|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$401.85
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.68 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna American Axle |
$261.20
|
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna Medicare |
$200.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: BCBS Complete |
$160.74
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Advantage |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$321.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.39
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.20
|
| Rate for Payer: UHC Core |
$209.36
|
| Rate for Payer: UHC Exchange |
$157.93
|
| Rate for Payer: UMR Bronson Commercial |
$148.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$155.10
|
|
|
Service Code
|
NDC 53746074501
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.24 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna American Axle |
$100.81
|
| Rate for Payer: Aetna Commercial |
$131.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.81
|
| Rate for Payer: Cash Price |
$124.08
|
| Rate for Payer: Cofinity Advantage |
$108.57
|
| Rate for Payer: Cofinity Commercial |
$133.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$139.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.33
|
| Rate for Payer: PHP Commercial |
$131.84
|
| Rate for Payer: Priority Health SBD |
$97.71
|
| Rate for Payer: UMR Bronson Commercial |
$68.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.33
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$152.75
|
|
|
Service Code
|
NDC 68382004001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.21 |
| Max. Negotiated Rate |
$137.47 |
| Rate for Payer: Aetna American Axle |
$99.29
|
| Rate for Payer: Aetna Commercial |
$129.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.29
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Advantage |
$106.92
|
| Rate for Payer: Cofinity Commercial |
$131.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$137.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$114.56
|
| Rate for Payer: PHP Commercial |
$129.84
|
| Rate for Payer: Priority Health SBD |
$96.23
|
| Rate for Payer: UMR Bronson Commercial |
$67.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.56
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 65162074510
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.03
|
| Rate for Payer: Aetna Commercial |
$147.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.03
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Advantage |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$121.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$130.43
|
| Rate for Payer: PHP Commercial |
$147.81
|
| Rate for Payer: Priority Health SBD |
$109.56
|
| Rate for Payer: UMR Bronson Commercial |
$76.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.43
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$16.85
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$15.16 |
| Rate for Payer: Aetna American Axle |
$10.95
|
| Rate for Payer: Aetna American Axle |
$14.45
|
| Rate for Payer: Aetna American Axle |
$14.33
|
| Rate for Payer: Aetna American Axle |
$13.55
|
| Rate for Payer: Aetna American Axle |
$14.46
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna Medicare |
$10.42
|
| Rate for Payer: Aetna Medicare |
$8.43
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: BCBS Complete |
$8.89
|
| Rate for Payer: BCBS Complete |
$6.74
|
| Rate for Payer: BCBS Complete |
$8.34
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: BCBS Trust/PPO |
$12.86
|
| Rate for Payer: BCBS Trust/PPO |
$12.86
|
| Rate for Payer: BCBS Trust/PPO |
$12.86
|
| Rate for Payer: BCBS Trust/PPO |
$12.86
|
| Rate for Payer: BCBS Trust/PPO |
$12.86
|
| Rate for Payer: BCN Commercial |
$12.86
|
| Rate for Payer: BCN Commercial |
$12.86
|
| Rate for Payer: BCN Commercial |
$12.86
|
| Rate for Payer: BCN Commercial |
$12.86
|
| Rate for Payer: BCN Commercial |
$12.86
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cofinity Advantage |
$15.56
|
| Rate for Payer: Cofinity Advantage |
$14.59
|
| Rate for Payer: Cofinity Advantage |
$15.44
|
| Rate for Payer: Cofinity Advantage |
$15.57
|
| Rate for Payer: Cofinity Advantage |
$11.79
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.92
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Healthscope Commercial |
$18.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.69
|
| Rate for Payer: PHP Commercial |
$17.71
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$13.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.55
|
| Rate for Payer: UHC Core |
$6.55
|
| Rate for Payer: UHC Core |
$6.55
|
| Rate for Payer: UHC Core |
$6.55
|
| Rate for Payer: UHC Core |
$6.55
|
| Rate for Payer: UHC Core |
$6.55
|
| Rate for Payer: UHC Exchange |
$6.55
|
| Rate for Payer: UHC Exchange |
$6.55
|
| Rate for Payer: UHC Exchange |
$6.55
|
| Rate for Payer: UHC Exchange |
$6.55
|
| Rate for Payer: UHC Exchange |
$6.55
|
| Rate for Payer: UMR Bronson Commercial |
$6.23
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: UMR Bronson Commercial |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: UMR Bronson Commercial |
$7.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$22.23
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$20.01 |
| Rate for Payer: Aetna American Axle |
$14.45
|
| Rate for Payer: Aetna American Axle |
$14.33
|
| Rate for Payer: Aetna American Axle |
$14.46
|
| Rate for Payer: Aetna American Axle |
$10.95
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cofinity Advantage |
$15.44
|
| Rate for Payer: Cofinity Advantage |
$11.79
|
| Rate for Payer: Cofinity Advantage |
$15.56
|
| Rate for Payer: Cofinity Advantage |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.64
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: UMR Bronson Commercial |
$9.70
|
| Rate for Payer: UMR Bronson Commercial |
$9.78
|
| Rate for Payer: UMR Bronson Commercial |
$7.41
|
| Rate for Payer: UMR Bronson Commercial |
$9.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
NDC 68084015511
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna American Axle |
$1.36
|
| Rate for Payer: Aetna Commercial |
$1.78
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.36
|
| Rate for Payer: BCBS Complete |
$0.84
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cofinity Advantage |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.68
|
| Rate for Payer: Healthscope Commercial |
$1.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.57
|
| Rate for Payer: PHP Commercial |
$1.78
|
| Rate for Payer: Priority Health SBD |
$1.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.36
|
| Rate for Payer: UHC Core |
$1.09
|
| Rate for Payer: UHC Exchange |
$0.83
|
| Rate for Payer: UMR Bronson Commercial |
$0.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.57
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$209.95
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.38 |
| Max. Negotiated Rate |
$188.96 |
| Rate for Payer: Aetna American Axle |
$136.47
|
| Rate for Payer: Aetna Commercial |
$178.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.47
|
| Rate for Payer: Cash Price |
$167.96
|
| Rate for Payer: Cofinity Advantage |
$146.97
|
| Rate for Payer: Cofinity Commercial |
$180.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.96
|
| Rate for Payer: Healthscope Commercial |
$188.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.46
|
| Rate for Payer: PHP Commercial |
$178.46
|
| Rate for Payer: Priority Health SBD |
$132.27
|
| Rate for Payer: UMR Bronson Commercial |
$92.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.46
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Advantage |
$176.01
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.59
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
NDC 53746052101
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.89
|
| Rate for Payer: Aetna Medicare |
$49.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: BCBS Complete |
$39.48
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Advantage |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.03
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.16
|
| Rate for Payer: UHC Core |
$51.42
|
| Rate for Payer: UHC Exchange |
$38.79
|
| Rate for Payer: UMR Bronson Commercial |
$36.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.03
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 53746052101
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Advantage |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.03
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.03
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$209.95
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.68 |
| Max. Negotiated Rate |
$188.96 |
| Rate for Payer: Aetna American Axle |
$136.47
|
| Rate for Payer: Aetna Commercial |
$178.46
|
| Rate for Payer: Aetna Medicare |
$104.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.47
|
| Rate for Payer: BCBS Complete |
$83.98
|
| Rate for Payer: Cash Price |
$167.96
|
| Rate for Payer: Cofinity Advantage |
$146.97
|
| Rate for Payer: Cofinity Commercial |
$180.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.96
|
| Rate for Payer: Healthscope Commercial |
$188.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$167.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.46
|
| Rate for Payer: PHP Commercial |
$178.46
|
| Rate for Payer: Priority Health SBD |
$132.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.47
|
| Rate for Payer: UHC Core |
$109.38
|
| Rate for Payer: UHC Exchange |
$82.51
|
| Rate for Payer: UMR Bronson Commercial |
$77.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.46
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
NDC 68084015511
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna American Axle |
$1.36
|
| Rate for Payer: Aetna Commercial |
$1.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.36
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cofinity Advantage |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.68
|
| Rate for Payer: Healthscope Commercial |
$1.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.57
|
| Rate for Payer: PHP Commercial |
$1.78
|
| Rate for Payer: Priority Health SBD |
$1.32
|
| Rate for Payer: UMR Bronson Commercial |
$0.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.57
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.04 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna Medicare |
$125.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: BCBS Complete |
$100.58
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Advantage |
$176.01
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$201.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.59
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.44
|
| Rate for Payer: UHC Core |
$131.01
|
| Rate for Payer: UHC Exchange |
$98.82
|
| Rate for Payer: UMR Bronson Commercial |
$93.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
PROMETHAZINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$15.36
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$13.82 |
| Rate for Payer: Aetna American Axle |
$9.98
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Medicare |
$7.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.98
|
| Rate for Payer: BCBS Complete |
$6.14
|
| Rate for Payer: BCBS Trust/PPO |
$12.86
|
| Rate for Payer: BCN Commercial |
$12.86
|
| Rate for Payer: Cash Price |
$12.29
|
| Rate for Payer: Cash Price |
$12.29
|
| Rate for Payer: Cofinity Advantage |
$10.75
|
| Rate for Payer: Cofinity Commercial |
$13.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.29
|
| Rate for Payer: Healthscope Commercial |
$13.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.52
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.55
|
| Rate for Payer: UHC Core |
$6.55
|
| Rate for Payer: UHC Exchange |
$6.55
|
| Rate for Payer: UMR Bronson Commercial |
$5.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.52
|
|
|
PROMETHAZINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$15.36
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$13.82 |
| Rate for Payer: Aetna American Axle |
$9.98
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.98
|
| Rate for Payer: Cash Price |
$12.29
|
| Rate for Payer: Cofinity Advantage |
$10.75
|
| Rate for Payer: Cofinity Commercial |
$13.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.29
|
| Rate for Payer: Healthscope Commercial |
$13.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.52
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: UMR Bronson Commercial |
$6.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.52
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$653.93
|
|
|
Service Code
|
NDC 70408014634
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.73 |
| Max. Negotiated Rate |
$588.54 |
| Rate for Payer: Aetna American Axle |
$425.05
|
| Rate for Payer: Aetna Commercial |
$555.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.05
|
| Rate for Payer: Cash Price |
$523.14
|
| Rate for Payer: Cofinity Advantage |
$457.75
|
| Rate for Payer: Cofinity Commercial |
$562.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$523.14
|
| Rate for Payer: Healthscope Commercial |
$588.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$457.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$490.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$555.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$490.45
|
| Rate for Payer: PHP Commercial |
$555.84
|
| Rate for Payer: Priority Health SBD |
$411.98
|
| Rate for Payer: UMR Bronson Commercial |
$287.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$490.45
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$314.55
|
|
|
Service Code
|
NDC 70752013812
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.38 |
| Max. Negotiated Rate |
$283.10 |
| Rate for Payer: Aetna American Axle |
$204.46
|
| Rate for Payer: Aetna Commercial |
$267.37
|
| Rate for Payer: Aetna Medicare |
$157.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$204.46
|
| Rate for Payer: BCBS Complete |
$125.82
|
| Rate for Payer: Cash Price |
$251.64
|
| Rate for Payer: Cofinity Advantage |
$220.19
|
| Rate for Payer: Cofinity Commercial |
$270.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.64
|
| Rate for Payer: Healthscope Commercial |
$283.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$220.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$251.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$235.91
|
| Rate for Payer: PHP Commercial |
$267.37
|
| Rate for Payer: Priority Health SBD |
$198.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$204.46
|
| Rate for Payer: UHC Core |
$163.88
|
| Rate for Payer: UHC Exchange |
$123.62
|
| Rate for Payer: UMR Bronson Commercial |
$116.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.91
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$653.93
|
|
|
Service Code
|
NDC 70408014634
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.95 |
| Max. Negotiated Rate |
$588.54 |
| Rate for Payer: Aetna American Axle |
$425.05
|
| Rate for Payer: Aetna Commercial |
$555.84
|
| Rate for Payer: Aetna Medicare |
$326.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.05
|
| Rate for Payer: BCBS Complete |
$261.57
|
| Rate for Payer: Cash Price |
$523.14
|
| Rate for Payer: Cofinity Advantage |
$457.75
|
| Rate for Payer: Cofinity Commercial |
$562.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$523.14
|
| Rate for Payer: Healthscope Commercial |
$588.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$457.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$490.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$523.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$555.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$490.45
|
| Rate for Payer: PHP Commercial |
$555.84
|
| Rate for Payer: Priority Health SBD |
$411.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$425.05
|
| Rate for Payer: UHC Core |
$340.70
|
| Rate for Payer: UHC Exchange |
$256.99
|
| Rate for Payer: UMR Bronson Commercial |
$241.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$490.45
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$389.05
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.95 |
| Max. Negotiated Rate |
$350.14 |
| Rate for Payer: Aetna American Axle |
$252.88
|
| Rate for Payer: Aetna Commercial |
$330.69
|
| Rate for Payer: Aetna Medicare |
$194.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.88
|
| Rate for Payer: BCBS Complete |
$155.62
|
| Rate for Payer: Cash Price |
$311.24
|
| Rate for Payer: Cofinity Advantage |
$272.33
|
| Rate for Payer: Cofinity Commercial |
$334.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.24
|
| Rate for Payer: Healthscope Commercial |
$350.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$272.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$291.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$311.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$291.79
|
| Rate for Payer: PHP Commercial |
$330.69
|
| Rate for Payer: Priority Health SBD |
$245.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.88
|
| Rate for Payer: UHC Core |
$202.70
|
| Rate for Payer: UHC Exchange |
$152.90
|
| Rate for Payer: UMR Bronson Commercial |
$143.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$291.79
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$389.05
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.18 |
| Max. Negotiated Rate |
$350.14 |
| Rate for Payer: Aetna American Axle |
$252.88
|
| Rate for Payer: Aetna Commercial |
$330.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.88
|
| Rate for Payer: Cash Price |
$311.24
|
| Rate for Payer: Cofinity Advantage |
$272.33
|
| Rate for Payer: Cofinity Commercial |
$334.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.24
|
| Rate for Payer: Healthscope Commercial |
$350.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$272.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$291.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$291.79
|
| Rate for Payer: PHP Commercial |
$330.69
|
| Rate for Payer: Priority Health SBD |
$245.10
|
| Rate for Payer: UMR Bronson Commercial |
$171.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$291.79
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$314.55
|
|
|
Service Code
|
NDC 70752013812
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.40 |
| Max. Negotiated Rate |
$283.10 |
| Rate for Payer: Aetna American Axle |
$204.46
|
| Rate for Payer: Aetna Commercial |
$267.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$204.46
|
| Rate for Payer: Cash Price |
$251.64
|
| Rate for Payer: Cofinity Advantage |
$220.19
|
| Rate for Payer: Cofinity Commercial |
$270.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.64
|
| Rate for Payer: Healthscope Commercial |
$283.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$220.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$235.91
|
| Rate for Payer: PHP Commercial |
$267.37
|
| Rate for Payer: Priority Health SBD |
$198.17
|
| Rate for Payer: UMR Bronson Commercial |
$138.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.91
|
|
|
PR OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX
|
Professional
|
Both
|
$2,191.00
|
|
|
Service Code
|
HCPCS 49255
|
| Min. Negotiated Rate |
$479.46 |
| Max. Negotiated Rate |
$1,643.25 |
| Rate for Payer: Aetna Commercial |
$995.18
|
| Rate for Payer: Aetna Medicare |
$772.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,069.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$995.18
|
| Rate for Payer: BCBS Complete |
$503.43
|
| Rate for Payer: BCBS MAPPO |
$742.67
|
| Rate for Payer: BCN Commercial |
$1,197.15
|
| Rate for Payer: BCN Medicare Advantage |
$742.67
|
| Rate for Payer: Cash Price |
$1,752.80
|
| Rate for Payer: Cash Price |
$1,752.80
|
| Rate for Payer: Cofinity Commercial |
$1,069.44
|
| Rate for Payer: Cofinity Commercial |
$995.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$742.67
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$779.80
|
| Rate for Payer: Meridian Medicaid |
$503.43
|
| Rate for Payer: Molina Medicare/Medicaid |
$816.94
|
| Rate for Payer: Nomi Health Commercial |
$891.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,643.25
|
| Rate for Payer: PACE SWMI |
$742.67
|
| Rate for Payer: PHP Commercial |
$1,039.74
|
| Rate for Payer: PHP Medicare Advantage |
$742.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$479.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,458.65
|
| Rate for Payer: Priority Health Medicare |
$742.67
|
| Rate for Payer: Priority Health SBD |
$1,458.65
|
| Rate for Payer: Priority Health Tiered Network |
$1,458.65
|
| Rate for Payer: Railroad Medicare Medicare |
$742.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,394.14
|
| Rate for Payer: UHC Core |
$1,394.14
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$742.67
|
| Rate for Payer: UHC Exchange |
$1,394.14
|
| Rate for Payer: UHC Medicaid |
$479.46
|
| Rate for Payer: UHCCP Medicaid |
$479.46
|
| Rate for Payer: UMR Bronson Commercial |
$1,007.86
|
|
|
PR ONDANSETRON HCL INJECTION
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS J2405
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Aetna Medicare |
$0.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.13
|
| Rate for Payer: BCBS MAPPO |
$0.09
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: BCN Medicare Advantage |
$0.09
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Cofinity Commercial |
$0.12
|
| Rate for Payer: Cofinity Commercial |
$0.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.10
|
| Rate for Payer: Nomi Health Commercial |
$0.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.00
|
| Rate for Payer: PACE SWMI |
$0.09
|
| Rate for Payer: PHP Commercial |
$0.13
|
| Rate for Payer: PHP Medicare Advantage |
$0.09
|
| Rate for Payer: Priority Health Medicare |
$0.09
|
| Rate for Payer: Railroad Medicare Medicare |
$0.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.09
|
| Rate for Payer: UHC Core |
$0.09
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.09
|
| Rate for Payer: UHC Exchange |
$0.09
|
| Rate for Payer: UMR Bronson Commercial |
$14.72
|
|
|
PR ONE AREA LIPOSUCTION - 1 AREA 1.0 HR
|
Professional
|
Both
|
$1,803.00
|
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$721.20 |
| Max. Negotiated Rate |
$1,352.25 |
| Rate for Payer: Aetna Medicare |
$901.50
|
| Rate for Payer: BCBS Complete |
$721.20
|
| Rate for Payer: Cash Price |
$1,442.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,352.25
|
| Rate for Payer: UMR Bronson Commercial |
$829.38
|
|
