|
DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;
|
Facility
|
OP
|
$9,755.07
|
|
|
Service Code
|
CPT 50436
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$143.42 |
| Max. Negotiated Rate |
$9,755.07 |
| Rate for Payer: Aetna Medicare |
$3,222.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,873.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,873.46
|
| Rate for Payer: BCBS Complete |
$1,779.93
|
| Rate for Payer: BCBS MAPPO |
$3,098.77
|
| Rate for Payer: BCBS Trust/PPO |
$1,332.47
|
| Rate for Payer: BCN Medicare Advantage |
$3,098.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,098.77
|
| Rate for Payer: Mclaren Medicaid |
$1,695.03
|
| Rate for Payer: Mclaren Medicare |
$3,098.77
|
| Rate for Payer: Meridian Medicaid |
$1,779.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,253.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,563.59
|
| Rate for Payer: PACE Medicare |
$2,943.83
|
| Rate for Payer: PACE SWMI |
$3,098.77
|
| Rate for Payer: PHP Medicare Advantage |
$3,098.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,755.07
|
| Rate for Payer: Priority Health Medicare |
$3,098.77
|
| Rate for Payer: Priority Health Narrow Network |
$7,804.06
|
| Rate for Payer: Railroad Medicare Medicare |
$3,098.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.76
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,098.77
|
| Rate for Payer: UHC Exchange |
$143.42
|
| Rate for Payer: UHC Medicare Advantage |
$3,191.73
|
| Rate for Payer: VA VA |
$3,098.77
|
|
|
DILATION OF RECTAL STRICTURE (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN LOCAL
|
Facility
|
OP
|
$3,302.11
|
|
|
Service Code
|
CPT 45910
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$190.57 |
| Max. Negotiated Rate |
$3,302.11 |
| Rate for Payer: Aetna Medicare |
$1,090.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,311.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,311.18
|
| Rate for Payer: BCBS Complete |
$602.51
|
| Rate for Payer: BCBS MAPPO |
$1,048.94
|
| Rate for Payer: BCBS Trust/PPO |
$1,034.21
|
| Rate for Payer: BCN Medicare Advantage |
$1,048.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,048.94
|
| Rate for Payer: Mclaren Medicaid |
$573.77
|
| Rate for Payer: Mclaren Medicare |
$1,048.94
|
| Rate for Payer: Meridian Medicaid |
$602.51
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,101.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,206.28
|
| Rate for Payer: PACE Medicare |
$996.49
|
| Rate for Payer: PACE SWMI |
$1,048.94
|
| Rate for Payer: PHP Medicare Advantage |
$1,048.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$573.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,302.11
|
| Rate for Payer: Priority Health Medicare |
$1,048.94
|
| Rate for Payer: Priority Health Narrow Network |
$2,641.69
|
| Rate for Payer: Railroad Medicare Medicare |
$1,048.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.63
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,048.94
|
| Rate for Payer: UHC Exchange |
$190.57
|
| Rate for Payer: UHC Medicare Advantage |
$1,080.41
|
| Rate for Payer: VA VA |
$1,048.94
|
|
|
DILATION SALIVARY DUCT
|
Facility
|
OP
|
$4,267.42
|
|
|
Service Code
|
CPT 42650
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$58.28 |
| Max. Negotiated Rate |
$4,267.42 |
| Rate for Payer: Aetna Medicare |
$1,409.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,694.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,694.48
|
| Rate for Payer: BCBS Complete |
$778.65
|
| Rate for Payer: BCBS MAPPO |
$1,355.58
|
| Rate for Payer: BCBS Trust/PPO |
$68.81
|
| Rate for Payer: BCN Medicare Advantage |
$1,355.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,355.58
|
| Rate for Payer: Mclaren Medicaid |
$741.50
|
| Rate for Payer: Mclaren Medicare |
$1,355.58
|
| Rate for Payer: Meridian Medicaid |
$778.65
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,423.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,558.92
|
| Rate for Payer: PACE Medicare |
$1,287.80
|
| Rate for Payer: PACE SWMI |
$1,355.58
|
| Rate for Payer: PHP Medicare Advantage |
$1,355.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$741.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,267.42
|
| Rate for Payer: Priority Health Medicare |
$1,355.58
|
| Rate for Payer: Priority Health Narrow Network |
$3,413.94
|
| Rate for Payer: Railroad Medicare Medicare |
$1,355.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.11
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,355.58
|
| Rate for Payer: UHC Exchange |
$58.28
|
| Rate for Payer: UHC Medicare Advantage |
$1,396.25
|
| Rate for Payer: VA VA |
$1,355.58
|
|
|
DILTIAZEM 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$82.05
|
|
|
Service Code
|
NDC 0409-4350-03
|
| Hospital Charge Code |
22156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.10 |
| Max. Negotiated Rate |
$73.84 |
| Rate for Payer: Aetna American Axle |
$53.33
|
| Rate for Payer: Aetna Commercial |
$69.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.33
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cofinity Commercial |
$57.44
|
| Rate for Payer: Cofinity Commercial |
$70.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.64
|
| Rate for Payer: Healthscope Commercial |
$73.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.74
|
| Rate for Payer: PHP Commercial |
$69.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.44
|
| Rate for Payer: Priority Health SBD |
$51.69
|
| Rate for Payer: UMR Bronson Commercial |
$36.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.54
|
|
|
DILTIAZEM 1MG/1 ML INFUSION 125 ML (IV PREMIX)
|
Facility
|
IP
|
$156.25
|
|
|
Service Code
|
NDC 9900-0003-02
|
| Hospital Charge Code |
155072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.75 |
| Max. Negotiated Rate |
$140.62 |
| Rate for Payer: Aetna American Axle |
$101.56
|
| Rate for Payer: Aetna Commercial |
$132.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.56
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cofinity Commercial |
$109.38
|
| Rate for Payer: Cofinity Commercial |
$134.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.00
|
| Rate for Payer: Healthscope Commercial |
$140.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$132.81
|
| Rate for Payer: PHP Commercial |
$132.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.38
|
| Rate for Payer: Priority Health SBD |
$98.44
|
| Rate for Payer: UMR Bronson Commercial |
$68.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.19
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 0378-0023-01
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.73 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna American Axle |
$212.32
|
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: Priority Health SBD |
$205.79
|
| Rate for Payer: UMR Bronson Commercial |
$143.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 0093-0318-01
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.73 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna American Axle |
$212.32
|
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: Priority Health SBD |
$205.79
|
| Rate for Payer: UMR Bronson Commercial |
$143.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 51079-745-01
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna American Axle |
$2.43
|
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.62
|
| Rate for Payer: Priority Health SBD |
$2.36
|
| Rate for Payer: UMR Bronson Commercial |
$1.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$307.85
|
|
|
Service Code
|
NDC 63739-079-10
|
| Hospital Charge Code |
2475
|
|
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
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$408.90
|
|
|
Service Code
|
NDC 60687-562-01
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.92 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna American Axle |
$265.78
|
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.78
|
| Rate for Payer: Cash Price |
$327.12
|
| Rate for Payer: Cofinity Commercial |
$286.23
|
| Rate for Payer: Cofinity Commercial |
$351.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.12
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$347.56
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.23
|
| Rate for Payer: Priority Health SBD |
$257.61
|
| Rate for Payer: UMR Bronson Commercial |
$179.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 51079-745-20
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.28 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Commercial |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| 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 Multiplan/Beech St/PHCS |
$317.60
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.56
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UMR Bronson Commercial |
$164.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
DILTIAZEM 30 MG TABLET
|
Facility
|
IP
|
$4.09
|
|
|
Service Code
|
NDC 60687-562-11
|
| Hospital Charge Code |
2475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna American Axle |
$2.66
|
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.66
|
| Rate for Payer: Cash Price |
$3.27
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.27
|
| Rate for Payer: Healthscope Commercial |
$3.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.48
|
| Rate for Payer: PHP Commercial |
$3.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.86
|
| Rate for Payer: Priority Health SBD |
$2.58
|
| Rate for Payer: UMR Bronson Commercial |
$1.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.07
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$48.63
|
|
|
Service Code
|
NDC 0641-6013-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$43.77 |
| Rate for Payer: Aetna American Axle |
$31.61
|
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.61
|
| Rate for Payer: Cash Price |
$38.90
|
| Rate for Payer: Cofinity Commercial |
$34.04
|
| Rate for Payer: Cofinity Commercial |
$41.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.90
|
| Rate for Payer: Healthscope Commercial |
$43.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.04
|
| Rate for Payer: Priority Health SBD |
$30.64
|
| Rate for Payer: UMR Bronson Commercial |
$21.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.47
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$65.25
|
|
|
Service Code
|
NDC 17478-937-05
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.71 |
| Max. Negotiated Rate |
$58.72 |
| Rate for Payer: Aetna American Axle |
$42.41
|
| Rate for Payer: Aetna Commercial |
$55.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.41
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cofinity Commercial |
$45.68
|
| Rate for Payer: Cofinity Commercial |
$56.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.20
|
| Rate for Payer: Healthscope Commercial |
$58.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.46
|
| Rate for Payer: PHP Commercial |
$55.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.68
|
| Rate for Payer: Priority Health SBD |
$41.11
|
| Rate for Payer: UMR Bronson Commercial |
$28.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.94
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$239.38
|
|
|
Service Code
|
NDC 55150-427-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.33 |
| Max. Negotiated Rate |
$215.44 |
| Rate for Payer: Aetna American Axle |
$155.60
|
| Rate for Payer: Aetna Commercial |
$203.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.60
|
| Rate for Payer: Cash Price |
$191.50
|
| Rate for Payer: Cofinity Commercial |
$167.57
|
| Rate for Payer: Cofinity Commercial |
$205.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.50
|
| Rate for Payer: Healthscope Commercial |
$215.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$203.47
|
| Rate for Payer: PHP Commercial |
$203.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.57
|
| Rate for Payer: Priority Health SBD |
$150.81
|
| Rate for Payer: UMR Bronson Commercial |
$105.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.54
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$90.50
|
|
|
Service Code
|
NDC 70860-301-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.82 |
| Max. Negotiated Rate |
$81.45 |
| Rate for Payer: Aetna American Axle |
$58.82
|
| Rate for Payer: Aetna Commercial |
$76.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.82
|
| Rate for Payer: Cash Price |
$72.40
|
| Rate for Payer: Cofinity Commercial |
$63.35
|
| Rate for Payer: Cofinity Commercial |
$77.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.40
|
| Rate for Payer: Healthscope Commercial |
$81.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.92
|
| Rate for Payer: PHP Commercial |
$76.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.35
|
| Rate for Payer: Priority Health SBD |
$57.02
|
| Rate for Payer: UMR Bronson Commercial |
$39.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.88
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.38
|
|
|
Service Code
|
NDC 0641-6015-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.57
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$56.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$90.50
|
|
|
Service Code
|
NDC 70860-301-42
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.82 |
| Max. Negotiated Rate |
$81.45 |
| Rate for Payer: Aetna American Axle |
$58.82
|
| Rate for Payer: Aetna Commercial |
$76.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.82
|
| Rate for Payer: Cash Price |
$72.40
|
| Rate for Payer: Cofinity Commercial |
$77.83
|
| Rate for Payer: Cofinity Commercial |
$63.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.40
|
| Rate for Payer: Healthscope Commercial |
$81.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.92
|
| Rate for Payer: PHP Commercial |
$76.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.35
|
| Rate for Payer: Priority Health SBD |
$57.02
|
| Rate for Payer: UMR Bronson Commercial |
$39.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.88
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$48.63
|
|
|
Service Code
|
NDC 0641-6013-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$43.77 |
| Rate for Payer: Aetna American Axle |
$31.61
|
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.61
|
| Rate for Payer: Cash Price |
$38.90
|
| Rate for Payer: Cofinity Commercial |
$34.04
|
| Rate for Payer: Cofinity Commercial |
$41.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.90
|
| Rate for Payer: Healthscope Commercial |
$43.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.04
|
| Rate for Payer: Priority Health SBD |
$30.64
|
| Rate for Payer: UMR Bronson Commercial |
$21.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.47
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$88.75
|
|
|
Service Code
|
NDC 0641-6014-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.05 |
| Max. Negotiated Rate |
$79.88 |
| Rate for Payer: Aetna American Axle |
$57.69
|
| Rate for Payer: Aetna Commercial |
$75.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.69
|
| Rate for Payer: Cash Price |
$71.00
|
| Rate for Payer: Cofinity Commercial |
$62.12
|
| Rate for Payer: Cofinity Commercial |
$76.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.00
|
| Rate for Payer: Healthscope Commercial |
$79.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.44
|
| Rate for Payer: PHP Commercial |
$75.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.12
|
| Rate for Payer: Priority Health SBD |
$55.91
|
| Rate for Payer: UMR Bronson Commercial |
$39.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.56
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$129.38
|
|
|
Service Code
|
NDC 0641-9219-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$116.44 |
| Rate for Payer: Aetna American Axle |
$84.10
|
| Rate for Payer: Aetna Commercial |
$109.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.10
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cofinity Commercial |
$111.27
|
| Rate for Payer: Cofinity Commercial |
$90.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.50
|
| Rate for Payer: Healthscope Commercial |
$116.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.97
|
| Rate for Payer: PHP Commercial |
$109.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.57
|
| Rate for Payer: Priority Health SBD |
$81.51
|
| Rate for Payer: UMR Bronson Commercial |
$56.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.04
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$57.25
|
|
|
Service Code
|
NDC 0409-1171-02
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.19 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna American Axle |
$37.21
|
| Rate for Payer: Aetna Commercial |
$48.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.21
|
| Rate for Payer: Cash Price |
$45.80
|
| Rate for Payer: Cofinity Commercial |
$49.24
|
| Rate for Payer: Cofinity Commercial |
$40.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.80
|
| Rate for Payer: Healthscope Commercial |
$51.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.66
|
| Rate for Payer: PHP Commercial |
$48.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.08
|
| Rate for Payer: Priority Health SBD |
$36.07
|
| Rate for Payer: UMR Bronson Commercial |
$25.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.94
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$59.50
|
|
|
Service Code
|
NDC 17478-937-10
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.18 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Aetna American Axle |
$38.68
|
| Rate for Payer: Aetna Commercial |
$50.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.68
|
| Rate for Payer: Cash Price |
$47.60
|
| Rate for Payer: Cofinity Commercial |
$41.65
|
| Rate for Payer: Cofinity Commercial |
$51.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.60
|
| Rate for Payer: Healthscope Commercial |
$53.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.58
|
| Rate for Payer: PHP Commercial |
$50.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.65
|
| Rate for Payer: Priority Health SBD |
$37.48
|
| Rate for Payer: UMR Bronson Commercial |
$26.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.62
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$253.75
|
|
|
Service Code
|
NDC 17478-937-26
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$228.38 |
| Rate for Payer: Aetna American Axle |
$164.94
|
| Rate for Payer: Aetna Commercial |
$215.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.94
|
| Rate for Payer: Cash Price |
$203.00
|
| Rate for Payer: Cofinity Commercial |
$177.62
|
| Rate for Payer: Cofinity Commercial |
$218.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.00
|
| Rate for Payer: Healthscope Commercial |
$228.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$215.69
|
| Rate for Payer: PHP Commercial |
$215.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.62
|
| Rate for Payer: Priority Health SBD |
$159.86
|
| Rate for Payer: UMR Bronson Commercial |
$111.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.31
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$47.75
|
|
|
Service Code
|
NDC 0409-1171-01
|
| Hospital Charge Code |
9869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$42.98 |
| Rate for Payer: Aetna American Axle |
$31.04
|
| Rate for Payer: Aetna Commercial |
$40.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.04
|
| Rate for Payer: Cash Price |
$38.20
|
| Rate for Payer: Cofinity Commercial |
$33.42
|
| Rate for Payer: Cofinity Commercial |
$41.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.20
|
| Rate for Payer: Healthscope Commercial |
$42.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.59
|
| Rate for Payer: PHP Commercial |
$40.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.42
|
| Rate for Payer: Priority Health SBD |
$30.08
|
| Rate for Payer: UMR Bronson Commercial |
$21.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.81
|
|
