|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$238.55
|
|
|
Service Code
|
NDC 51991-748-90
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.96 |
| Max. Negotiated Rate |
$214.70 |
| Rate for Payer: Aetna American Axle |
$155.06
|
| Rate for Payer: Aetna Commercial |
$202.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.06
|
| Rate for Payer: Cash Price |
$190.84
|
| Rate for Payer: Cofinity Commercial |
$166.98
|
| Rate for Payer: Cofinity Commercial |
$205.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.84
|
| Rate for Payer: Healthscope Commercial |
$214.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.77
|
| Rate for Payer: PHP Commercial |
$202.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.98
|
| Rate for Payer: Priority Health SBD |
$150.29
|
| Rate for Payer: UMR Bronson Commercial |
$104.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.91
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$78.96
|
|
|
Service Code
|
NDC 57237-019-30
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$71.06 |
| Rate for Payer: Aetna American Axle |
$51.32
|
| Rate for Payer: Aetna Commercial |
$67.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.32
|
| Rate for Payer: Cash Price |
$63.17
|
| Rate for Payer: Cofinity Commercial |
$67.91
|
| Rate for Payer: Cofinity Commercial |
$55.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.17
|
| Rate for Payer: Healthscope Commercial |
$71.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.12
|
| Rate for Payer: PHP Commercial |
$67.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.27
|
| Rate for Payer: Priority Health SBD |
$49.74
|
| Rate for Payer: UMR Bronson Commercial |
$34.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.22
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$965.26
|
|
|
Service Code
|
NDC 0002-3270-30
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$424.71 |
| Max. Negotiated Rate |
$868.73 |
| Rate for Payer: Aetna American Axle |
$627.42
|
| Rate for Payer: Aetna Commercial |
$820.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$627.42
|
| Rate for Payer: Cash Price |
$772.21
|
| Rate for Payer: Cofinity Commercial |
$675.68
|
| Rate for Payer: Cofinity Commercial |
$830.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$772.21
|
| Rate for Payer: Healthscope Commercial |
$868.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$675.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$723.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$820.47
|
| Rate for Payer: PHP Commercial |
$820.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$675.68
|
| Rate for Payer: Priority Health SBD |
$608.11
|
| Rate for Payer: UMR Bronson Commercial |
$424.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$723.94
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$85.50
|
|
|
Service Code
|
NDC 27241-099-03
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.62 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna American Axle |
$55.58
|
| Rate for Payer: Aetna Commercial |
$72.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.58
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cofinity Commercial |
$59.85
|
| Rate for Payer: Cofinity Commercial |
$73.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.40
|
| Rate for Payer: Healthscope Commercial |
$76.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$72.68
|
| Rate for Payer: PHP Commercial |
$72.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.85
|
| Rate for Payer: Priority Health SBD |
$53.86
|
| Rate for Payer: UMR Bronson Commercial |
$37.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.12
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$714.24
|
|
|
Service Code
|
NDC 68084-692-01
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$314.27 |
| Max. Negotiated Rate |
$642.82 |
| Rate for Payer: Aetna American Axle |
$464.26
|
| Rate for Payer: Aetna Commercial |
$607.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.26
|
| Rate for Payer: Cash Price |
$571.39
|
| Rate for Payer: Cofinity Commercial |
$499.97
|
| Rate for Payer: Cofinity Commercial |
$614.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$571.39
|
| Rate for Payer: Healthscope Commercial |
$642.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$499.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$535.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$607.10
|
| Rate for Payer: PHP Commercial |
$607.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$499.97
|
| Rate for Payer: Priority Health SBD |
$449.97
|
| Rate for Payer: UMR Bronson Commercial |
$314.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$535.68
|
|
|
DUODERM CGF DRESSING 4X4
|
Facility
|
IP
|
$7.74
|
|
|
Service Code
|
NDC 6845510697
|
| Hospital Charge Code |
150727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Aetna American Axle |
$5.03
|
| Rate for Payer: Aetna Commercial |
$6.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.03
|
| Rate for Payer: Cash Price |
$6.19
|
| Rate for Payer: Cofinity Commercial |
$5.42
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.19
|
| Rate for Payer: Healthscope Commercial |
$6.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.58
|
| Rate for Payer: PHP Commercial |
$6.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.42
|
| Rate for Payer: Priority Health SBD |
$4.88
|
| Rate for Payer: UMR Bronson Commercial |
$3.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.80
|
|
|
DUODERM CGF DRESSING EXTRA THIN 4X4
|
Facility
|
IP
|
$6.95
|
|
|
Service Code
|
NDC 6845510691
|
| Hospital Charge Code |
150728
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: Aetna American Axle |
$4.52
|
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.52
|
| Rate for Payer: Cash Price |
$5.56
|
| Rate for Payer: Cofinity Commercial |
$4.86
|
| Rate for Payer: Cofinity Commercial |
$5.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.56
|
| Rate for Payer: Healthscope Commercial |
$6.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.91
|
| Rate for Payer: PHP Commercial |
$5.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.86
|
| Rate for Payer: Priority Health SBD |
$4.38
|
| Rate for Payer: UMR Bronson Commercial |
$3.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.21
|
|
|
DUPILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5918-01
|
| Hospital Charge Code |
188703
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,093.89 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: BCBS Complete |
$2,263.67
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,093.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5918-01
|
| Hospital Charge Code |
188703
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,490.03 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,490.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5918-00
|
| Hospital Charge Code |
188703
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,490.03 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,490.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5918-00
|
| Hospital Charge Code |
188703
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,093.89 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: BCBS Complete |
$2,263.67
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,093.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 300 MG/2 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5914-00
|
| Hospital Charge Code |
182455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,490.03 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,490.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 300 MG/2 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5914-01
|
| Hospital Charge Code |
182455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,093.89 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: BCBS Complete |
$2,263.67
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,093.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 300 MG/2 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5914-01
|
| Hospital Charge Code |
182455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,490.03 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,490.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DUPILUMAB 300 MG/2 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,659.17
|
|
|
Service Code
|
NDC 0024-5914-00
|
| Hospital Charge Code |
182455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,093.89 |
| Max. Negotiated Rate |
$5,093.25 |
| Rate for Payer: Aetna American Axle |
$3,678.46
|
| Rate for Payer: Aetna Commercial |
$4,810.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,678.46
|
| Rate for Payer: BCBS Complete |
$2,263.67
|
| Rate for Payer: Cash Price |
$4,527.34
|
| Rate for Payer: Cofinity Commercial |
$4,866.89
|
| Rate for Payer: Cofinity Commercial |
$3,961.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,527.34
|
| Rate for Payer: Healthscope Commercial |
$5,093.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,961.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,244.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,810.29
|
| Rate for Payer: PHP Commercial |
$4,810.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,961.42
|
| Rate for Payer: Priority Health SBD |
$3,565.28
|
| Rate for Payer: UMR Bronson Commercial |
$2,093.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,244.38
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18,082.22
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
183305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,956.18 |
| Max. Negotiated Rate |
$16,274.00 |
| Rate for Payer: Aetna American Axle |
$11,753.44
|
| Rate for Payer: Aetna American Axle |
$2,820.82
|
| Rate for Payer: Aetna Commercial |
$3,688.77
|
| Rate for Payer: Aetna Commercial |
$15,369.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,753.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,820.82
|
| Rate for Payer: Cash Price |
$14,465.78
|
| Rate for Payer: Cash Price |
$3,471.78
|
| Rate for Payer: Cofinity Commercial |
$12,657.55
|
| Rate for Payer: Cofinity Commercial |
$15,550.71
|
| Rate for Payer: Cofinity Commercial |
$3,037.81
|
| Rate for Payer: Cofinity Commercial |
$3,732.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,471.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,465.78
|
| Rate for Payer: Healthscope Commercial |
$16,274.00
|
| Rate for Payer: Healthscope Commercial |
$3,905.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,037.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,657.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,561.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,254.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,688.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15,369.89
|
| Rate for Payer: PHP Commercial |
$3,688.77
|
| Rate for Payer: PHP Commercial |
$15,369.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,657.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,037.81
|
| Rate for Payer: Priority Health SBD |
$2,734.03
|
| Rate for Payer: Priority Health SBD |
$11,391.80
|
| Rate for Payer: UMR Bronson Commercial |
$7,956.18
|
| Rate for Payer: UMR Bronson Commercial |
$1,909.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,254.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,561.66
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$4,339.73
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
183305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.15 |
| Max. Negotiated Rate |
$3,905.76 |
| Rate for Payer: Aetna American Axle |
$2,820.82
|
| Rate for Payer: Aetna American Axle |
$11,753.44
|
| Rate for Payer: Aetna Commercial |
$3,688.77
|
| Rate for Payer: Aetna Commercial |
$15,369.89
|
| Rate for Payer: Aetna Medicare |
$83.93
|
| Rate for Payer: Aetna Medicare |
$83.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,753.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,820.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$100.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$100.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$100.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$100.88
|
| Rate for Payer: BCBS Complete |
$46.36
|
| Rate for Payer: BCBS Complete |
$46.36
|
| Rate for Payer: BCBS MAPPO |
$80.71
|
| Rate for Payer: BCBS MAPPO |
$80.71
|
| Rate for Payer: BCBS Trust/PPO |
$260.78
|
| Rate for Payer: BCBS Trust/PPO |
$260.78
|
| Rate for Payer: BCN Medicare Advantage |
$80.71
|
| Rate for Payer: BCN Medicare Advantage |
$80.71
|
| Rate for Payer: Cash Price |
$14,465.78
|
| Rate for Payer: Cash Price |
$3,471.78
|
| Rate for Payer: Cash Price |
$3,471.78
|
| Rate for Payer: Cash Price |
$14,465.78
|
| Rate for Payer: Cofinity Commercial |
$15,550.71
|
| Rate for Payer: Cofinity Commercial |
$3,037.81
|
| Rate for Payer: Cofinity Commercial |
$3,732.17
|
| Rate for Payer: Cofinity Commercial |
$12,657.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,471.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,465.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.71
|
| Rate for Payer: Healthscope Commercial |
$16,274.00
|
| Rate for Payer: Healthscope Commercial |
$3,905.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,657.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,037.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,561.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,254.80
|
| Rate for Payer: Mclaren Medicaid |
$44.15
|
| Rate for Payer: Mclaren Medicaid |
$44.15
|
| Rate for Payer: Mclaren Medicare |
$80.71
|
| Rate for Payer: Mclaren Medicare |
$80.71
|
| Rate for Payer: Meridian Medicaid |
$46.36
|
| Rate for Payer: Meridian Medicaid |
$46.36
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$84.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$84.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$92.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$92.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15,369.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,688.77
|
| Rate for Payer: PACE Medicare |
$76.67
|
| Rate for Payer: PACE Medicare |
$76.67
|
| Rate for Payer: PACE SWMI |
$80.71
|
| Rate for Payer: PACE SWMI |
$80.71
|
| Rate for Payer: PHP Commercial |
$3,688.77
|
| Rate for Payer: PHP Commercial |
$15,369.89
|
| Rate for Payer: PHP Medicare Advantage |
$80.71
|
| Rate for Payer: PHP Medicare Advantage |
$80.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$44.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$44.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,657.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,037.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$234.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$234.20
|
| Rate for Payer: Priority Health Medicare |
$80.71
|
| Rate for Payer: Priority Health Medicare |
$80.71
|
| Rate for Payer: Priority Health Narrow Network |
$187.36
|
| Rate for Payer: Priority Health Narrow Network |
$187.36
|
| Rate for Payer: Priority Health SBD |
$2,734.03
|
| Rate for Payer: Priority Health SBD |
$11,391.80
|
| Rate for Payer: Railroad Medicare Medicare |
$80.71
|
| Rate for Payer: Railroad Medicare Medicare |
$80.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.71
|
| Rate for Payer: UHC Medicare Advantage |
$83.13
|
| Rate for Payer: UHC Medicare Advantage |
$83.13
|
| Rate for Payer: UMR Bronson Commercial |
$6,690.42
|
| Rate for Payer: UMR Bronson Commercial |
$1,605.70
|
| Rate for Payer: VA VA |
$80.71
|
| Rate for Payer: VA VA |
$80.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,561.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,254.80
|
|
|
DUTASTERIDE 0.5 MG CAPSULE
|
Facility
|
IP
|
$2,582.75
|
|
|
Service Code
|
NDC 0173-0712-04
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,136.41 |
| Max. Negotiated Rate |
$2,324.48 |
| Rate for Payer: Aetna American Axle |
$1,678.79
|
| Rate for Payer: Aetna Commercial |
$2,195.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,678.79
|
| Rate for Payer: Cash Price |
$2,066.20
|
| Rate for Payer: Cofinity Commercial |
$1,807.92
|
| Rate for Payer: Cofinity Commercial |
$2,221.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,066.20
|
| Rate for Payer: Healthscope Commercial |
$2,324.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,807.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,937.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,195.34
|
| Rate for Payer: PHP Commercial |
$2,195.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,807.92
|
| Rate for Payer: Priority Health SBD |
$1,627.13
|
| Rate for Payer: UMR Bronson Commercial |
$1,136.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,937.06
|
|
|
DUTASTERIDE 0.5 MG CAPSULE
|
Facility
|
IP
|
$860.92
|
|
|
Service Code
|
NDC 0173-0712-15
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$378.80 |
| Max. Negotiated Rate |
$774.83 |
| Rate for Payer: Aetna American Axle |
$559.60
|
| Rate for Payer: Aetna Commercial |
$731.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$559.60
|
| Rate for Payer: Cash Price |
$688.74
|
| Rate for Payer: Cofinity Commercial |
$602.64
|
| Rate for Payer: Cofinity Commercial |
$740.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$688.74
|
| Rate for Payer: Healthscope Commercial |
$774.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$602.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$645.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$731.78
|
| Rate for Payer: PHP Commercial |
$731.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$602.64
|
| Rate for Payer: Priority Health SBD |
$542.38
|
| Rate for Payer: UMR Bronson Commercial |
$378.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$645.69
|
|
|
DUTASTERIDE 0.5 MG CAPSULE
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 31722-131-30
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.22 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna American Axle |
$54.99
|
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
| Rate for Payer: Priority Health SBD |
$53.30
|
| Rate for Payer: UMR Bronson Commercial |
$37.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
|
DUTASTERIDE 0.5 MG CAPSULE
|
Facility
|
IP
|
$132.24
|
|
|
Service Code
|
NDC 65162-750-03
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.19 |
| Max. Negotiated Rate |
$119.02 |
| Rate for Payer: Aetna American Axle |
$85.96
|
| Rate for Payer: Aetna Commercial |
$112.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.96
|
| Rate for Payer: Cash Price |
$105.79
|
| Rate for Payer: Cofinity Commercial |
$113.73
|
| Rate for Payer: Cofinity Commercial |
$92.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.79
|
| Rate for Payer: Healthscope Commercial |
$119.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.40
|
| Rate for Payer: PHP Commercial |
$112.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.57
|
| Rate for Payer: Priority Health SBD |
$83.31
|
| Rate for Payer: UMR Bronson Commercial |
$58.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.18
|
|
|
DUTASTERIDE 0.5 MG CAPSULE
|
Facility
|
IP
|
$176.99
|
|
|
Service Code
|
NDC 31722-131-90
|
| Hospital Charge Code |
34089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$159.29 |
| Rate for Payer: Aetna American Axle |
$115.04
|
| Rate for Payer: Aetna Commercial |
$150.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.04
|
| Rate for Payer: Cash Price |
$141.59
|
| Rate for Payer: Cofinity Commercial |
$123.89
|
| Rate for Payer: Cofinity Commercial |
$152.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.59
|
| Rate for Payer: Healthscope Commercial |
$159.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$150.44
|
| Rate for Payer: PHP Commercial |
$150.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.89
|
| Rate for Payer: Priority Health SBD |
$111.50
|
| Rate for Payer: UMR Bronson Commercial |
$77.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.74
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$16,255.95
|
|
|
Service Code
|
MS-DRG 149
|
| Min. Negotiated Rate |
$5,938.49 |
| Max. Negotiated Rate |
$16,255.95 |
| Rate for Payer: Aetna Medicare |
$6,501.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,813.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,813.80
|
| Rate for Payer: BCBS MAPPO |
$6,251.04
|
| Rate for Payer: BCBS Trust/PPO |
$16,255.95
|
| Rate for Payer: BCN Medicare Advantage |
$6,251.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,251.04
|
| Rate for Payer: Mclaren Medicare |
$6,251.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,563.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,188.70
|
| Rate for Payer: PACE Medicare |
$5,938.49
|
| Rate for Payer: PACE SWMI |
$6,251.04
|
| Rate for Payer: PHP Medicare Advantage |
$6,251.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,686.39
|
| Rate for Payer: Priority Health Medicare |
$6,251.04
|
| Rate for Payer: Priority Health Narrow Network |
$8,549.11
|
| Rate for Payer: Railroad Medicare Medicare |
$6,251.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,359.65
|
| Rate for Payer: UHC Core |
$9,314.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,251.04
|
| Rate for Payer: UHC Exchange |
$7,405.30
|
| Rate for Payer: UHC Medicare Advantage |
$6,438.57
|
| Rate for Payer: VA VA |
$6,251.04
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC
|
Facility
|
IP
|
$24,646.52
|
|
|
Service Code
|
MS-DRG 147
|
| Min. Negotiated Rate |
$9,533.69 |
| Max. Negotiated Rate |
$24,646.52 |
| Rate for Payer: Aetna Medicare |
$10,436.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,544.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,544.32
|
| Rate for Payer: BCBS MAPPO |
$10,035.46
|
| Rate for Payer: BCBS Trust/PPO |
$24,646.52
|
| Rate for Payer: BCN Medicare Advantage |
$10,035.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,035.46
|
| Rate for Payer: Mclaren Medicare |
$10,035.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,537.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,540.78
|
| Rate for Payer: PACE Medicare |
$9,533.69
|
| Rate for Payer: PACE SWMI |
$10,035.46
|
| Rate for Payer: PHP Medicare Advantage |
$10,035.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,733.63
|
| Rate for Payer: Priority Health Medicare |
$10,035.46
|
| Rate for Payer: Priority Health Narrow Network |
$14,186.90
|
| Rate for Payer: Railroad Medicare Medicare |
$10,035.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18,850.89
|
| Rate for Payer: UHC Core |
$15,457.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,035.46
|
| Rate for Payer: UHC Exchange |
$12,288.80
|
| Rate for Payer: UHC Medicare Advantage |
$10,336.52
|
| Rate for Payer: VA VA |
$10,035.46
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$32,916.48
|
|
|
Service Code
|
MS-DRG 146
|
| Min. Negotiated Rate |
$15,940.80 |
| Max. Negotiated Rate |
$32,916.48 |
| Rate for Payer: Aetna Medicare |
$17,450.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,974.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,974.74
|
| Rate for Payer: BCBS MAPPO |
$16,779.79
|
| Rate for Payer: BCBS Trust/PPO |
$32,916.48
|
| Rate for Payer: BCN Medicare Advantage |
$16,779.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,779.79
|
| Rate for Payer: Mclaren Medicare |
$16,779.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,618.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,296.76
|
| Rate for Payer: PACE Medicare |
$15,940.80
|
| Rate for Payer: PACE SWMI |
$16,779.79
|
| Rate for Payer: PHP Medicare Advantage |
$16,779.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30,292.68
|
| Rate for Payer: Priority Health Medicare |
$16,779.79
|
| Rate for Payer: Priority Health Narrow Network |
$24,234.14
|
| Rate for Payer: Railroad Medicare Medicare |
$16,779.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32,201.19
|
| Rate for Payer: UHC Core |
$26,404.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,779.79
|
| Rate for Payer: UHC Exchange |
$20,991.78
|
| Rate for Payer: UHC Medicare Advantage |
$17,283.18
|
| Rate for Payer: VA VA |
$16,779.79
|
|
