|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
HCPCS 99202
|
| Min. Negotiated Rate |
$44.53 |
| Max. Negotiated Rate |
$72.80 |
| Rate for Payer: Aetna Commercial |
$59.67
|
| Rate for Payer: Aetna Medicare |
$46.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.67
|
| Rate for Payer: BCBS Complete |
$44.80
|
| Rate for Payer: BCBS MAPPO |
$44.53
|
| Rate for Payer: BCN Medicare Advantage |
$44.53
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cofinity Commercial |
$64.12
|
| Rate for Payer: Cofinity Commercial |
$59.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$46.76
|
| Rate for Payer: Nomi Health Commercial |
$53.44
|
| Rate for Payer: PACE SWMI |
$44.53
|
| Rate for Payer: PHP Commercial |
$62.34
|
| Rate for Payer: PHP Medicare Advantage |
$44.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.80
|
| Rate for Payer: Priority Health Medicare |
$44.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$44.53
|
| Rate for Payer: UHC Medicare Advantage |
$44.53
|
| Rate for Payer: UMR Bronson Commercial |
$51.52
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 59651015201
|
| Hospital Charge Code |
23122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.73 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna Medicare |
$218.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: BCBS Complete |
$174.84
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$161.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE
|
Facility
|
IP
|
$1,804.64
|
|
|
Service Code
|
NDC 72989037230
|
| Hospital Charge Code |
23122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$794.04 |
| Max. Negotiated Rate |
$1,624.18 |
| Rate for Payer: Aetna American Axle |
$1,173.02
|
| Rate for Payer: Aetna Commercial |
$1,533.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,173.02
|
| Rate for Payer: Cash Price |
$1,443.71
|
| Rate for Payer: Cofinity Commercial |
$1,263.25
|
| Rate for Payer: Cofinity Commercial |
$1,551.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,263.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,443.71
|
| Rate for Payer: Healthscope Commercial |
$1,624.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,263.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,353.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,533.94
|
| Rate for Payer: PHP Commercial |
$1,533.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,173.02
|
| Rate for Payer: Priority Health SBD |
$1,136.92
|
| Rate for Payer: UMR Bronson Commercial |
$794.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,353.48
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE
|
Facility
|
OP
|
$1,804.64
|
|
|
Service Code
|
NDC 72989037230
|
| Hospital Charge Code |
23122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$667.72 |
| Max. Negotiated Rate |
$1,624.18 |
| Rate for Payer: Aetna American Axle |
$1,173.02
|
| Rate for Payer: Aetna Commercial |
$1,533.94
|
| Rate for Payer: Aetna Medicare |
$902.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,173.02
|
| Rate for Payer: BCBS Complete |
$721.86
|
| Rate for Payer: Cash Price |
$1,443.71
|
| Rate for Payer: Cofinity Commercial |
$1,263.25
|
| Rate for Payer: Cofinity Commercial |
$1,551.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,263.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,443.71
|
| Rate for Payer: Healthscope Commercial |
$1,624.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,263.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,353.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,533.94
|
| Rate for Payer: PHP Commercial |
$1,533.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,173.02
|
| Rate for Payer: Priority Health SBD |
$1,136.92
|
| Rate for Payer: UMR Bronson Commercial |
$667.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,353.48
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE
|
Facility
|
OP
|
$256.80
|
|
|
Service Code
|
NDC 17478076610
|
| Hospital Charge Code |
23122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.02 |
| Max. Negotiated Rate |
$231.12 |
| Rate for Payer: Aetna American Axle |
$166.92
|
| Rate for Payer: Aetna Commercial |
$218.28
|
| Rate for Payer: Aetna Medicare |
$128.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.92
|
| Rate for Payer: BCBS Complete |
$102.72
|
| Rate for Payer: Cash Price |
$205.44
|
| Rate for Payer: Cofinity Commercial |
$179.76
|
| Rate for Payer: Cofinity Commercial |
$220.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.44
|
| Rate for Payer: Healthscope Commercial |
$231.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$218.28
|
| Rate for Payer: PHP Commercial |
$218.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$161.78
|
| Rate for Payer: UMR Bronson Commercial |
$95.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.60
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE
|
Facility
|
IP
|
$256.80
|
|
|
Service Code
|
NDC 17478076610
|
| Hospital Charge Code |
23122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.99 |
| Max. Negotiated Rate |
$231.12 |
| Rate for Payer: Aetna American Axle |
$166.92
|
| Rate for Payer: Aetna Commercial |
$218.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.92
|
| Rate for Payer: Cash Price |
$205.44
|
| Rate for Payer: Cofinity Commercial |
$179.76
|
| Rate for Payer: Cofinity Commercial |
$220.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.44
|
| Rate for Payer: Healthscope Commercial |
$231.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$218.28
|
| Rate for Payer: PHP Commercial |
$218.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$161.78
|
| Rate for Payer: UMR Bronson Commercial |
$112.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.60
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 59651015201
|
| Hospital Charge Code |
23122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.32 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$192.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
PROGESTERONE MICRONIZED 8 % VAGINAL GEL
|
Facility
|
IP
|
$107.07
|
|
|
Service Code
|
NDC 00023615108
|
| Hospital Charge Code |
21321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.11 |
| Max. Negotiated Rate |
$96.36 |
| Rate for Payer: Aetna American Axle |
$69.60
|
| Rate for Payer: Aetna Commercial |
$91.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.60
|
| Rate for Payer: Cash Price |
$85.66
|
| Rate for Payer: Cofinity Commercial |
$74.95
|
| Rate for Payer: Cofinity Commercial |
$92.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.66
|
| Rate for Payer: Healthscope Commercial |
$96.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.01
|
| Rate for Payer: PHP Commercial |
$91.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.60
|
| Rate for Payer: Priority Health SBD |
$67.45
|
| Rate for Payer: UMR Bronson Commercial |
$47.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.30
|
|
|
PROGESTERONE MICRONIZED 8 % VAGINAL GEL
|
Facility
|
IP
|
$107.07
|
|
|
Service Code
|
NDC 00023615109
|
| Hospital Charge Code |
21321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.11 |
| Max. Negotiated Rate |
$96.36 |
| Rate for Payer: Aetna American Axle |
$69.60
|
| Rate for Payer: Aetna Commercial |
$91.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.60
|
| Rate for Payer: Cash Price |
$85.66
|
| Rate for Payer: Cofinity Commercial |
$74.95
|
| Rate for Payer: Cofinity Commercial |
$92.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.66
|
| Rate for Payer: Healthscope Commercial |
$96.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.01
|
| Rate for Payer: PHP Commercial |
$91.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.60
|
| Rate for Payer: Priority Health SBD |
$67.45
|
| Rate for Payer: UMR Bronson Commercial |
$47.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.30
|
|
|
PROGESTERONE MICRONIZED 8 % VAGINAL GEL
|
Facility
|
OP
|
$107.07
|
|
|
Service Code
|
NDC 00023615108
|
| Hospital Charge Code |
21321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.62 |
| Max. Negotiated Rate |
$96.36 |
| Rate for Payer: Aetna American Axle |
$69.60
|
| Rate for Payer: Aetna Commercial |
$91.01
|
| Rate for Payer: Aetna Medicare |
$53.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.60
|
| Rate for Payer: BCBS Complete |
$42.83
|
| Rate for Payer: Cash Price |
$85.66
|
| Rate for Payer: Cofinity Commercial |
$74.95
|
| Rate for Payer: Cofinity Commercial |
$92.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.66
|
| Rate for Payer: Healthscope Commercial |
$96.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.01
|
| Rate for Payer: PHP Commercial |
$91.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.60
|
| Rate for Payer: Priority Health SBD |
$67.45
|
| Rate for Payer: UMR Bronson Commercial |
$39.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.30
|
|
|
PROGESTERONE MICRONIZED 8 % VAGINAL GEL
|
Facility
|
OP
|
$107.07
|
|
|
Service Code
|
NDC 00023615109
|
| Hospital Charge Code |
21321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.62 |
| Max. Negotiated Rate |
$96.36 |
| Rate for Payer: Aetna American Axle |
$69.60
|
| Rate for Payer: Aetna Commercial |
$91.01
|
| Rate for Payer: Aetna Medicare |
$53.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.60
|
| Rate for Payer: BCBS Complete |
$42.83
|
| Rate for Payer: Cash Price |
$85.66
|
| Rate for Payer: Cofinity Commercial |
$74.95
|
| Rate for Payer: Cofinity Commercial |
$92.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.66
|
| Rate for Payer: Healthscope Commercial |
$96.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.01
|
| Rate for Payer: PHP Commercial |
$91.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.60
|
| Rate for Payer: Priority Health SBD |
$67.45
|
| Rate for Payer: UMR Bronson Commercial |
$39.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.30
|
|
|
PR OMALIZUMAB INJECTION
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J2357
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$64.22 |
| Rate for Payer: Aetna Commercial |
$59.76
|
| Rate for Payer: Aetna Medicare |
$46.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.76
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: BCBS MAPPO |
$44.60
|
| Rate for Payer: BCN Medicare Advantage |
$44.60
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cofinity Commercial |
$64.22
|
| Rate for Payer: Cofinity Commercial |
$59.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$46.83
|
| Rate for Payer: Nomi Health Commercial |
$53.52
|
| Rate for Payer: PACE SWMI |
$44.60
|
| Rate for Payer: PHP Commercial |
$62.44
|
| Rate for Payer: PHP Medicare Advantage |
$44.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
| Rate for Payer: Priority Health Medicare |
$44.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$44.60
|
| Rate for Payer: UHC Medicare Advantage |
$44.60
|
| Rate for Payer: UMR Bronson Commercial |
$14.26
|
|
|
PR OMENTAL FLAP INTRA-ABDOMINAL
|
Professional
|
Both
|
$642.00
|
|
|
Service Code
|
HCPCS 49905
|
| Min. Negotiated Rate |
$256.80 |
| Max. Negotiated Rate |
$490.18 |
| Rate for Payer: Aetna Commercial |
$456.14
|
| Rate for Payer: Aetna Medicare |
$354.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$490.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$456.14
|
| Rate for Payer: BCBS Complete |
$256.80
|
| Rate for Payer: BCBS MAPPO |
$340.40
|
| Rate for Payer: BCN Medicare Advantage |
$340.40
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cofinity Commercial |
$490.18
|
| Rate for Payer: Cofinity Commercial |
$456.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$340.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$357.42
|
| Rate for Payer: Nomi Health Commercial |
$408.48
|
| Rate for Payer: PACE SWMI |
$340.40
|
| Rate for Payer: PHP Commercial |
$476.56
|
| Rate for Payer: PHP Medicare Advantage |
$340.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$417.30
|
| Rate for Payer: Priority Health Medicare |
$340.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$340.40
|
| Rate for Payer: UHC Medicare Advantage |
$340.40
|
| Rate for Payer: UMR Bronson Commercial |
$295.32
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$15.26
|
|
|
Service Code
|
NDC 00713053606
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$13.73 |
| Rate for Payer: Aetna American Axle |
$9.92
|
| Rate for Payer: Aetna Commercial |
$12.97
|
| Rate for Payer: Aetna Medicare |
$7.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.92
|
| Rate for Payer: BCBS Complete |
$6.10
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Cofinity Commercial |
$10.68
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.21
|
| Rate for Payer: Healthscope Commercial |
$13.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.97
|
| Rate for Payer: PHP Commercial |
$12.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.92
|
| Rate for Payer: Priority Health SBD |
$9.61
|
| Rate for Payer: UMR Bronson Commercial |
$5.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.45
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$15.26
|
|
|
Service Code
|
NDC 00713053606
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$13.73 |
| Rate for Payer: Aetna American Axle |
$9.92
|
| Rate for Payer: Aetna Commercial |
$12.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.92
|
| Rate for Payer: Cash Price |
$12.21
|
| Rate for Payer: Cofinity Commercial |
$10.68
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.21
|
| Rate for Payer: Healthscope Commercial |
$13.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.97
|
| Rate for Payer: PHP Commercial |
$12.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.92
|
| Rate for Payer: Priority Health SBD |
$9.61
|
| Rate for Payer: UMR Bronson Commercial |
$6.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.45
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$183.02
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.72 |
| Max. Negotiated Rate |
$164.72 |
| Rate for Payer: Aetna American Axle |
$118.96
|
| Rate for Payer: Aetna Commercial |
$155.57
|
| Rate for Payer: Aetna Medicare |
$91.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.96
|
| Rate for Payer: BCBS Complete |
$73.21
|
| Rate for Payer: Cash Price |
$146.42
|
| Rate for Payer: Cofinity Commercial |
$128.11
|
| Rate for Payer: Cofinity Commercial |
$157.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.42
|
| Rate for Payer: Healthscope Commercial |
$164.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.57
|
| Rate for Payer: PHP Commercial |
$155.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.96
|
| Rate for Payer: Priority Health SBD |
$115.30
|
| Rate for Payer: UMR Bronson Commercial |
$67.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.26
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$183.02
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.53 |
| Max. Negotiated Rate |
$164.72 |
| Rate for Payer: Aetna American Axle |
$118.96
|
| Rate for Payer: Aetna Commercial |
$155.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.96
|
| Rate for Payer: Cash Price |
$146.42
|
| Rate for Payer: Cofinity Commercial |
$128.11
|
| Rate for Payer: Cofinity Commercial |
$157.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.42
|
| Rate for Payer: Healthscope Commercial |
$164.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.57
|
| Rate for Payer: PHP Commercial |
$155.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.96
|
| Rate for Payer: Priority Health SBD |
$115.30
|
| Rate for Payer: UMR Bronson Commercial |
$80.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.26
|
|
|
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 Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| 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: PHP Commercial |
$147.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.03
|
| 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 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 Commercial |
$106.92
|
| Rate for Payer: Cofinity Commercial |
$131.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$106.92
|
| 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: PHP Commercial |
$129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.29
|
| 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
|
$346.75
|
|
|
Service Code
|
NDC 68084015401
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.57 |
| Max. Negotiated Rate |
$312.07 |
| Rate for Payer: Aetna American Axle |
$225.39
|
| Rate for Payer: Aetna Commercial |
$294.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$225.39
|
| Rate for Payer: Cash Price |
$277.40
|
| Rate for Payer: Cofinity Commercial |
$242.72
|
| Rate for Payer: Cofinity Commercial |
$298.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$242.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$277.40
|
| Rate for Payer: Healthscope Commercial |
$312.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$242.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$260.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.39
|
| Rate for Payer: Priority Health SBD |
$218.45
|
| Rate for Payer: UMR Bronson Commercial |
$152.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$260.06
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$131.60
|
|
|
Service Code
|
NDC 10702000201
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna Medicare |
$65.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: BCBS Complete |
$52.64
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$48.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$3.98
|
|
|
Service Code
|
NDC 60687066011
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna American Axle |
$2.59
|
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.59
|
| Rate for Payer: BCBS Complete |
$1.59
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$3.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.18
|
| Rate for Payer: Healthscope Commercial |
$3.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.38
|
| Rate for Payer: PHP Commercial |
$3.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.59
|
| Rate for Payer: Priority Health SBD |
$2.51
|
| Rate for Payer: UMR Bronson Commercial |
$1.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.98
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 53746074501
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.18 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna American Axle |
$97.76
|
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$105.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| Rate for Payer: UMR Bronson Commercial |
$66.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.80
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$173.90
|
|
|
Service Code
|
NDC 65162074510
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.03
|
| Rate for Payer: Aetna Commercial |
$147.81
|
| Rate for Payer: Aetna Medicare |
$86.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.03
|
| Rate for Payer: BCBS Complete |
$69.56
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| 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: PHP Commercial |
$147.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.03
|
| Rate for Payer: Priority Health SBD |
$109.56
|
| Rate for Payer: UMR Bronson Commercial |
$64.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.43
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$346.75
|
|
|
Service Code
|
NDC 68084015411
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.30 |
| Max. Negotiated Rate |
$312.07 |
| Rate for Payer: Aetna American Axle |
$225.39
|
| Rate for Payer: Aetna Commercial |
$294.74
|
| Rate for Payer: Aetna Medicare |
$173.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$225.39
|
| Rate for Payer: BCBS Complete |
$138.70
|
| Rate for Payer: Cash Price |
$277.40
|
| Rate for Payer: Cofinity Commercial |
$242.72
|
| Rate for Payer: Cofinity Commercial |
$298.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$242.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$277.40
|
| Rate for Payer: Healthscope Commercial |
$312.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$242.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$260.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.39
|
| Rate for Payer: Priority Health SBD |
$218.45
|
| Rate for Payer: UMR Bronson Commercial |
$128.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$260.06
|
|
