|
DIALYSATE RFP-456 (K-4/CA-0) SOLUTION
|
Facility
|
IP
|
$208.80
|
|
|
Service Code
|
NDC 9900-0008-49
|
| Hospital Charge Code |
180369
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.87 |
| Max. Negotiated Rate |
$187.92 |
| Rate for Payer: Aetna American Axle |
$135.72
|
| Rate for Payer: Aetna Commercial |
$177.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.72
|
| Rate for Payer: Cash Price |
$167.04
|
| Rate for Payer: Cofinity Commercial |
$146.16
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.04
|
| Rate for Payer: Healthscope Commercial |
$187.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$177.48
|
| Rate for Payer: PHP Commercial |
$177.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.16
|
| Rate for Payer: Priority Health SBD |
$131.54
|
| Rate for Payer: UMR Bronson Commercial |
$91.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.60
|
|
|
DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$6,664.24
|
|
|
Service Code
|
CPT 36909
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$191.55 |
| Max. Negotiated Rate |
$6,664.24 |
| Rate for Payer: BCBS Trust/PPO |
$6,664.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.70
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$191.55
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna American Axle |
$58.50
|
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.50
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cofinity Commercial |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$77.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.00
|
| Rate for Payer: Healthscope Commercial |
$81.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.50
|
| Rate for Payer: PHP Commercial |
$76.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.00
|
| Rate for Payer: Priority Health SBD |
$56.70
|
| Rate for Payer: UMR Bronson Commercial |
$39.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.50
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 51079-284-20
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.01 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.06
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UMR Bronson Commercial |
$61.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$307.85
|
|
|
Service Code
|
NDC 51862-941-01
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.45 |
| Max. Negotiated Rate |
$277.06 |
| Rate for Payer: Aetna American Axle |
$200.10
|
| Rate for Payer: Aetna Commercial |
$261.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.10
|
| Rate for Payer: Cash Price |
$246.28
|
| Rate for Payer: Cofinity Commercial |
$215.50
|
| Rate for Payer: Cofinity Commercial |
$264.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.28
|
| Rate for Payer: Healthscope Commercial |
$277.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$261.67
|
| Rate for Payer: PHP Commercial |
$261.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.50
|
| Rate for Payer: Priority Health SBD |
$193.95
|
| Rate for Payer: UMR Bronson Commercial |
$135.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.89
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 0172-3925-60
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna American Axle |
$30.55
|
| Rate for Payer: Aetna Commercial |
$39.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.55
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Cofinity Commercial |
$40.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.60
|
| Rate for Payer: Healthscope Commercial |
$42.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.95
|
| Rate for Payer: PHP Commercial |
$39.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.90
|
| Rate for Payer: Priority Health SBD |
$29.61
|
| Rate for Payer: UMR Bronson Commercial |
$20.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.25
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 51079-284-01
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna American Axle |
$0.90
|
| Rate for Payer: Aetna Commercial |
$1.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.90
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cofinity Commercial |
$0.97
|
| Rate for Payer: Cofinity Commercial |
$1.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.11
|
| Rate for Payer: Healthscope Commercial |
$1.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.18
|
| Rate for Payer: PHP Commercial |
$1.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health SBD |
$0.88
|
| Rate for Payer: UMR Bronson Commercial |
$0.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.04
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 9900-0005-96
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna American Axle |
$1.97
|
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.97
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$2.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.42
|
| Rate for Payer: Healthscope Commercial |
$2.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.58
|
| Rate for Payer: PHP Commercial |
$2.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.12
|
| Rate for Payer: Priority Health SBD |
$1.91
|
| Rate for Payer: UMR Bronson Commercial |
$1.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.27
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$207.06
|
|
|
Service Code
|
NDC 0054-3185-44
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.11 |
| Max. Negotiated Rate |
$186.35 |
| Rate for Payer: Aetna American Axle |
$134.59
|
| Rate for Payer: Aetna Commercial |
$176.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.59
|
| Rate for Payer: Cash Price |
$165.65
|
| Rate for Payer: Cofinity Commercial |
$144.94
|
| Rate for Payer: Cofinity Commercial |
$178.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.65
|
| Rate for Payer: Healthscope Commercial |
$186.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.00
|
| Rate for Payer: PHP Commercial |
$176.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.94
|
| Rate for Payer: Priority Health SBD |
$130.45
|
| Rate for Payer: UMR Bronson Commercial |
$91.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.30
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$180.60
|
|
|
Service Code
|
NDC 0527-1768-36
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.46 |
| Max. Negotiated Rate |
$162.54 |
| Rate for Payer: Aetna American Axle |
$117.39
|
| Rate for Payer: Aetna Commercial |
$153.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.39
|
| Rate for Payer: Cash Price |
$144.48
|
| Rate for Payer: Cofinity Commercial |
$126.42
|
| Rate for Payer: Cofinity Commercial |
$155.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.48
|
| Rate for Payer: Healthscope Commercial |
$162.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$126.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.51
|
| Rate for Payer: PHP Commercial |
$153.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.42
|
| Rate for Payer: Priority Health SBD |
$113.78
|
| Rate for Payer: UMR Bronson Commercial |
$79.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.45
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 51862-942-01
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.36
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$141.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 0378-0345-01
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 51079-285-20
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.87 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna American Axle |
$84.01
|
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.01
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Cofinity Commercial |
$90.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.48
|
| Rate for Payer: Priority Health SBD |
$81.43
|
| Rate for Payer: UMR Bronson Commercial |
$56.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.94
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna American Axle |
$0.85
|
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.85
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$0.91
|
| Rate for Payer: Cofinity Commercial |
$1.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.04
|
| Rate for Payer: Healthscope Commercial |
$1.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.10
|
| Rate for Payer: PHP Commercial |
$1.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.91
|
| Rate for Payer: Priority Health SBD |
$0.82
|
| Rate for Payer: UMR Bronson Commercial |
$0.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.98
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$63.45
|
|
|
Service Code
|
NDC 0172-3926-60
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.42
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.42
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$27.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$541.35
|
|
|
Service Code
|
NDC 0254-1010-19
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.19 |
| Max. Negotiated Rate |
$487.22 |
| Rate for Payer: Aetna American Axle |
$351.88
|
| Rate for Payer: Aetna Commercial |
$460.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$351.88
|
| Rate for Payer: Cash Price |
$433.08
|
| Rate for Payer: Cofinity Commercial |
$378.94
|
| Rate for Payer: Cofinity Commercial |
$465.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.08
|
| Rate for Payer: Healthscope Commercial |
$487.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$378.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$406.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$460.15
|
| Rate for Payer: PHP Commercial |
$460.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$378.94
|
| Rate for Payer: Priority Health SBD |
$341.05
|
| Rate for Payer: UMR Bronson Commercial |
$238.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$406.01
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,453.99
|
|
|
Service Code
|
NDC 0575-6200-30
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$639.76 |
| Max. Negotiated Rate |
$1,308.59 |
| Rate for Payer: Aetna American Axle |
$945.09
|
| Rate for Payer: Aetna Commercial |
$1,235.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$945.09
|
| Rate for Payer: Cash Price |
$1,163.19
|
| Rate for Payer: Cofinity Commercial |
$1,017.79
|
| Rate for Payer: Cofinity Commercial |
$1,250.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,163.19
|
| Rate for Payer: Healthscope Commercial |
$1,308.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,017.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,090.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,235.89
|
| Rate for Payer: PHP Commercial |
$1,235.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,017.79
|
| Rate for Payer: Priority Health SBD |
$916.01
|
| Rate for Payer: UMR Bronson Commercial |
$639.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,090.49
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$21.66
|
|
|
Service Code
|
NDC 45802-050-03
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna American Axle |
$14.08
|
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.08
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$15.16
|
| Rate for Payer: Cofinity Commercial |
$18.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$19.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.41
|
| Rate for Payer: PHP Commercial |
$18.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.16
|
| Rate for Payer: Priority Health SBD |
$13.65
|
| Rate for Payer: UMR Bronson Commercial |
$9.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.24
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$34.20
|
|
|
Service Code
|
NDC 61314-014-25
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$30.78 |
| Rate for Payer: Aetna American Axle |
$22.23
|
| Rate for Payer: Aetna Commercial |
$29.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.23
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$29.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$30.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.07
|
| Rate for Payer: PHP Commercial |
$29.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.94
|
| Rate for Payer: Priority Health SBD |
$21.55
|
| Rate for Payer: UMR Bronson Commercial |
$15.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.65
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$45.57
|
|
|
Service Code
|
NDC 61314-014-05
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Aetna American Axle |
$29.62
|
| Rate for Payer: Aetna Commercial |
$38.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.62
|
| Rate for Payer: Cash Price |
$36.46
|
| Rate for Payer: Cofinity Commercial |
$31.90
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.46
|
| Rate for Payer: Healthscope Commercial |
$41.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.73
|
| Rate for Payer: PHP Commercial |
$38.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.90
|
| Rate for Payer: Priority Health SBD |
$28.71
|
| Rate for Payer: UMR Bronson Commercial |
$20.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.18
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$15.57
|
|
|
Service Code
|
NDC 17478-892-25
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.85 |
| Max. Negotiated Rate |
$14.01 |
| Rate for Payer: Aetna American Axle |
$10.12
|
| Rate for Payer: Aetna Commercial |
$13.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.12
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cofinity Commercial |
$10.90
|
| Rate for Payer: Cofinity Commercial |
$13.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.46
|
| Rate for Payer: Healthscope Commercial |
$14.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.23
|
| Rate for Payer: PHP Commercial |
$13.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.90
|
| Rate for Payer: Priority Health SBD |
$9.81
|
| Rate for Payer: UMR Bronson Commercial |
$6.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.68
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$23.18
|
|
|
Service Code
|
NDC 17478-892-10
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$20.86 |
| Rate for Payer: Aetna American Axle |
$15.07
|
| Rate for Payer: Aetna Commercial |
$19.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.07
|
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: Cofinity Commercial |
$16.23
|
| Rate for Payer: Cofinity Commercial |
$19.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.54
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.70
|
| Rate for Payer: PHP Commercial |
$19.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.23
|
| Rate for Payer: Priority Health SBD |
$14.60
|
| Rate for Payer: UMR Bronson Commercial |
$10.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.38
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$22.86
|
|
|
Service Code
|
NDC 24208-457-05
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$20.57 |
| Rate for Payer: Aetna American Axle |
$14.86
|
| Rate for Payer: Aetna Commercial |
$19.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.86
|
| Rate for Payer: Cash Price |
$18.29
|
| Rate for Payer: Cofinity Commercial |
$16.00
|
| Rate for Payer: Cofinity Commercial |
$19.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.29
|
| Rate for Payer: Healthscope Commercial |
$20.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.43
|
| Rate for Payer: PHP Commercial |
$19.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.00
|
| Rate for Payer: Priority Health SBD |
$14.40
|
| Rate for Payer: UMR Bronson Commercial |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.14
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$26.95
|
|
|
Service Code
|
NDC 70000-0555-2
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$24.26 |
| Rate for Payer: Aetna American Axle |
$17.52
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.52
|
| Rate for Payer: Cash Price |
$21.56
|
| Rate for Payer: Cofinity Commercial |
$18.86
|
| Rate for Payer: Cofinity Commercial |
$23.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.56
|
| Rate for Payer: Healthscope Commercial |
$24.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.91
|
| Rate for Payer: PHP Commercial |
$22.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.86
|
| Rate for Payer: Priority Health SBD |
$16.98
|
| Rate for Payer: UMR Bronson Commercial |
$11.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.21
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$34.13
|
|
|
Service Code
|
NDC 50580-574-01
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$30.72 |
| Rate for Payer: Aetna American Axle |
$22.18
|
| Rate for Payer: Aetna Commercial |
$29.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.18
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cofinity Commercial |
$23.89
|
| Rate for Payer: Cofinity Commercial |
$29.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.30
|
| Rate for Payer: Healthscope Commercial |
$30.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.01
|
| Rate for Payer: PHP Commercial |
$29.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.89
|
| Rate for Payer: Priority Health SBD |
$21.50
|
| Rate for Payer: UMR Bronson Commercial |
$15.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.60
|
|
