|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$19,146.17
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,424.31 |
| Max. Negotiated Rate |
$17,231.55 |
| Rate for Payer: Aetna American Axle |
$12,445.01
|
| Rate for Payer: Aetna Commercial |
$16,274.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,445.01
|
| Rate for Payer: Cash Price |
$15,316.94
|
| Rate for Payer: Cofinity Commercial |
$13,402.32
|
| Rate for Payer: Cofinity Commercial |
$16,465.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,402.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,316.94
|
| Rate for Payer: Healthscope Commercial |
$17,231.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,402.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,359.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,274.24
|
| Rate for Payer: PHP Commercial |
$16,274.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,445.01
|
| Rate for Payer: Priority Health SBD |
$12,062.09
|
| Rate for Payer: UMR Bronson Commercial |
$8,424.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,359.63
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$19,146.17
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$17,231.55 |
| Rate for Payer: Aetna American Axle |
$12,445.01
|
| Rate for Payer: Aetna Commercial |
$16,274.24
|
| Rate for Payer: Aetna Medicare |
$172.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,445.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$207.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$207.36
|
| Rate for Payer: BCBS Complete |
$93.36
|
| Rate for Payer: BCBS MAPPO |
$165.89
|
| Rate for Payer: BCBS Trust/PPO |
$451.08
|
| Rate for Payer: BCN Commercial |
$451.08
|
| Rate for Payer: BCN Medicare Advantage |
$165.89
|
| Rate for Payer: Cash Price |
$15,316.94
|
| Rate for Payer: Cash Price |
$15,316.94
|
| Rate for Payer: Cofinity Commercial |
$16,465.71
|
| Rate for Payer: Cofinity Commercial |
$13,402.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,402.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,316.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$165.89
|
| Rate for Payer: Healthscope Commercial |
$17,231.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,402.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,359.63
|
| Rate for Payer: Mclaren Medicaid |
$88.92
|
| Rate for Payer: Mclaren Medicare |
$165.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$174.18
|
| Rate for Payer: Meridian Medicaid |
$93.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,274.24
|
| Rate for Payer: Nomi Health Commercial |
$497.67
|
| Rate for Payer: PACE Medicare |
$157.60
|
| Rate for Payer: PACE SWMI |
$165.89
|
| Rate for Payer: PHP Commercial |
$16,274.24
|
| Rate for Payer: PHP Medicare Advantage |
$165.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$88.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,445.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$481.49
|
| Rate for Payer: Priority Health Medicare |
$165.89
|
| Rate for Payer: Priority Health Narrow Network |
$385.19
|
| Rate for Payer: Priority Health SBD |
$12,062.09
|
| Rate for Payer: Railroad Medicare Medicare |
$165.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$466.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$165.89
|
| Rate for Payer: UHC Exchange |
$317.03
|
| Rate for Payer: UHC Medicare Advantage |
$165.89
|
| Rate for Payer: UHCCP Medicaid |
$88.92
|
| Rate for Payer: UMR Bronson Commercial |
$7,084.08
|
| Rate for Payer: VA VA |
$165.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,359.63
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$100.09
|
|
|
Service Code
|
NDC 00283067902
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.03 |
| Max. Negotiated Rate |
$90.08 |
| Rate for Payer: Aetna American Axle |
$65.06
|
| Rate for Payer: Aetna Commercial |
$85.08
|
| Rate for Payer: Aetna Medicare |
$50.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.06
|
| Rate for Payer: BCBS Complete |
$40.04
|
| Rate for Payer: Cash Price |
$80.07
|
| Rate for Payer: Cofinity Commercial |
$70.06
|
| Rate for Payer: Cofinity Commercial |
$86.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.07
|
| Rate for Payer: Healthscope Commercial |
$90.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.08
|
| Rate for Payer: PHP Commercial |
$85.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.06
|
| Rate for Payer: Priority Health SBD |
$63.06
|
| Rate for Payer: UMR Bronson Commercial |
$37.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.07
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$95.57
|
|
|
Service Code
|
NDC 00283091402
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.36 |
| Max. Negotiated Rate |
$86.01 |
| Rate for Payer: Aetna American Axle |
$62.12
|
| Rate for Payer: Aetna Commercial |
$81.23
|
| Rate for Payer: Aetna Medicare |
$47.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.12
|
| Rate for Payer: BCBS Complete |
$38.23
|
| Rate for Payer: Cash Price |
$76.46
|
| Rate for Payer: Cofinity Commercial |
$66.90
|
| Rate for Payer: Cofinity Commercial |
$82.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.46
|
| Rate for Payer: Healthscope Commercial |
$86.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.23
|
| Rate for Payer: PHP Commercial |
$81.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.12
|
| Rate for Payer: Priority Health SBD |
$60.21
|
| Rate for Payer: UMR Bronson Commercial |
$35.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.68
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$129.14
|
|
|
Service Code
|
NDC 00283067960
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.78 |
| Max. Negotiated Rate |
$116.23 |
| Rate for Payer: Aetna American Axle |
$83.94
|
| Rate for Payer: Aetna Commercial |
$109.77
|
| Rate for Payer: Aetna Medicare |
$64.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.94
|
| Rate for Payer: BCBS Complete |
$51.66
|
| Rate for Payer: Cash Price |
$103.31
|
| Rate for Payer: Cofinity Commercial |
$111.06
|
| Rate for Payer: Cofinity Commercial |
$90.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.31
|
| Rate for Payer: Healthscope Commercial |
$116.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.77
|
| Rate for Payer: PHP Commercial |
$109.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.94
|
| Rate for Payer: Priority Health SBD |
$81.36
|
| Rate for Payer: UMR Bronson Commercial |
$47.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.86
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$95.57
|
|
|
Service Code
|
NDC 00283091402
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.05 |
| Max. Negotiated Rate |
$86.01 |
| Rate for Payer: Aetna American Axle |
$62.12
|
| Rate for Payer: Aetna Commercial |
$81.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.12
|
| Rate for Payer: Cash Price |
$76.46
|
| Rate for Payer: Cofinity Commercial |
$66.90
|
| Rate for Payer: Cofinity Commercial |
$82.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.46
|
| Rate for Payer: Healthscope Commercial |
$86.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.23
|
| Rate for Payer: PHP Commercial |
$81.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.12
|
| Rate for Payer: Priority Health SBD |
$60.21
|
| Rate for Payer: UMR Bronson Commercial |
$42.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.68
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$100.09
|
|
|
Service Code
|
NDC 00283067902
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.04 |
| Max. Negotiated Rate |
$90.08 |
| Rate for Payer: Aetna American Axle |
$65.06
|
| Rate for Payer: Aetna Commercial |
$85.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.06
|
| Rate for Payer: Cash Price |
$80.07
|
| Rate for Payer: Cofinity Commercial |
$70.06
|
| Rate for Payer: Cofinity Commercial |
$86.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.07
|
| Rate for Payer: Healthscope Commercial |
$90.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.08
|
| Rate for Payer: PHP Commercial |
$85.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.06
|
| Rate for Payer: Priority Health SBD |
$63.06
|
| Rate for Payer: UMR Bronson Commercial |
$44.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.07
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$129.14
|
|
|
Service Code
|
NDC 00283067960
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.82 |
| Max. Negotiated Rate |
$116.23 |
| Rate for Payer: Aetna American Axle |
$83.94
|
| Rate for Payer: Aetna Commercial |
$109.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.94
|
| Rate for Payer: Cash Price |
$103.31
|
| Rate for Payer: Cofinity Commercial |
$111.06
|
| Rate for Payer: Cofinity Commercial |
$90.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$90.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.31
|
| Rate for Payer: Healthscope Commercial |
$116.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.77
|
| Rate for Payer: PHP Commercial |
$109.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.94
|
| Rate for Payer: Priority Health SBD |
$81.36
|
| Rate for Payer: UMR Bronson Commercial |
$56.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.86
|
|
|
BENZOCAINE 20 % MUCOSAL GEL
|
Facility
|
OP
|
$10.38
|
|
|
Service Code
|
NDC 10310028340
|
| Hospital Charge Code |
19691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$9.34 |
| Rate for Payer: Aetna American Axle |
$6.75
|
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Aetna Medicare |
$5.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.75
|
| Rate for Payer: BCBS Complete |
$4.15
|
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: Cofinity Commercial |
$7.27
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.30
|
| Rate for Payer: Healthscope Commercial |
$9.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.82
|
| Rate for Payer: PHP Commercial |
$8.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.75
|
| Rate for Payer: Priority Health SBD |
$6.54
|
| Rate for Payer: UMR Bronson Commercial |
$3.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.78
|
|
|
BENZOCAINE 20 % MUCOSAL GEL
|
Facility
|
IP
|
$26.98
|
|
|
Service Code
|
NDC 00573022567
|
| Hospital Charge Code |
19691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$24.28 |
| Rate for Payer: Aetna American Axle |
$17.54
|
| Rate for Payer: Aetna Commercial |
$22.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.54
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cofinity Commercial |
$18.89
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Healthscope Commercial |
$24.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.93
|
| Rate for Payer: PHP Commercial |
$22.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.54
|
| Rate for Payer: Priority Health SBD |
$17.00
|
| Rate for Payer: UMR Bronson Commercial |
$11.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.24
|
|
|
BENZOCAINE 20 % MUCOSAL GEL
|
Facility
|
IP
|
$10.38
|
|
|
Service Code
|
NDC 10310028340
|
| Hospital Charge Code |
19691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$9.34 |
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: Cofinity Commercial |
$7.27
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.27
|
| Rate for Payer: Aetna American Axle |
$6.75
|
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.30
|
| Rate for Payer: Healthscope Commercial |
$9.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.82
|
| Rate for Payer: PHP Commercial |
$8.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.75
|
| Rate for Payer: Priority Health SBD |
$6.54
|
| Rate for Payer: UMR Bronson Commercial |
$4.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.78
|
|
|
BENZOCAINE 20 % MUCOSAL GEL
|
Facility
|
OP
|
$26.98
|
|
|
Service Code
|
NDC 00573022567
|
| Hospital Charge Code |
19691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$24.28 |
| Rate for Payer: Aetna American Axle |
$17.54
|
| Rate for Payer: Aetna Commercial |
$22.93
|
| Rate for Payer: Aetna Medicare |
$13.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.54
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cofinity Commercial |
$18.89
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Healthscope Commercial |
$24.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.93
|
| Rate for Payer: PHP Commercial |
$22.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.54
|
| Rate for Payer: Priority Health SBD |
$17.00
|
| Rate for Payer: UMR Bronson Commercial |
$9.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.24
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
OP
|
$34.86
|
|
|
Service Code
|
NDC 00283061026
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.90 |
| Max. Negotiated Rate |
$31.37 |
| Rate for Payer: Aetna American Axle |
$22.66
|
| Rate for Payer: Aetna Commercial |
$29.63
|
| Rate for Payer: Aetna Medicare |
$17.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.66
|
| Rate for Payer: BCBS Complete |
$13.94
|
| Rate for Payer: Cash Price |
$27.89
|
| Rate for Payer: Cofinity Commercial |
$24.40
|
| Rate for Payer: Cofinity Commercial |
$29.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.89
|
| Rate for Payer: Healthscope Commercial |
$31.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.63
|
| Rate for Payer: PHP Commercial |
$29.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.66
|
| Rate for Payer: Priority Health SBD |
$21.96
|
| Rate for Payer: UMR Bronson Commercial |
$12.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.14
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
OP
|
$37.17
|
|
|
Service Code
|
NDC 00283061043
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.75 |
| Max. Negotiated Rate |
$33.45 |
| Rate for Payer: Aetna American Axle |
$24.16
|
| Rate for Payer: Aetna Commercial |
$31.59
|
| Rate for Payer: Aetna Medicare |
$18.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.16
|
| Rate for Payer: BCBS Complete |
$14.87
|
| Rate for Payer: Cash Price |
$29.74
|
| Rate for Payer: Cofinity Commercial |
$26.02
|
| Rate for Payer: Cofinity Commercial |
$31.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.74
|
| Rate for Payer: Healthscope Commercial |
$33.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.59
|
| Rate for Payer: PHP Commercial |
$31.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.16
|
| Rate for Payer: Priority Health SBD |
$23.42
|
| Rate for Payer: UMR Bronson Commercial |
$13.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.88
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
IP
|
$37.17
|
|
|
Service Code
|
NDC 00283061043
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$33.45 |
| Rate for Payer: Aetna American Axle |
$24.16
|
| Rate for Payer: Aetna Commercial |
$31.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.16
|
| Rate for Payer: Cash Price |
$29.74
|
| Rate for Payer: Cofinity Commercial |
$26.02
|
| Rate for Payer: Cofinity Commercial |
$31.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.74
|
| Rate for Payer: Healthscope Commercial |
$33.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.59
|
| Rate for Payer: PHP Commercial |
$31.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.16
|
| Rate for Payer: Priority Health SBD |
$23.42
|
| Rate for Payer: UMR Bronson Commercial |
$16.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.88
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
IP
|
$34.86
|
|
|
Service Code
|
NDC 00283061026
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$31.37 |
| Rate for Payer: PHP Commercial |
$29.63
|
| Rate for Payer: Aetna American Axle |
$22.66
|
| Rate for Payer: Aetna Commercial |
$29.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.66
|
| Rate for Payer: Cash Price |
$27.89
|
| Rate for Payer: Cofinity Commercial |
$24.40
|
| Rate for Payer: Cofinity Commercial |
$29.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.89
|
| Rate for Payer: Healthscope Commercial |
$31.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.66
|
| Rate for Payer: Priority Health SBD |
$21.96
|
| Rate for Payer: UMR Bronson Commercial |
$15.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.14
|
|
|
BENZOIN (BULK) TOPICAL TINCTURE
|
Facility
|
OP
|
$30.87
|
|
|
Service Code
|
NDC 00395024792
|
| Hospital Charge Code |
165061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.42 |
| Max. Negotiated Rate |
$27.78 |
| Rate for Payer: Aetna American Axle |
$20.07
|
| Rate for Payer: Aetna Commercial |
$26.24
|
| Rate for Payer: Aetna Medicare |
$15.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.07
|
| Rate for Payer: BCBS Complete |
$12.35
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cofinity Commercial |
$21.61
|
| Rate for Payer: Cofinity Commercial |
$26.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.70
|
| Rate for Payer: Healthscope Commercial |
$27.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.24
|
| Rate for Payer: PHP Commercial |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.07
|
| Rate for Payer: Priority Health SBD |
$19.45
|
| Rate for Payer: UMR Bronson Commercial |
$11.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.15
|
|
|
BENZOIN (BULK) TOPICAL TINCTURE
|
Facility
|
IP
|
$30.87
|
|
|
Service Code
|
NDC 00395024792
|
| Hospital Charge Code |
165061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.58 |
| Max. Negotiated Rate |
$27.78 |
| Rate for Payer: Aetna American Axle |
$20.07
|
| Rate for Payer: Aetna Commercial |
$26.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.07
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cofinity Commercial |
$21.61
|
| Rate for Payer: Cofinity Commercial |
$26.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.70
|
| Rate for Payer: Healthscope Commercial |
$27.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.24
|
| Rate for Payer: PHP Commercial |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.07
|
| Rate for Payer: Priority Health SBD |
$19.45
|
| Rate for Payer: UMR Bronson Commercial |
$13.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.15
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$373.65
|
|
|
Service Code
|
NDC 64380071206
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$336.28 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna Medicare |
$186.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: BCBS Complete |
$149.46
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Commercial |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.87
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UMR Bronson Commercial |
$138.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 42806071401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.17 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna Medicare |
$97.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$309.70
|
|
|
Service Code
|
NDC 00904715361
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.27 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna American Axle |
$201.30
|
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health SBD |
$195.11
|
| Rate for Payer: UMR Bronson Commercial |
$136.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.28
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$371.30
|
|
|
Service Code
|
NDC 67877057301
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.38 |
| Max. Negotiated Rate |
$334.17 |
| Rate for Payer: Aetna American Axle |
$241.34
|
| Rate for Payer: Aetna Commercial |
$315.60
|
| Rate for Payer: Aetna Medicare |
$185.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.34
|
| Rate for Payer: BCBS Complete |
$148.52
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$259.91
|
| Rate for Payer: Cofinity Commercial |
$319.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$259.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$334.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.60
|
| Rate for Payer: PHP Commercial |
$315.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.34
|
| Rate for Payer: Priority Health SBD |
$233.92
|
| Rate for Payer: UMR Bronson Commercial |
$137.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.48
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$264.10
|
|
|
Service Code
|
NDC 62332042631
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.72 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna American Axle |
$171.66
|
| Rate for Payer: Aetna Commercial |
$224.48
|
| Rate for Payer: Aetna Medicare |
$132.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: BCBS Complete |
$105.64
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Commercial |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$184.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.48
|
| Rate for Payer: PHP Commercial |
$224.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.66
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UMR Bronson Commercial |
$97.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.08
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 42806071401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$371.30
|
|
|
Service Code
|
NDC 67877057301
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.37 |
| Max. Negotiated Rate |
$334.17 |
| Rate for Payer: Aetna American Axle |
$241.34
|
| Rate for Payer: Aetna Commercial |
$315.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.34
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$259.91
|
| Rate for Payer: Cofinity Commercial |
$319.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$259.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$334.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.60
|
| Rate for Payer: PHP Commercial |
$315.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.34
|
| Rate for Payer: Priority Health SBD |
$233.92
|
| Rate for Payer: UMR Bronson Commercial |
$163.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.48
|
|
