medicare Advantage |
$108.01
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cofinity Commercial |
$688.50
|
| Rate for Payer: Cofinity Commercial |
$845.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$108.01
|
| Rate for Payer: Healthscope Commercial |
$885.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$688.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$737.68
|
| Rate for Payer: Mclaren Medicaid |
$59.08
|
| Rate for Payer: Mclaren Medicare |
$108.01
|
| Rate for Payer: Meridian Medicaid |
$62.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$113.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$124.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$836.03
|
| Rate for Payer: PACE Medicare |
$102.61
|
| Rate for Payer: PACE SWMI |
$108.01
|
| Rate for Payer: PHP Commercial |
$836.03
|
| Rate for Payer: PHP Medicare Advantage |
$108.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$59.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$688.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$363.82
|
| Rate for Payer: Priority Health Medicare |
$108.01
|
| Rate for Payer: Priority Health Narrow Network |
$291.06
|
| Rate for Payer: Priority Health SBD |
$619.65
|
| Rate for Payer: Railroad Medicare Medicare |
$108.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$108.01
|
| Rate for Payer: UHC Medicare Advantage |
$111.25
|
| Rate for Payer: UMR Bronson Commercial |
$363.92
|
| Rate for Payer: VA VA |
$108.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$737.68
|
|
|
DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS
|
Facility
|
IP
|
$134.56
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
9759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.21 |
| Max. Negotiated Rate |
$121.10 |
| Rate for Payer: Aetna American Axle |
$87.46
|
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.46
|
| Rate for Payer: Cash Price |
$107.65
|
| Rate for Payer: Cofinity Commercial |
$115.72
|
| Rate for Payer: Cofinity Commercial |
$94.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.65
|
| Rate for Payer: Healthscope Commercial |
$121.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$114.38
|
| Rate for Payer: PHP Commercial |
$114.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.19
|
| Rate for Payer: Priority Health SBD |
$84.77
|
| Rate for Payer: UMR Bronson Commercial |
$59.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.92
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$607.25
|
|
|
Service Code
|
NDC 47781-176-01
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.19 |
| Max. Negotiated Rate |
$546.52 |
| Rate for Payer: Aetna American Axle |
$394.71
|
| Rate for Payer: Aetna Commercial |
$516.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$394.71
|
| Rate for Payer: Cash Price |
$485.80
|
| Rate for Payer: Cofinity Commercial |
$425.08
|
| Rate for Payer: Cofinity Commercial |
$522.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$485.80
|
| Rate for Payer: Healthscope Commercial |
$546.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$425.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$455.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$516.16
|
| Rate for Payer: PHP Commercial |
$516.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.08
|
| Rate for Payer: Priority Health SBD |
$382.57
|
| Rate for Payer: UMR Bronson Commercial |
$267.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$455.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$610.75
|
|
|
Service Code
|
NDC 13107-070-01
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.73 |
| Max. Negotiated Rate |
$549.68 |
| Rate for Payer: Aetna American Axle |
$396.99
|
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Commercial |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$458.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$519.14
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$427.52
|
| Rate for Payer: Priority Health SBD |
$384.77
|
| Rate for Payer: UMR Bronson Commercial |
$268.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$458.06
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$605.50
|
|
|
Service Code
|
NDC 68382-952-01
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.42 |
| Max. Negotiated Rate |
$544.95 |
| Rate for Payer: Aetna American Axle |
$393.58
|
| Rate for Payer: Aetna Commercial |
$514.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.58
|
| Rate for Payer: Cash Price |
$484.40
|
| Rate for Payer: Cofinity Commercial |
$423.85
|
| Rate for Payer: Cofinity Commercial |
$520.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.40
|
| Rate for Payer: Healthscope Commercial |
$544.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$454.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$514.68
|
| Rate for Payer: PHP Commercial |
$514.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$423.85
|
| Rate for Payer: Priority Health SBD |
$381.46
|
| Rate for Payer: UMR Bronson Commercial |
$266.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$454.12
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 0555-0972-02
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.28
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.28
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Commercial |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$478.98
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$394.45
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$247.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
|
Service Code
|
NDC 0527-1502-37
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$361.90 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Commercial |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$699.12
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$575.75
|
| Rate for Payer: Priority Health SBD |
$518.18
|
| Rate for Payer: UMR Bronson Commercial |
$361.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
