|
DILTIAZEM ER 240 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$464.98
|
|
|
Service Code
|
NDC 0187-2047-30
|
| Hospital Charge Code |
35179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.59 |
| Max. Negotiated Rate |
$418.48 |
| Rate for Payer: Aetna American Axle |
$302.24
|
| Rate for Payer: Aetna Commercial |
$395.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.24
|
| Rate for Payer: Cash Price |
$371.98
|
| Rate for Payer: Cofinity Commercial |
$325.49
|
| Rate for Payer: Cofinity Commercial |
$399.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.98
|
| Rate for Payer: Healthscope Commercial |
$418.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$325.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$395.23
|
| Rate for Payer: PHP Commercial |
$395.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$325.49
|
| Rate for Payer: Priority Health SBD |
$292.94
|
| Rate for Payer: UMR Bronson Commercial |
$204.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.74
|
|
|
DILUENT FOR TREPROSTINIL (GLYCINE) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$159.60
|
|
|
Service Code
|
NDC 0781-6021-94
|
| Hospital Charge Code |
182315
|
| Min. Negotiated Rate |
$70.22 |
| Max. Negotiated Rate |
$143.64 |
| Rate for Payer: Aetna American Axle |
$103.74
|
| Rate for Payer: Aetna Commercial |
$135.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.74
|
| Rate for Payer: Cash Price |
$127.68
|
| Rate for Payer: Cofinity Commercial |
$111.72
|
| Rate for Payer: Cofinity Commercial |
$137.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.68
|
| Rate for Payer: Healthscope Commercial |
$143.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.66
|
| Rate for Payer: PHP Commercial |
$135.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.72
|
| Rate for Payer: Priority Health SBD |
$100.55
|
| Rate for Payer: UMR Bronson Commercial |
$70.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.70
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0006-4309-01
|
| Hospital Charge Code |
173258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0006-4309-00
|
| Hospital Charge Code |
173258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINE (STERILE WATER) SYRINGE
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0006-4175-88
|
| Hospital Charge Code |
206168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINE (STERILE WATER) SYRINGE
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0006-4175-89
|
| Hospital Charge Code |
206168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.01
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Aetna American Axle |
$15.61
|
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.61
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cofinity Commercial |
$16.81
|
| Rate for Payer: Cofinity Commercial |
$20.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.21
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.41
|
| Rate for Payer: PHP Commercial |
$20.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.81
|
| Rate for Payer: Priority Health SBD |
$15.13
|
| Rate for Payer: UMR Bronson Commercial |
$10.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.01
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.01
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$28.89 |
| Rate for Payer: Aetna American Axle |
$15.61
|
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.61
|
| Rate for Payer: BCBS Complete |
$9.60
|
| Rate for Payer: BCBS Trust/PPO |
$28.89
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cofinity Commercial |
$20.65
|
| Rate for Payer: Cofinity Commercial |
$16.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.21
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.41
|
| Rate for Payer: PHP Commercial |
$20.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.81
|
| Rate for Payer: Priority Health SBD |
$15.13
|
| Rate for Payer: UMR Bronson Commercial |
$8.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.01
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 0904-2051-59
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.81 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna American Axle |
$57.33
|
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.33
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$61.74
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.74
|
| Rate for Payer: Priority Health SBD |
$55.57
|
| Rate for Payer: UMR Bronson Commercial |
$38.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 0904-6772-12
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Aetna American Axle |
$15.60
|
| Rate for Payer: Aetna Commercial |
$20.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.60
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cofinity Commercial |
$16.80
|
| Rate for Payer: Cofinity Commercial |
$20.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.20
|
| Rate for Payer: Healthscope Commercial |
$21.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.40
|
| Rate for Payer: PHP Commercial |
$20.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.80
|
| Rate for Payer: Priority Health SBD |
$15.12
|
| Rate for Payer: UMR Bronson Commercial |
$10.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.00
|
|
|
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION
|
Facility
|
IP
|
$2,277.54
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
118456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,002.12 |
| Max. Negotiated Rate |
$2,049.79 |
| Rate for Payer: Aetna American Axle |
$1,480.40
|
| Rate for Payer: Aetna Commercial |
$1,935.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,480.40
|
| Rate for Payer: Cash Price |
$1,822.03
|
| Rate for Payer: Cofinity Commercial |
$1,594.28
|
| Rate for Payer: Cofinity Commercial |
$1,958.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,822.03
|
| Rate for Payer: Healthscope Commercial |
$2,049.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,594.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,708.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,935.91
|
| Rate for Payer: PHP Commercial |
$1,935.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,594.28
|
| Rate for Payer: Priority Health SBD |
$1,434.85
|
| Rate for Payer: UMR Bronson Commercial |
$1,002.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,708.16
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,733.68
|
|
|
Service Code
|
NDC 55566-2800-1
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$762.82 |
| Max. Negotiated Rate |
$1,560.31 |
| Rate for Payer: Aetna American Axle |
$1,126.89
|
| Rate for Payer: Aetna Commercial |
$1,473.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,126.89
|
| Rate for Payer: Cash Price |
$1,386.94
|
| Rate for Payer: Cofinity Commercial |
$1,213.58
|
| Rate for Payer: Cofinity Commercial |
$1,490.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,386.94
|
| Rate for Payer: Healthscope Commercial |
$1,560.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,213.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,300.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,473.63
|
| Rate for Payer: PHP Commercial |
$1,473.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,213.58
|
| Rate for Payer: Priority Health SBD |
$1,092.22
|
| Rate for Payer: UMR Bronson Commercial |
$762.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,300.26
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,733.68
|
|
|
Service Code
|
NDC 55566-2800-0
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$762.82 |
| Max. Negotiated Rate |
$1,560.31 |
| Rate for Payer: Aetna American Axle |
$1,126.89
|
| Rate for Payer: Aetna Commercial |
$1,473.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,126.89
|
| Rate for Payer: Cash Price |
$1,386.94
|
| Rate for Payer: Cofinity Commercial |
$1,213.58
|
| Rate for Payer: Cofinity Commercial |
$1,490.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,386.94
|
| Rate for Payer: Healthscope Commercial |
$1,560.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,213.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,300.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,473.63
|
| Rate for Payer: PHP Commercial |
$1,473.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,213.58
|
| Rate for Payer: Priority Health SBD |
$1,092.22
|
| Rate for Payer: UMR Bronson Commercial |
$762.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,300.26
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19,500.00
|
|
|
Service Code
|
HCPCS J9999
|
| Hospital Charge Code |
171873
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,580.00 |
| Max. Negotiated Rate |
$17,550.00 |
| Rate for Payer: Aetna American Axle |
$12,675.00
|
| Rate for Payer: Aetna Commercial |
$16,575.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,675.00
|
| Rate for Payer: Cash Price |
$15,600.00
|
| Rate for Payer: Cofinity Commercial |
$13,650.00
|
| Rate for Payer: Cofinity Commercial |
$16,770.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,600.00
|
| Rate for Payer: Healthscope Commercial |
$17,550.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,650.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,625.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16,575.00
|
| Rate for Payer: PHP Commercial |
$16,575.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,650.00
|
| Rate for Payer: Priority Health SBD |
$12,285.00
|
| Rate for Payer: UMR Bronson Commercial |
$8,580.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,625.00
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19,500.00
|
|
|
Service Code
|
HCPCS J9999
|
| Hospital Charge Code |
171873
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,215.00 |
| Max. Negotiated Rate |
$17,550.00 |
| Rate for Payer: Aetna American Axle |
$12,675.00
|
| Rate for Payer: Aetna Commercial |
$16,575.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,675.00
|
| Rate for Payer: BCBS Complete |
$7,800.00
|
| Rate for Payer: Cash Price |
$15,600.00
|
| Rate for Payer: Cofinity Commercial |
$13,650.00
|
| Rate for Payer: Cofinity Commercial |
$16,770.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,600.00
|
| Rate for Payer: Healthscope Commercial |
$17,550.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,650.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,625.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16,575.00
|
| Rate for Payer: PHP Commercial |
$16,575.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,650.00
|
| Rate for Payer: Priority Health SBD |
$12,285.00
|
| Rate for Payer: UMR Bronson Commercial |
$7,215.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,625.00
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$292.80
|
|
|
Service Code
|
NDC 65628-050-04
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.83 |
| Max. Negotiated Rate |
$263.52 |
| Rate for Payer: Aetna American Axle |
$190.32
|
| Rate for Payer: Aetna Commercial |
$248.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.32
|
| Rate for Payer: Cash Price |
$234.24
|
| Rate for Payer: Cofinity Commercial |
$204.96
|
| Rate for Payer: Cofinity Commercial |
$251.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.24
|
| Rate for Payer: Healthscope Commercial |
$263.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$248.88
|
| Rate for Payer: PHP Commercial |
$248.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.96
|
| Rate for Payer: Priority Health SBD |
$184.46
|
| Rate for Payer: UMR Bronson Commercial |
$128.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.60
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna American Axle |
$8.48
|
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna Commercial |
$11.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cash Price |
$10.44
|
| Rate for Payer: Cofinity Commercial |
$9.14
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$11.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$11.74
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.09
|
| Rate for Payer: PHP Commercial |
$11.09
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.14
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: Priority Health SBD |
$8.22
|
| Rate for Payer: UMR Bronson Commercial |
$5.70
|
| Rate for Payer: UMR Bronson Commercial |
$5.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.79
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna American Axle |
$8.48
|
| Rate for Payer: Aetna Commercial |
$11.09
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: BCBS Complete |
$5.18
|
| Rate for Payer: BCBS Complete |
$5.22
|
| Rate for Payer: BCBS Trust/PPO |
$0.32
|
| Rate for Payer: BCBS Trust/PPO |
$0.32
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cash Price |
$10.44
|
| Rate for Payer: Cash Price |
$10.44
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$9.14
|
| Rate for Payer: Cofinity Commercial |
$11.22
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.44
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Healthscope Commercial |
$11.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.06
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: Priority Health SBD |
$8.22
|
| Rate for Payer: UMR Bronson Commercial |
$4.83
|
| Rate for Payer: UMR Bronson Commercial |
$4.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.79
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$41.83
|
|
|
Service Code
|
NDC 68094-024-62
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna American Axle |
$27.19
|
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Commercial |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.56
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.28
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UMR Bronson Commercial |
$15.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.37
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$14.06
|
|
|
Service Code
|
NDC 68094-022-62
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna American Axle |
$9.14
|
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cofinity Commercial |
$12.09
|
| Rate for Payer: Cofinity Commercial |
$9.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
| Rate for Payer: Healthscope Commercial |
$12.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.95
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.84
|
| Rate for Payer: Priority Health SBD |
$8.86
|
| Rate for Payer: UMR Bronson Commercial |
$6.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$266.78
|
|
|
Service Code
|
NDC 58657-528-16
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.38 |
| Max. Negotiated Rate |
$240.10 |
| Rate for Payer: Aetna American Axle |
$173.41
|
| Rate for Payer: Aetna Commercial |
$226.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.41
|
| Rate for Payer: Cash Price |
$213.42
|
| Rate for Payer: Cofinity Commercial |
$186.75
|
| Rate for Payer: Cofinity Commercial |
$229.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.42
|
| Rate for Payer: Healthscope Commercial |
$240.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$226.76
|
| Rate for Payer: PHP Commercial |
$226.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.75
|
| Rate for Payer: Priority Health SBD |
$168.07
|
| Rate for Payer: UMR Bronson Commercial |
$117.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.08
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$178.23
|
|
|
Service Code
|
NDC 54838-135-70
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.42 |
| Max. Negotiated Rate |
$160.41 |
| Rate for Payer: Aetna American Axle |
$115.85
|
| Rate for Payer: Aetna Commercial |
$151.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.85
|
| Rate for Payer: Cash Price |
$142.58
|
| Rate for Payer: Cofinity Commercial |
$153.28
|
| Rate for Payer: Cofinity Commercial |
$124.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.58
|
| Rate for Payer: Healthscope Commercial |
$160.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.50
|
| Rate for Payer: PHP Commercial |
$151.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.76
|
| Rate for Payer: Priority Health SBD |
$112.28
|
| Rate for Payer: UMR Bronson Commercial |
$78.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.67
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$16.53
|
|
|
Service Code
|
NDC 69339-151-17
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$14.88 |
| Rate for Payer: Aetna American Axle |
$10.74
|
| Rate for Payer: Aetna Commercial |
$14.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.74
|
| Rate for Payer: BCBS Complete |
$6.61
|
| Rate for Payer: Cash Price |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$11.57
|
| Rate for Payer: Cofinity Commercial |
$14.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.22
|
| Rate for Payer: Healthscope Commercial |
$14.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.05
|
| Rate for Payer: PHP Commercial |
$14.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.57
|
| Rate for Payer: Priority Health SBD |
$10.41
|
| Rate for Payer: UMR Bronson Commercial |
$6.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.40
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$14.06
|
|
|
Service Code
|
NDC 68094-022-59
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna American Axle |
$9.14
|
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
| Rate for Payer: BCBS Complete |
$5.62
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cofinity Commercial |
$12.09
|
| Rate for Payer: Cofinity Commercial |
$9.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
| Rate for Payer: Healthscope Commercial |
$12.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.95
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.84
|
| Rate for Payer: Priority Health SBD |
$8.86
|
| Rate for Payer: UMR Bronson Commercial |
$5.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$41.83
|
|
|
Service Code
|
NDC 68094-024-59
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna American Axle |
$27.19
|
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Commercial |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.56
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.28
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UMR Bronson Commercial |
$15.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.37
|
|
