|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$944.23
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
107800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.18 |
| Max. Negotiated Rate |
$849.81 |
| Rate for Payer: Aetna American Axle |
$613.75
|
| Rate for Payer: Aetna American Axle |
$479.09
|
| Rate for Payer: Aetna American Axle |
$1,334.49
|
| Rate for Payer: Aetna American Axle |
$1,435.75
|
| Rate for Payer: Aetna Commercial |
$802.60
|
| Rate for Payer: Aetna Commercial |
$1,877.51
|
| Rate for Payer: Aetna Commercial |
$1,745.10
|
| Rate for Payer: Aetna Commercial |
$626.50
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,334.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.30
|
| Rate for Payer: BCBS Complete |
$97.84
|
| Rate for Payer: BCBS Complete |
$97.84
|
| Rate for Payer: BCBS Complete |
$97.84
|
| Rate for Payer: BCBS Complete |
$97.84
|
| Rate for Payer: BCBS MAPPO |
$173.84
|
| Rate for Payer: BCBS MAPPO |
$173.84
|
| Rate for Payer: BCBS MAPPO |
$173.84
|
| Rate for Payer: BCBS MAPPO |
$173.84
|
| Rate for Payer: BCBS Trust/PPO |
$470.72
|
| Rate for Payer: BCBS Trust/PPO |
$470.72
|
| Rate for Payer: BCBS Trust/PPO |
$470.72
|
| Rate for Payer: BCBS Trust/PPO |
$470.72
|
| Rate for Payer: BCN Commercial |
$470.72
|
| Rate for Payer: BCN Commercial |
$470.72
|
| Rate for Payer: BCN Commercial |
$470.72
|
| Rate for Payer: BCN Commercial |
$470.72
|
| Rate for Payer: BCN Medicare Advantage |
$173.84
|
| Rate for Payer: BCN Medicare Advantage |
$173.84
|
| Rate for Payer: BCN Medicare Advantage |
$173.84
|
| Rate for Payer: BCN Medicare Advantage |
$173.84
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cash Price |
$1,767.07
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cash Price |
$589.65
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cash Price |
$589.65
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cash Price |
$1,767.07
|
| Rate for Payer: Cofinity Commercial |
$1,437.14
|
| Rate for Payer: Cofinity Commercial |
$1,765.63
|
| Rate for Payer: Cofinity Commercial |
$660.96
|
| Rate for Payer: Cofinity Commercial |
$812.04
|
| Rate for Payer: Cofinity Commercial |
$1,546.19
|
| Rate for Payer: Cofinity Commercial |
$633.87
|
| Rate for Payer: Cofinity Commercial |
$515.94
|
| Rate for Payer: Cofinity Commercial |
$1,899.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,437.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$515.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$660.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,642.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$173.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$173.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$173.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$173.84
|
| Rate for Payer: Healthscope Commercial |
$663.35
|
| Rate for Payer: Healthscope Commercial |
$1,847.75
|
| Rate for Payer: Healthscope Commercial |
$849.81
|
| Rate for Payer: Healthscope Commercial |
$1,987.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$515.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,437.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$660.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$552.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,539.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.17
|
| Rate for Payer: Mclaren Medicaid |
$93.18
|
| Rate for Payer: Mclaren Medicaid |
$93.18
|
| Rate for Payer: Mclaren Medicaid |
$93.18
|
| Rate for Payer: Mclaren Medicaid |
$93.18
|
| Rate for Payer: Mclaren Medicare |
$173.84
|
| Rate for Payer: Mclaren Medicare |
$173.84
|
| Rate for Payer: Mclaren Medicare |
$173.84
|
| Rate for Payer: Mclaren Medicare |
$173.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$182.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$182.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$182.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$182.53
|
| Rate for Payer: Meridian Medicaid |
$97.84
|
| Rate for Payer: Meridian Medicaid |
$97.84
|
| Rate for Payer: Meridian Medicaid |
$97.84
|
| Rate for Payer: Meridian Medicaid |
$97.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$802.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,745.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.50
|
| Rate for Payer: Nomi Health Commercial |
$521.52
|
| Rate for Payer: Nomi Health Commercial |
$521.52
|
| Rate for Payer: Nomi Health Commercial |
$521.52
|
| Rate for Payer: Nomi Health Commercial |
$521.52
|
| Rate for Payer: PACE Medicare |
$165.15
|
| Rate for Payer: PACE Medicare |
$165.15
|
| Rate for Payer: PACE Medicare |
$165.15
|
| Rate for Payer: PACE Medicare |
$165.15
|
| Rate for Payer: PACE SWMI |
$173.84
|
| Rate for Payer: PACE SWMI |
$173.84
|
| Rate for Payer: PACE SWMI |
$173.84
|
| Rate for Payer: PACE SWMI |
$173.84
|
| Rate for Payer: PHP Commercial |
$802.60
|
| Rate for Payer: PHP Commercial |
$1,877.51
|
| Rate for Payer: PHP Commercial |
$1,745.10
|
| Rate for Payer: PHP Commercial |
$626.50
|
| Rate for Payer: PHP Medicare Advantage |
$173.84
|
| Rate for Payer: PHP Medicare Advantage |
$173.84
|
| Rate for Payer: PHP Medicare Advantage |
$173.84
|
| Rate for Payer: PHP Medicare Advantage |
$173.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$93.18
|
| Rate for Payer: Priority Health Choice Medicaid |
$93.18
|
| Rate for Payer: Priority Health Choice Medicaid |
$93.18
|
| Rate for Payer: Priority Health Choice Medicaid |
$93.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,435.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,334.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$613.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$502.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$502.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$502.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$502.46
|
| Rate for Payer: Priority Health Medicare |
$173.84
|
| Rate for Payer: Priority Health Medicare |
$173.84
|
| Rate for Payer: Priority Health Medicare |
$173.84
|
| Rate for Payer: Priority Health Medicare |
$173.84
|
| Rate for Payer: Priority Health Narrow Network |
$401.97
|
| Rate for Payer: Priority Health Narrow Network |
$401.97
|
| Rate for Payer: Priority Health Narrow Network |
$401.97
|
| Rate for Payer: Priority Health Narrow Network |
$401.97
|
| Rate for Payer: Priority Health SBD |
$594.86
|
| Rate for Payer: Priority Health SBD |
$1,293.43
|
| Rate for Payer: Priority Health SBD |
$1,391.57
|
| Rate for Payer: Priority Health SBD |
$464.35
|
| Rate for Payer: Railroad Medicare Medicare |
$173.84
|
| Rate for Payer: Railroad Medicare Medicare |
$173.84
|
| Rate for Payer: Railroad Medicare Medicare |
$173.84
|
| Rate for Payer: Railroad Medicare Medicare |
$173.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$173.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$173.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$173.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$173.84
|
| Rate for Payer: UHC Exchange |
$332.23
|
| Rate for Payer: UHC Exchange |
$332.23
|
| Rate for Payer: UHC Exchange |
$332.23
|
| Rate for Payer: UHC Exchange |
$332.23
|
| Rate for Payer: UHC Medicare Advantage |
$173.84
|
| Rate for Payer: UHC Medicare Advantage |
$173.84
|
| Rate for Payer: UHC Medicare Advantage |
$173.84
|
| Rate for Payer: UHC Medicare Advantage |
$173.84
|
| Rate for Payer: UHCCP Medicaid |
$93.18
|
| Rate for Payer: UHCCP Medicaid |
$93.18
|
| Rate for Payer: UHCCP Medicaid |
$93.18
|
| Rate for Payer: UHCCP Medicaid |
$93.18
|
| Rate for Payer: UMR Bronson Commercial |
$272.71
|
| Rate for Payer: UMR Bronson Commercial |
$349.37
|
| Rate for Payer: UMR Bronson Commercial |
$817.27
|
| Rate for Payer: UMR Bronson Commercial |
$759.63
|
| Rate for Payer: VA VA |
$173.84
|
| Rate for Payer: VA VA |
$173.84
|
| Rate for Payer: VA VA |
$173.84
|
| Rate for Payer: VA VA |
$173.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,539.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$552.80
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$737.06
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
107800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$324.31 |
| Max. Negotiated Rate |
$663.35 |
| Rate for Payer: Aetna American Axle |
$479.09
|
| Rate for Payer: Aetna American Axle |
$1,435.75
|
| Rate for Payer: Aetna American Axle |
$1,334.49
|
| Rate for Payer: Aetna American Axle |
$613.75
|
| Rate for Payer: Aetna Commercial |
$626.50
|
| Rate for Payer: Aetna Commercial |
$802.60
|
| Rate for Payer: Aetna Commercial |
$1,877.51
|
| Rate for Payer: Aetna Commercial |
$1,745.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,334.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.09
|
| Rate for Payer: Cash Price |
$1,767.07
|
| Rate for Payer: Cash Price |
$589.65
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cofinity Commercial |
$1,437.14
|
| Rate for Payer: Cofinity Commercial |
$812.04
|
| Rate for Payer: Cofinity Commercial |
$660.96
|
| Rate for Payer: Cofinity Commercial |
$515.94
|
| Rate for Payer: Cofinity Commercial |
$1,546.19
|
| Rate for Payer: Cofinity Commercial |
$1,899.60
|
| Rate for Payer: Cofinity Commercial |
$633.87
|
| Rate for Payer: Cofinity Commercial |
$1,765.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$515.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$660.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,437.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,642.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.07
|
| Rate for Payer: Healthscope Commercial |
$663.35
|
| Rate for Payer: Healthscope Commercial |
$1,847.75
|
| Rate for Payer: Healthscope Commercial |
$1,987.96
|
| Rate for Payer: Healthscope Commercial |
$849.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,437.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$660.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$515.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,539.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$552.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$802.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,745.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.50
|
| Rate for Payer: PHP Commercial |
$626.50
|
| Rate for Payer: PHP Commercial |
$802.60
|
| Rate for Payer: PHP Commercial |
$1,745.10
|
| Rate for Payer: PHP Commercial |
$1,877.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$613.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,435.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,334.49
|
| Rate for Payer: Priority Health SBD |
$594.86
|
| Rate for Payer: Priority Health SBD |
$1,293.43
|
| Rate for Payer: Priority Health SBD |
$1,391.57
|
| Rate for Payer: Priority Health SBD |
$464.35
|
| Rate for Payer: UMR Bronson Commercial |
$324.31
|
| Rate for Payer: UMR Bronson Commercial |
$415.46
|
| Rate for Payer: UMR Bronson Commercial |
$971.89
|
| Rate for Payer: UMR Bronson Commercial |
$903.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,539.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$552.80
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
OP
|
$838.80
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.18 |
| Max. Negotiated Rate |
$754.92 |
| Rate for Payer: Aetna American Axle |
$545.22
|
| Rate for Payer: Aetna American Axle |
$545.27
|
| Rate for Payer: Aetna Commercial |
$713.04
|
| Rate for Payer: Aetna Commercial |
$712.98
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.30
|
| Rate for Payer: BCBS Complete |
$97.84
|
| Rate for Payer: BCBS Complete |
$97.84
|
| Rate for Payer: BCBS MAPPO |
$173.84
|
| Rate for Payer: BCBS MAPPO |
$173.84
|
| Rate for Payer: BCBS Trust/PPO |
$470.72
|
| Rate for Payer: BCBS Trust/PPO |
$470.72
|
| Rate for Payer: BCN Commercial |
$470.72
|
| Rate for Payer: BCN Commercial |
$470.72
|
| Rate for Payer: BCN Medicare Advantage |
$173.84
|
| Rate for Payer: BCN Medicare Advantage |
$173.84
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cofinity Commercial |
$587.21
|
| Rate for Payer: Cofinity Commercial |
$587.16
|
| Rate for Payer: Cofinity Commercial |
$721.37
|
| Rate for Payer: Cofinity Commercial |
$721.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$173.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$173.84
|
| Rate for Payer: Healthscope Commercial |
$754.92
|
| Rate for Payer: Healthscope Commercial |
$754.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.15
|
| Rate for Payer: Mclaren Medicaid |
$93.18
|
| Rate for Payer: Mclaren Medicaid |
$93.18
|
| Rate for Payer: Mclaren Medicare |
$173.84
|
| Rate for Payer: Mclaren Medicare |
$173.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$182.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$182.53
|
| Rate for Payer: Meridian Medicaid |
$97.84
|
| Rate for Payer: Meridian Medicaid |
$97.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$712.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$713.04
|
| Rate for Payer: Nomi Health Commercial |
$521.52
|
| Rate for Payer: Nomi Health Commercial |
$521.52
|
| Rate for Payer: PACE Medicare |
$165.15
|
| Rate for Payer: PACE Medicare |
$165.15
|
| Rate for Payer: PACE SWMI |
$173.84
|
| Rate for Payer: PACE SWMI |
$173.84
|
| Rate for Payer: PHP Commercial |
$712.98
|
| Rate for Payer: PHP Commercial |
$713.04
|
| Rate for Payer: PHP Medicare Advantage |
$173.84
|
| Rate for Payer: PHP Medicare Advantage |
$173.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$93.18
|
| Rate for Payer: Priority Health Choice Medicaid |
$93.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$502.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$502.46
|
| Rate for Payer: Priority Health Medicare |
$173.84
|
| Rate for Payer: Priority Health Medicare |
$173.84
|
| Rate for Payer: Priority Health Narrow Network |
$401.97
|
| Rate for Payer: Priority Health Narrow Network |
$401.97
|
| Rate for Payer: Priority Health SBD |
$528.44
|
| Rate for Payer: Priority Health SBD |
$528.49
|
| Rate for Payer: Railroad Medicare Medicare |
$173.84
|
| Rate for Payer: Railroad Medicare Medicare |
$173.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$173.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$173.84
|
| Rate for Payer: UHC Exchange |
$332.23
|
| Rate for Payer: UHC Exchange |
$332.23
|
| Rate for Payer: UHC Medicare Advantage |
$173.84
|
| Rate for Payer: UHC Medicare Advantage |
$173.84
|
| Rate for Payer: UHCCP Medicaid |
$93.18
|
| Rate for Payer: UHCCP Medicaid |
$93.18
|
| Rate for Payer: UMR Bronson Commercial |
$310.36
|
| Rate for Payer: UMR Bronson Commercial |
$310.38
|
| Rate for Payer: VA VA |
$173.84
|
| Rate for Payer: VA VA |
$173.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.15
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
IP
|
$838.80
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$369.07 |
| Max. Negotiated Rate |
$754.92 |
| Rate for Payer: Aetna American Axle |
$545.22
|
| Rate for Payer: Aetna American Axle |
$545.27
|
| Rate for Payer: Aetna Commercial |
$712.98
|
| Rate for Payer: Aetna Commercial |
$713.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.27
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cofinity Commercial |
$721.43
|
| Rate for Payer: Cofinity Commercial |
$587.21
|
| Rate for Payer: Cofinity Commercial |
$587.16
|
| Rate for Payer: Cofinity Commercial |
$721.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$587.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.10
|
| Rate for Payer: Healthscope Commercial |
$754.92
|
| Rate for Payer: Healthscope Commercial |
$754.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$713.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$712.98
|
| Rate for Payer: PHP Commercial |
$713.04
|
| Rate for Payer: PHP Commercial |
$712.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.27
|
| Rate for Payer: Priority Health SBD |
$528.44
|
| Rate for Payer: Priority Health SBD |
$528.49
|
| Rate for Payer: UMR Bronson Commercial |
$369.07
|
| Rate for Payer: UMR Bronson Commercial |
$369.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.15
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$261.84
|
|
|
Service Code
|
NDC 50268010515
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.88 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna American Axle |
$170.20
|
| Rate for Payer: Aetna Commercial |
$222.56
|
| Rate for Payer: Aetna Medicare |
$130.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.20
|
| Rate for Payer: BCBS Complete |
$104.74
|
| Rate for Payer: Cash Price |
$209.47
|
| Rate for Payer: Cofinity Commercial |
$183.29
|
| Rate for Payer: Cofinity Commercial |
$225.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.47
|
| Rate for Payer: Healthscope Commercial |
$235.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.56
|
| Rate for Payer: PHP Commercial |
$222.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.20
|
| Rate for Payer: Priority Health SBD |
$164.96
|
| Rate for Payer: UMR Bronson Commercial |
$96.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.38
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$5.24
|
|
|
Service Code
|
NDC 50268010511
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna American Axle |
$3.41
|
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Aetna Medicare |
$2.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.41
|
| Rate for Payer: BCBS Complete |
$2.10
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Cofinity Commercial |
$4.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.19
|
| Rate for Payer: Healthscope Commercial |
$4.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.45
|
| Rate for Payer: PHP Commercial |
$4.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.41
|
| Rate for Payer: Priority Health SBD |
$3.30
|
| Rate for Payer: UMR Bronson Commercial |
$1.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.93
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$5.24
|
|
|
Service Code
|
NDC 50268010511
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna American Axle |
$3.41
|
| Rate for Payer: Aetna Commercial |
$4.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.41
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Cofinity Commercial |
$4.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.19
|
| Rate for Payer: Healthscope Commercial |
$4.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.45
|
| Rate for Payer: PHP Commercial |
$4.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.41
|
| Rate for Payer: Priority Health SBD |
$3.30
|
| Rate for Payer: UMR Bronson Commercial |
$2.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.93
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$261.84
|
|
|
Service Code
|
NDC 50268010515
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.21 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna American Axle |
$170.20
|
| Rate for Payer: Aetna Commercial |
$222.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.20
|
| 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 |
$115.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.38
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$284.16
|
|
|
Service Code
|
NDC 71930006612
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.14 |
| Max. Negotiated Rate |
$255.74 |
| Rate for Payer: Aetna American Axle |
$184.70
|
| Rate for Payer: Aetna Commercial |
$241.54
|
| Rate for Payer: Aetna Medicare |
$142.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.70
|
| Rate for Payer: BCBS Complete |
$113.66
|
| Rate for Payer: Cash Price |
$227.33
|
| Rate for Payer: Cofinity Commercial |
$198.91
|
| Rate for Payer: Cofinity Commercial |
$244.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.33
|
| Rate for Payer: Healthscope Commercial |
$255.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.54
|
| Rate for Payer: PHP Commercial |
$241.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.70
|
| Rate for Payer: Priority Health SBD |
$179.02
|
| Rate for Payer: UMR Bronson Commercial |
$105.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.12
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$211.50
|
|
|
Service Code
|
NDC 72888000901
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.06 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna American Axle |
$137.48
|
| Rate for Payer: Aetna Commercial |
$179.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.48
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cofinity Commercial |
$148.05
|
| Rate for Payer: Cofinity Commercial |
$181.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.20
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.78
|
| Rate for Payer: PHP Commercial |
$179.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.48
|
| Rate for Payer: Priority Health SBD |
$133.24
|
| Rate for Payer: UMR Bronson Commercial |
$93.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.62
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
OP
|
$211.50
|
|
|
Service Code
|
NDC 72888000901
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.26 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna American Axle |
$137.48
|
| Rate for Payer: Aetna Commercial |
$179.78
|
| Rate for Payer: Aetna Medicare |
$105.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.48
|
| Rate for Payer: BCBS Complete |
$84.60
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cofinity Commercial |
$148.05
|
| Rate for Payer: Cofinity Commercial |
$181.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.20
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.78
|
| Rate for Payer: PHP Commercial |
$179.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.48
|
| Rate for Payer: Priority Health SBD |
$133.24
|
| Rate for Payer: UMR Bronson Commercial |
$78.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.62
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$284.16
|
|
|
Service Code
|
NDC 71930006612
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.03 |
| Max. Negotiated Rate |
$255.74 |
| Rate for Payer: Aetna American Axle |
$184.70
|
| Rate for Payer: Aetna Commercial |
$241.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.70
|
| Rate for Payer: Cash Price |
$227.33
|
| Rate for Payer: Cofinity Commercial |
$198.91
|
| Rate for Payer: Cofinity Commercial |
$244.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$198.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.33
|
| Rate for Payer: Healthscope Commercial |
$255.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.54
|
| Rate for Payer: PHP Commercial |
$241.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.70
|
| Rate for Payer: Priority Health SBD |
$179.02
|
| Rate for Payer: UMR Bronson Commercial |
$125.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.12
|
|
|
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 |
$173.08
|
| 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.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 |
$173.08
|
| 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.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 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
|
OP
|
$24.75
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$22.28 |
| 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 |
$21.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.80
|
| Rate for Payer: Healthscope Commercial |
$22.28
|
| 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
|
IP
|
$24.75
|
|
|
Service Code
|
NDC 00065079550
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$22.28 |
| 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 |
$21.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.80
|
| Rate for Payer: Healthscope Commercial |
$22.28
|
| 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 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 |
$66.46
|
| 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 |
$66.46
|
|
|
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 |
$66.46
|
| 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 |
$66.46
|
|
|
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
|
|
|
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
|
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
|
$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 |
$481.16
|
| 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
|
|
