|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 0555-0971-02
|
| Hospital Charge Code |
109893
|
|
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 5 MG TABLET
|
Facility
|
IP
|
$3,290.76
|
|
|
Service Code
|
NDC 57844-105-01
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,447.93 |
| Max. Negotiated Rate |
$2,961.68 |
| Rate for Payer: Aetna American Axle |
$2,138.99
|
| Rate for Payer: Aetna Commercial |
$2,797.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,138.99
|
| Rate for Payer: Cash Price |
$2,632.61
|
| Rate for Payer: Cofinity Commercial |
$2,303.53
|
| Rate for Payer: Cofinity Commercial |
$2,830.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,632.61
|
| Rate for Payer: Healthscope Commercial |
$2,961.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,303.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,468.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,797.15
|
| Rate for Payer: PHP Commercial |
$2,797.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,303.53
|
| Rate for Payer: Priority Health SBD |
$2,073.18
|
| Rate for Payer: UMR Bronson Commercial |
$1,447.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,468.07
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$788.20
|
|
|
Service Code
|
NDC 0228-3059-11
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.81 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Commercial |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$669.97
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$551.74
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$346.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$720.30
|
|
|
Service Code
|
NDC 57664-337-88
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$316.93 |
| Max. Negotiated Rate |
$648.27 |
| Rate for Payer: Aetna American Axle |
$468.20
|
| Rate for Payer: Aetna Commercial |
$612.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.20
|
| Rate for Payer: Cash Price |
$576.24
|
| Rate for Payer: Cofinity Commercial |
$504.21
|
| Rate for Payer: Cofinity Commercial |
$619.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$576.24
|
| Rate for Payer: Healthscope Commercial |
$648.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$504.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$540.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$612.26
|
| Rate for Payer: PHP Commercial |
$612.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$504.21
|
| Rate for Payer: Priority Health SBD |
$453.79
|
| Rate for Payer: UMR Bronson Commercial |
$316.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$540.22
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$759.50
|
|
|
Service Code
|
NDC 0115-1487-01
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.18 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$645.58
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$531.65
|
| Rate for Payer: Priority Health SBD |
$478.48
|
| Rate for Payer: UMR Bronson Commercial |
$334.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092-383-01
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$961.80 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Commercial |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,858.03
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,530.14
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$961.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$716.10
|
|
|
Service Code
|
NDC 66993-596-02
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.08 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Commercial |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$608.68
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.27
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$315.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$788.20
|
|
|
Service Code
|
NDC 0228-3063-11
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.81 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Cofinity Commercial |
$551.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$669.97
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$551.74
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$346.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092-385-01
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$961.80 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Commercial |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,858.03
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,530.14
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$961.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$759.50
|
|
|
Service Code
|
NDC 0115-1488-01
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.18 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$645.58
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$531.65
|
| Rate for Payer: Priority Health SBD |
$478.48
|
| Rate for Payer: UMR Bronson Commercial |
$334.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$455.70
|
|
|
Service Code
|
NDC 31722-187-01
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.51 |
| Max. Negotiated Rate |
$410.13 |
| Rate for Payer: Aetna American Axle |
$296.20
|
| Rate for Payer: Aetna Commercial |
$387.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.20
|
| Rate for Payer: Cash Price |
$364.56
|
| Rate for Payer: Cofinity Commercial |
$318.99
|
| Rate for Payer: Cofinity Commercial |
$391.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.56
|
| Rate for Payer: Healthscope Commercial |
$410.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$318.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$387.34
|
| Rate for Payer: PHP Commercial |
$387.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$318.99
|
| Rate for Payer: Priority Health SBD |
$287.09
|
| Rate for Payer: UMR Bronson Commercial |
$200.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.78
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$907.20
|
|
|
Service Code
|
NDC 43975-333-10
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$399.17 |
| Max. Negotiated Rate |
$816.48 |
| Rate for Payer: Aetna American Axle |
$589.68
|
| Rate for Payer: Aetna Commercial |
$771.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$589.68
|
| Rate for Payer: Cash Price |
$725.76
|
| Rate for Payer: Cofinity Commercial |
$635.04
|
| Rate for Payer: Cofinity Commercial |
$780.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$725.76
|
| Rate for Payer: Healthscope Commercial |
$816.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$635.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$680.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$771.12
|
| Rate for Payer: PHP Commercial |
$771.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$635.04
|
| Rate for Payer: Priority Health SBD |
$571.54
|
| Rate for Payer: UMR Bronson Commercial |
$399.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$680.40
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 30 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$716.10
|
|
|
Service Code
|
NDC 66993-599-02
|
| Hospital Charge Code |
31589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.08 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Commercial |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$608.68
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.27
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$315.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$8.74
|
|
|
Service Code
|
NDC 0121-1276-10
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Aetna American Axle |
$5.68
|
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.68
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cofinity Commercial |
$6.12
|
| Rate for Payer: Cofinity Commercial |
$7.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.99
|
| Rate for Payer: Healthscope Commercial |
$7.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.43
|
| Rate for Payer: PHP Commercial |
$7.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.12
|
| Rate for Payer: Priority Health SBD |
$5.51
|
| Rate for Payer: UMR Bronson Commercial |
$3.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.56
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$8.74
|
|
|
Service Code
|
NDC 0121-1276-00
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Aetna American Axle |
$5.68
|
| Rate for Payer: Aetna Commercial |
$7.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.68
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cofinity Commercial |
$6.12
|
| Rate for Payer: Cofinity Commercial |
$7.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.99
|
| Rate for Payer: Healthscope Commercial |
$7.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.43
|
| Rate for Payer: PHP Commercial |
$7.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.12
|
| Rate for Payer: Priority Health SBD |
$5.51
|
| Rate for Payer: UMR Bronson Commercial |
$3.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.56
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$142.23
|
|
|
Service Code
|
NDC 63824-175-63
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.58 |
| Max. Negotiated Rate |
$128.01 |
| Rate for Payer: Aetna American Axle |
$92.45
|
| Rate for Payer: Aetna Commercial |
$120.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.45
|
| Rate for Payer: Cash Price |
$113.78
|
| Rate for Payer: Cofinity Commercial |
$122.32
|
| Rate for Payer: Cofinity Commercial |
$99.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.78
|
| Rate for Payer: Healthscope Commercial |
$128.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.90
|
| Rate for Payer: PHP Commercial |
$120.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.56
|
| Rate for Payer: Priority Health SBD |
$89.60
|
| Rate for Payer: UMR Bronson Commercial |
$62.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.67
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$142.23
|
|
|
Service Code
|
NDC 63824-171-63
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.58 |
| Max. Negotiated Rate |
$128.01 |
| Rate for Payer: Aetna American Axle |
$92.45
|
| Rate for Payer: Aetna Commercial |
$120.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.45
|
| Rate for Payer: Cash Price |
$113.78
|
| Rate for Payer: Cofinity Commercial |
$122.32
|
| Rate for Payer: Cofinity Commercial |
$99.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.78
|
| Rate for Payer: Healthscope Commercial |
$128.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.90
|
| Rate for Payer: PHP Commercial |
$120.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.56
|
| Rate for Payer: Priority Health SBD |
$89.60
|
| Rate for Payer: UMR Bronson Commercial |
$62.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.67
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$133.86
|
|
|
Service Code
|
NDC 0904-6312-56
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.90 |
| Max. Negotiated Rate |
$120.47 |
| Rate for Payer: Aetna American Axle |
$87.01
|
| Rate for Payer: Aetna Commercial |
$113.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.01
|
| Rate for Payer: Cash Price |
$107.09
|
| Rate for Payer: Cofinity Commercial |
$115.12
|
| Rate for Payer: Cofinity Commercial |
$93.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.09
|
| Rate for Payer: Healthscope Commercial |
$120.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.78
|
| Rate for Payer: PHP Commercial |
$113.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.70
|
| Rate for Payer: Priority Health SBD |
$84.33
|
| Rate for Payer: UMR Bronson Commercial |
$58.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.40
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$133.86
|
|
|
Service Code
|
NDC 45802-433-21
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.90 |
| Max. Negotiated Rate |
$120.47 |
| Rate for Payer: Aetna American Axle |
$87.01
|
| Rate for Payer: Aetna Commercial |
$113.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.01
|
| Rate for Payer: Cash Price |
$107.09
|
| Rate for Payer: Cofinity Commercial |
$115.12
|
| Rate for Payer: Cofinity Commercial |
$93.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.09
|
| Rate for Payer: Healthscope Commercial |
$120.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.78
|
| Rate for Payer: PHP Commercial |
$113.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.70
|
| Rate for Payer: Priority Health SBD |
$84.33
|
| Rate for Payer: UMR Bronson Commercial |
$58.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.40
|
|
|
DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR
|
Facility
|
IP
|
$194.77
|
|
|
Service Code
|
NDC 63824-175-65
|
| Hospital Charge Code |
9773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.70 |
| Max. Negotiated Rate |
$175.29 |
| Rate for Payer: Aetna American Axle |
$126.60
|
| Rate for Payer: Aetna Commercial |
$165.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.60
|
| Rate for Payer: Cash Price |
$155.82
|
| Rate for Payer: Cofinity Commercial |
$136.34
|
| Rate for Payer: Cofinity Commercial |
$167.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.82
|
| Rate for Payer: Healthscope Commercial |
$175.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.55
|
| Rate for Payer: PHP Commercial |
$165.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.34
|
| Rate for Payer: Priority Health SBD |
$122.71
|
| Rate for Payer: UMR Bronson Commercial |
$85.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.08
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$61.18
|
|
|
Service Code
|
NDC 0338-0023-02
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.92 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna American Axle |
$39.77
|
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.00
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.83
|
| Rate for Payer: Priority Health SBD |
$38.54
|
| Rate for Payer: UMR Bronson Commercial |
$26.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0023-03
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0023-04
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0023-04
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
IP
|
$61.18
|
|
|
Service Code
|
NDC 0338-0023-02
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.92 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna American Axle |
$39.77
|
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.00
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.83
|
| Rate for Payer: Priority Health SBD |
$38.54
|
| Rate for Payer: UMR Bronson Commercial |
$26.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
