|
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
|
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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION
|
Facility
|
OP
|
$201.25
|
|
|
Service Code
|
NDC 00065080050
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.46 |
| Max. Negotiated Rate |
$181.12 |
| Rate for Payer: Aetna American Axle |
$130.81
|
| Rate for Payer: Aetna Commercial |
$171.06
|
| Rate for Payer: Aetna Medicare |
$100.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.81
|
| Rate for Payer: BCBS Complete |
$80.50
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cofinity Commercial |
$140.88
|
| Rate for Payer: Cofinity Commercial |
$173.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.00
|
| Rate for Payer: Healthscope Commercial |
$181.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$171.06
|
| Rate for Payer: PHP Commercial |
$171.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.81
|
| Rate for Payer: Priority Health SBD |
$126.79
|
| Rate for Payer: UMR Bronson Commercial |
$74.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.94
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION
|
Facility
|
IP
|
$201.25
|
|
|
Service Code
|
NDC 00065080050
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.55 |
| Max. Negotiated Rate |
$181.12 |
| Rate for Payer: Aetna American Axle |
$130.81
|
| Rate for Payer: Aetna Commercial |
$171.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.81
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cofinity Commercial |
$140.88
|
| Rate for Payer: Cofinity Commercial |
$173.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.00
|
| Rate for Payer: Healthscope Commercial |
$181.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$171.06
|
| Rate for Payer: PHP Commercial |
$171.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.81
|
| Rate for Payer: Priority Health SBD |
$126.79
|
| Rate for Payer: UMR Bronson Commercial |
$88.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.94
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION
|
Facility
|
OP
|
$24.75
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$22.27 |
| Rate for Payer: Aetna American Axle |
$16.09
|
| Rate for Payer: Aetna Commercial |
$21.04
|
| Rate for Payer: Aetna Medicare |
$12.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.09
|
| Rate for Payer: BCBS Complete |
$9.90
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cofinity Commercial |
$17.32
|
| Rate for Payer: Cofinity Commercial |
$21.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.80
|
| Rate for Payer: Healthscope Commercial |
$22.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.04
|
| Rate for Payer: PHP Commercial |
$21.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.09
|
| Rate for Payer: Priority Health SBD |
$15.59
|
| Rate for Payer: UMR Bronson Commercial |
$9.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.56
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION
|
Facility
|
OP
|
$10.53
|
|
|
Service Code
|
NDC 00065079515
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Aetna American Axle |
$6.84
|
| Rate for Payer: Aetna Commercial |
$8.95
|
| Rate for Payer: Aetna Medicare |
$5.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.84
|
| Rate for Payer: BCBS Complete |
$4.21
|
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Cofinity Commercial |
$7.37
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.42
|
| Rate for Payer: Healthscope Commercial |
$9.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.95
|
| Rate for Payer: PHP Commercial |
$8.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.84
|
| Rate for Payer: Priority Health SBD |
$6.63
|
| Rate for Payer: UMR Bronson Commercial |
$3.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.90
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION
|
Facility
|
IP
|
$24.75
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$22.27 |
| Rate for Payer: Aetna American Axle |
$16.09
|
| Rate for Payer: Aetna Commercial |
$21.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.09
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cofinity Commercial |
$17.32
|
| Rate for Payer: Cofinity Commercial |
$21.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.80
|
| Rate for Payer: Healthscope Commercial |
$22.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.04
|
| Rate for Payer: PHP Commercial |
$21.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.09
|
| Rate for Payer: Priority Health SBD |
$15.59
|
| Rate for Payer: UMR Bronson Commercial |
$10.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.56
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION
|
Facility
|
IP
|
$10.53
|
|
|
Service Code
|
NDC 00065079515
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Aetna American Axle |
$6.84
|
| Rate for Payer: Aetna Commercial |
$8.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.84
|
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Cofinity Commercial |
$7.37
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.42
|
| Rate for Payer: Healthscope Commercial |
$9.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.95
|
| Rate for Payer: PHP Commercial |
$8.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.84
|
| Rate for Payer: Priority Health SBD |
$6.63
|
| Rate for Payer: UMR Bronson Commercial |
$4.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.90
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH
|
Facility
|
OP
|
$88.62
|
|
|
Service Code
|
NDC 00065053001
|
| Hospital Charge Code |
10780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.79 |
| Max. Negotiated Rate |
$79.76 |
| Rate for Payer: Aetna American Axle |
$57.60
|
| Rate for Payer: Aetna Commercial |
$75.33
|
| Rate for Payer: Aetna Medicare |
$44.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.60
|
| Rate for Payer: BCBS Complete |
$35.45
|
| Rate for Payer: Cash Price |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$62.03
|
| Rate for Payer: Cofinity Commercial |
$76.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.90
|
| Rate for Payer: Healthscope Commercial |
$79.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.33
|
| Rate for Payer: PHP Commercial |
$75.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.60
|
| Rate for Payer: Priority Health SBD |
$55.83
|
| Rate for Payer: UMR Bronson Commercial |
$32.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.47
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH
|
Facility
|
IP
|
$88.62
|
|
|
Service Code
|
NDC 00065053001
|
| Hospital Charge Code |
10780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.99 |
| Max. Negotiated Rate |
$79.76 |
| Rate for Payer: Aetna American Axle |
$57.60
|
| Rate for Payer: Aetna Commercial |
$75.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.60
|
| Rate for Payer: Cash Price |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$62.03
|
| Rate for Payer: Cofinity Commercial |
$76.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.90
|
| Rate for Payer: Healthscope Commercial |
$79.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.33
|
| Rate for Payer: PHP Commercial |
$75.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.60
|
| Rate for Payer: Priority Health SBD |
$55.83
|
| Rate for Payer: UMR Bronson Commercial |
$38.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.47
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
IP
|
$962.31
|
|
|
Service Code
|
NDC 00054007928
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$423.42 |
| Max. Negotiated Rate |
$866.08 |
| Rate for Payer: Aetna American Axle |
$625.50
|
| Rate for Payer: Aetna Commercial |
$817.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$625.50
|
| Rate for Payer: Cash Price |
$769.85
|
| Rate for Payer: Cofinity Commercial |
$673.62
|
| Rate for Payer: Cofinity Commercial |
$827.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$673.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$769.85
|
| Rate for Payer: Healthscope Commercial |
$866.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$673.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$721.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$817.96
|
| Rate for Payer: PHP Commercial |
$817.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$625.50
|
| Rate for Payer: Priority Health SBD |
$606.26
|
| Rate for Payer: UMR Bronson Commercial |
$423.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$721.73
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
OP
|
$731.14
|
|
|
Service Code
|
NDC 00378675082
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.52 |
| Max. Negotiated Rate |
$658.03 |
| Rate for Payer: Aetna American Axle |
$475.24
|
| Rate for Payer: Aetna Commercial |
$621.47
|
| Rate for Payer: Aetna Medicare |
$365.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.24
|
| Rate for Payer: BCBS Complete |
$292.46
|
| Rate for Payer: Cash Price |
$584.91
|
| Rate for Payer: Cofinity Commercial |
$511.80
|
| Rate for Payer: Cofinity Commercial |
$628.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$511.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$584.91
|
| Rate for Payer: Healthscope Commercial |
$658.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$511.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$548.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$621.47
|
| Rate for Payer: PHP Commercial |
$621.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$475.24
|
| Rate for Payer: Priority Health SBD |
$460.62
|
| Rate for Payer: UMR Bronson Commercial |
$270.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$548.36
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
OP
|
$1,223.60
|
|
|
Service Code
|
NDC 60505257507
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$452.73 |
| Max. Negotiated Rate |
$1,101.24 |
| Rate for Payer: Aetna American Axle |
$795.34
|
| Rate for Payer: Aetna Commercial |
$1,040.06
|
| Rate for Payer: Aetna Medicare |
$611.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$795.34
|
| Rate for Payer: BCBS Complete |
$489.44
|
| Rate for Payer: Cash Price |
$978.88
|
| Rate for Payer: Cofinity Commercial |
$1,052.30
|
| Rate for Payer: Cofinity Commercial |
$856.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$856.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$978.88
|
| Rate for Payer: Healthscope Commercial |
$1,101.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$856.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$917.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,040.06
|
| Rate for Payer: PHP Commercial |
$1,040.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.34
|
| Rate for Payer: Priority Health SBD |
$770.87
|
| Rate for Payer: UMR Bronson Commercial |
$452.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$917.70
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
IP
|
$731.14
|
|
|
Service Code
|
NDC 00378675082
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.70 |
| Max. Negotiated Rate |
$658.03 |
| Rate for Payer: Aetna American Axle |
$475.24
|
| Rate for Payer: Aetna Commercial |
$621.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.24
|
| Rate for Payer: Cash Price |
$584.91
|
| Rate for Payer: Cofinity Commercial |
$511.80
|
| Rate for Payer: Cofinity Commercial |
$628.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$511.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$584.91
|
| Rate for Payer: Healthscope Commercial |
$658.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$511.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$548.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$621.47
|
| Rate for Payer: PHP Commercial |
$621.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$475.24
|
| Rate for Payer: Priority Health SBD |
$460.62
|
| Rate for Payer: UMR Bronson Commercial |
$321.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$548.36
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
OP
|
$962.31
|
|
|
Service Code
|
NDC 00054007928
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$356.05 |
| Max. Negotiated Rate |
$866.08 |
| Rate for Payer: Aetna American Axle |
$625.50
|
| Rate for Payer: Aetna Commercial |
$817.96
|
| Rate for Payer: Aetna Medicare |
$481.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$625.50
|
| Rate for Payer: BCBS Complete |
$384.92
|
| Rate for Payer: Cash Price |
$769.85
|
| Rate for Payer: Cofinity Commercial |
$673.62
|
| Rate for Payer: Cofinity Commercial |
$827.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$673.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$769.85
|
| Rate for Payer: Healthscope Commercial |
$866.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$673.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$721.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$817.96
|
| Rate for Payer: PHP Commercial |
$817.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$625.50
|
| Rate for Payer: Priority Health SBD |
$606.26
|
| Rate for Payer: UMR Bronson Commercial |
$356.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$721.73
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
IP
|
$1,223.60
|
|
|
Service Code
|
NDC 60505257507
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$538.38 |
| Max. Negotiated Rate |
$1,101.24 |
| Rate for Payer: Aetna American Axle |
$795.34
|
| Rate for Payer: Aetna Commercial |
$1,040.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$795.34
|
| Rate for Payer: Cash Price |
$978.88
|
| Rate for Payer: Cofinity Commercial |
$1,052.30
|
| Rate for Payer: Cofinity Commercial |
$856.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$856.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$978.88
|
| Rate for Payer: Healthscope Commercial |
$1,101.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$856.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$917.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,040.06
|
| Rate for Payer: PHP Commercial |
$1,040.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.34
|
| Rate for Payer: Priority Health SBD |
$770.87
|
| Rate for Payer: UMR Bronson Commercial |
$538.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$917.70
|
|
|
BARICITINIB 2 MG TABLET
|
Facility
|
IP
|
$9,736.26
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
186973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,283.95 |
| Max. Negotiated Rate |
$8,762.63 |
| Rate for Payer: Aetna American Axle |
$6,328.57
|
| Rate for Payer: Aetna Commercial |
$8,275.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,328.57
|
| Rate for Payer: Cash Price |
$7,789.01
|
| Rate for Payer: Cofinity Commercial |
$6,815.38
|
| Rate for Payer: Cofinity Commercial |
$8,373.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,815.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,789.01
|
| Rate for Payer: Healthscope Commercial |
$8,762.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,815.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,302.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,275.82
|
| Rate for Payer: PHP Commercial |
$8,275.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,328.57
|
| Rate for Payer: Priority Health SBD |
$6,133.84
|
| Rate for Payer: UMR Bronson Commercial |
$4,283.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,302.19
|
|
|
BARICITINIB 2 MG TABLET
|
Facility
|
OP
|
$9,736.26
|
|
|
Service Code
|
NDC 00002418230
|
| Hospital Charge Code |
186973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,602.42 |
| Max. Negotiated Rate |
$8,762.63 |
| Rate for Payer: Aetna American Axle |
$6,328.57
|
| Rate for Payer: Aetna Commercial |
$8,275.82
|
| Rate for Payer: Aetna Medicare |
$4,868.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,328.57
|
| Rate for Payer: BCBS Complete |
$3,894.50
|
| Rate for Payer: Cash Price |
$7,789.01
|
| Rate for Payer: Cofinity Commercial |
$6,815.38
|
| Rate for Payer: Cofinity Commercial |
$8,373.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,815.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,789.01
|
| Rate for Payer: Healthscope Commercial |
$8,762.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,815.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,302.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,275.82
|
| Rate for Payer: PHP Commercial |
$8,275.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,328.57
|
| Rate for Payer: Priority Health SBD |
$6,133.84
|
| Rate for Payer: UMR Bronson Commercial |
$3,602.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,302.19
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15,380.50
|
|
|
Service Code
|
HCPCS J0480
|
| Hospital Charge Code |
23082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,512.15 |
| Max. Negotiated Rate |
$13,842.45 |
| Rate for Payer: Aetna American Axle |
$9,997.33
|
| Rate for Payer: Aetna Commercial |
$13,073.42
|
| Rate for Payer: Aetna Medicare |
$4,874.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,997.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,858.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,858.56
|
| Rate for Payer: BCBS Complete |
$2,637.76
|
| Rate for Payer: BCBS MAPPO |
$4,686.85
|
| Rate for Payer: BCN Medicare Advantage |
$4,686.85
|
| Rate for Payer: Cash Price |
$12,304.40
|
| Rate for Payer: Cash Price |
$12,304.40
|
| Rate for Payer: Cofinity Commercial |
$13,227.23
|
| Rate for Payer: Cofinity Commercial |
$10,766.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$10,766.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,304.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,686.85
|
| Rate for Payer: Healthscope Commercial |
$13,842.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,766.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11,535.38
|
| Rate for Payer: Mclaren Medicaid |
$2,512.15
|
| Rate for Payer: Mclaren Medicare |
$4,686.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4,921.19
|
| Rate for Payer: Meridian Medicaid |
$2,637.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,389.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,073.42
|
| Rate for Payer: PACE Medicare |
$4,452.51
|
| Rate for Payer: PACE SWMI |
$4,686.85
|
| Rate for Payer: PHP Commercial |
$13,073.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,686.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,512.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,997.33
|
| Rate for Payer: Priority Health Medicare |
$4,686.85
|
| Rate for Payer: Priority Health SBD |
$9,689.72
|
| Rate for Payer: Railroad Medicare Medicare |
$4,686.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,193.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,686.85
|
| Rate for Payer: UHC Exchange |
$8,957.04
|
| Rate for Payer: UHC Medicare Advantage |
$4,686.85
|
| Rate for Payer: UHCCP Medicaid |
$2,512.15
|
| Rate for Payer: UMR Bronson Commercial |
$5,690.78
|
| Rate for Payer: VA VA |
$4,686.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11,535.38
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15,380.50
|
|
|
Service Code
|
HCPCS J0480
|
| Hospital Charge Code |
23082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,767.42 |
| Max. Negotiated Rate |
$13,842.45 |
| Rate for Payer: Aetna American Axle |
$9,997.33
|
| Rate for Payer: Aetna Commercial |
$13,073.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,997.33
|
| Rate for Payer: Cash Price |
$12,304.40
|
| Rate for Payer: Cofinity Commercial |
$10,766.35
|
| Rate for Payer: Cofinity Commercial |
$13,227.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$10,766.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,304.40
|
| Rate for Payer: Healthscope Commercial |
$13,842.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,766.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11,535.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,073.42
|
| Rate for Payer: PHP Commercial |
$13,073.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,997.33
|
| Rate for Payer: Priority Health SBD |
$9,689.72
|
| Rate for Payer: UMR Bronson Commercial |
$6,767.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11,535.38
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION
|
Facility
|
IP
|
$488.06
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
116210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.75 |
| Max. Negotiated Rate |
$439.25 |
| Rate for Payer: Aetna American Axle |
$317.24
|
| Rate for Payer: Aetna Commercial |
$414.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$317.24
|
| Rate for Payer: Cash Price |
$390.45
|
| Rate for Payer: Cofinity Commercial |
$341.64
|
| Rate for Payer: Cofinity Commercial |
$419.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$341.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.45
|
| Rate for Payer: Healthscope Commercial |
$439.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$341.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$366.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$414.85
|
| Rate for Payer: PHP Commercial |
$414.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.24
|
| Rate for Payer: Priority Health SBD |
$307.48
|
| Rate for Payer: UMR Bronson Commercial |
$214.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$366.05
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION
|
Facility
|
OP
|
$488.06
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
116210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.58 |
| Max. Negotiated Rate |
$439.25 |
| Rate for Payer: Aetna American Axle |
$317.24
|
| Rate for Payer: Aetna Commercial |
$414.85
|
| Rate for Payer: Aetna Medicare |
$244.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$317.24
|
| Rate for Payer: BCBS Complete |
$195.22
|
| Rate for Payer: Cash Price |
$390.45
|
| Rate for Payer: Cofinity Commercial |
$341.64
|
| Rate for Payer: Cofinity Commercial |
$419.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$341.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.45
|
| Rate for Payer: Healthscope Commercial |
$439.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$341.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$366.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$414.85
|
| Rate for Payer: PHP Commercial |
$414.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.24
|
| Rate for Payer: Priority Health SBD |
$307.48
|
| Rate for Payer: UMR Bronson Commercial |
$180.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$366.05
|
|
|
B-COMPLEX WITH VITAMIN C TABLET
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
NDC 80681015400
|
| Hospital Charge Code |
807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.76 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna American Axle |
$96.20
|
| Rate for Payer: Aetna Commercial |
$125.80
|
| Rate for Payer: Aetna Medicare |
$74.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.20
|
| Rate for Payer: BCBS Complete |
$59.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cofinity Commercial |
$103.60
|
| Rate for Payer: Cofinity Commercial |
$127.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.40
|
| Rate for Payer: Healthscope Commercial |
$133.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.80
|
| Rate for Payer: PHP Commercial |
$125.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.20
|
| Rate for Payer: Priority Health SBD |
$93.24
|
| Rate for Payer: UMR Bronson Commercial |
$54.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.00
|
|
|
B-COMPLEX WITH VITAMIN C TABLET
|
Facility
|
IP
|
$188.37
|
|
|
Service Code
|
NDC 80681012600
|
| Hospital Charge Code |
807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.88 |
| Max. Negotiated Rate |
$169.53 |
| Rate for Payer: Aetna American Axle |
$122.44
|
| Rate for Payer: Aetna Commercial |
$160.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.44
|
| Rate for Payer: Cash Price |
$150.70
|
| Rate for Payer: Cofinity Commercial |
$131.86
|
| Rate for Payer: Cofinity Commercial |
$162.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.70
|
| Rate for Payer: Healthscope Commercial |
$169.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.11
|
| Rate for Payer: PHP Commercial |
$160.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.44
|
| Rate for Payer: Priority Health SBD |
$118.67
|
| Rate for Payer: UMR Bronson Commercial |
$82.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.28
|
|
|
B-COMPLEX WITH VITAMIN C TABLET
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
NDC 40985022668
|
| Hospital Charge Code |
807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.44 |
| Max. Negotiated Rate |
$190.80 |
| Rate for Payer: Aetna American Axle |
$137.80
|
| Rate for Payer: Aetna Commercial |
$180.20
|
| Rate for Payer: Aetna Medicare |
$106.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.80
|
| Rate for Payer: BCBS Complete |
$84.80
|
| Rate for Payer: Cash Price |
$169.60
|
| Rate for Payer: Cofinity Commercial |
$148.40
|
| Rate for Payer: Cofinity Commercial |
$182.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.60
|
| Rate for Payer: Healthscope Commercial |
$190.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.20
|
| Rate for Payer: PHP Commercial |
$180.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.80
|
| Rate for Payer: Priority Health SBD |
$133.56
|
| Rate for Payer: UMR Bronson Commercial |
$78.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.00
|
|
