|
CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER
|
Facility
|
OP
|
$11,768.05
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.42 |
| Max. Negotiated Rate |
$10,591.24 |
| Rate for Payer: Aetna American Axle |
$7,649.23
|
| Rate for Payer: Aetna Commercial |
$10,002.84
|
| Rate for Payer: Aetna Medicare |
$24.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,649.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.96
|
| Rate for Payer: BCBS Complete |
$13.04
|
| Rate for Payer: BCBS MAPPO |
$23.17
|
| Rate for Payer: BCBS Trust/PPO |
$62.48
|
| Rate for Payer: BCN Commercial |
$62.48
|
| Rate for Payer: BCN Medicare Advantage |
$23.17
|
| Rate for Payer: Cash Price |
$9,414.44
|
| Rate for Payer: Cash Price |
$9,414.44
|
| Rate for Payer: Cofinity Commercial |
$8,237.64
|
| Rate for Payer: Cofinity Commercial |
$10,120.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,237.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,414.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.17
|
| Rate for Payer: Healthscope Commercial |
$10,591.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,237.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,826.04
|
| Rate for Payer: Mclaren Medicaid |
$12.42
|
| Rate for Payer: Mclaren Medicare |
$23.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.33
|
| Rate for Payer: Meridian Medicaid |
$13.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,002.84
|
| Rate for Payer: Nomi Health Commercial |
$69.51
|
| Rate for Payer: PACE Medicare |
$22.01
|
| Rate for Payer: PACE SWMI |
$23.17
|
| Rate for Payer: PHP Commercial |
$10,002.84
|
| Rate for Payer: PHP Medicare Advantage |
$23.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,649.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$65.90
|
| Rate for Payer: Priority Health Medicare |
$23.17
|
| Rate for Payer: Priority Health Narrow Network |
$52.72
|
| Rate for Payer: Priority Health SBD |
$7,413.87
|
| Rate for Payer: Railroad Medicare Medicare |
$23.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.17
|
| Rate for Payer: UHC Exchange |
$44.28
|
| Rate for Payer: UHC Medicare Advantage |
$23.17
|
| Rate for Payer: UHCCP Medicaid |
$12.42
|
| Rate for Payer: UMR Bronson Commercial |
$4,354.18
|
| Rate for Payer: VA VA |
$23.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,826.04
|
|
|
CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER
|
Facility
|
IP
|
$11,768.05
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,177.94 |
| Max. Negotiated Rate |
$10,591.24 |
| Rate for Payer: Aetna American Axle |
$7,649.23
|
| Rate for Payer: Aetna Commercial |
$10,002.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,649.23
|
| Rate for Payer: Cash Price |
$9,414.44
|
| Rate for Payer: Cofinity Commercial |
$10,120.52
|
| Rate for Payer: Cofinity Commercial |
$8,237.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,237.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,414.44
|
| Rate for Payer: Healthscope Commercial |
$10,591.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,237.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,826.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,002.84
|
| Rate for Payer: PHP Commercial |
$10,002.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,649.23
|
| Rate for Payer: Priority Health SBD |
$7,413.87
|
| Rate for Payer: UMR Bronson Commercial |
$5,177.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,826.04
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML (200 MG/ML) IM SUSPENSION,EXTENDED RELEASE
|
Facility
|
OP
|
$10,465.58
|
|
|
Service Code
|
HCPCS J0739
|
| Hospital Charge Code |
198975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$9,419.02 |
| Rate for Payer: Aetna American Axle |
$6,802.63
|
| Rate for Payer: Aetna Commercial |
$8,895.74
|
| Rate for Payer: Aetna Medicare |
$7.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,802.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.61
|
| Rate for Payer: BCBS Complete |
$3.88
|
| Rate for Payer: BCBS MAPPO |
$6.89
|
| Rate for Payer: BCBS Trust/PPO |
$18.58
|
| Rate for Payer: BCN Commercial |
$18.58
|
| Rate for Payer: BCN Medicare Advantage |
$6.89
|
| Rate for Payer: Cash Price |
$8,372.46
|
| Rate for Payer: Cash Price |
$8,372.46
|
| Rate for Payer: Cofinity Commercial |
$9,000.40
|
| Rate for Payer: Cofinity Commercial |
$7,325.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,325.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,372.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.89
|
| Rate for Payer: Healthscope Commercial |
$9,419.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,325.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,849.18
|
| Rate for Payer: Mclaren Medicaid |
$3.69
|
| Rate for Payer: Mclaren Medicare |
$6.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.23
|
| Rate for Payer: Meridian Medicaid |
$3.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,895.74
|
| Rate for Payer: Nomi Health Commercial |
$20.67
|
| Rate for Payer: PACE Medicare |
$6.55
|
| Rate for Payer: PACE SWMI |
$6.89
|
| Rate for Payer: PHP Commercial |
$8,895.74
|
| Rate for Payer: PHP Medicare Advantage |
$6.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,802.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.61
|
| Rate for Payer: Priority Health Medicare |
$6.89
|
| Rate for Payer: Priority Health Narrow Network |
$15.69
|
| Rate for Payer: Priority Health SBD |
$6,593.32
|
| Rate for Payer: Railroad Medicare Medicare |
$6.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.89
|
| Rate for Payer: UHC Exchange |
$13.17
|
| Rate for Payer: UHC Medicare Advantage |
$6.89
|
| Rate for Payer: UHCCP Medicaid |
$3.69
|
| Rate for Payer: UMR Bronson Commercial |
$3,872.26
|
| Rate for Payer: VA VA |
$6.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,849.18
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML (200 MG/ML) IM SUSPENSION,EXTENDED RELEASE
|
Facility
|
IP
|
$10,465.58
|
|
|
Service Code
|
HCPCS J0739
|
| Hospital Charge Code |
198975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,604.86 |
| Max. Negotiated Rate |
$9,419.02 |
| Rate for Payer: Aetna American Axle |
$6,802.63
|
| Rate for Payer: Aetna Commercial |
$8,895.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,802.63
|
| Rate for Payer: Cash Price |
$8,372.46
|
| Rate for Payer: Cofinity Commercial |
$7,325.91
|
| Rate for Payer: Cofinity Commercial |
$9,000.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,325.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,372.46
|
| Rate for Payer: Healthscope Commercial |
$9,419.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,325.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,849.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,895.74
|
| Rate for Payer: PHP Commercial |
$8,895.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,802.63
|
| Rate for Payer: Priority Health SBD |
$6,593.32
|
| Rate for Payer: UMR Bronson Commercial |
$4,604.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,849.18
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER
|
Facility
|
OP
|
$17,652.08
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.42 |
| Max. Negotiated Rate |
$15,886.87 |
| Rate for Payer: Aetna American Axle |
$11,473.85
|
| Rate for Payer: Aetna Commercial |
$15,004.27
|
| Rate for Payer: Aetna Medicare |
$24.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,473.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.96
|
| Rate for Payer: BCBS Complete |
$13.04
|
| Rate for Payer: BCBS MAPPO |
$23.17
|
| Rate for Payer: BCBS Trust/PPO |
$62.48
|
| Rate for Payer: BCN Commercial |
$62.48
|
| Rate for Payer: BCN Medicare Advantage |
$23.17
|
| Rate for Payer: Cash Price |
$14,121.66
|
| Rate for Payer: Cash Price |
$14,121.66
|
| Rate for Payer: Cofinity Commercial |
$15,180.79
|
| Rate for Payer: Cofinity Commercial |
$12,356.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,356.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,121.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.17
|
| Rate for Payer: Healthscope Commercial |
$15,886.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,356.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,239.06
|
| Rate for Payer: Mclaren Medicaid |
$12.42
|
| Rate for Payer: Mclaren Medicare |
$23.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.33
|
| Rate for Payer: Meridian Medicaid |
$13.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,004.27
|
| Rate for Payer: Nomi Health Commercial |
$69.51
|
| Rate for Payer: PACE Medicare |
$22.01
|
| Rate for Payer: PACE SWMI |
$23.17
|
| Rate for Payer: PHP Commercial |
$15,004.27
|
| Rate for Payer: PHP Medicare Advantage |
$23.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,473.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$65.90
|
| Rate for Payer: Priority Health Medicare |
$23.17
|
| Rate for Payer: Priority Health Narrow Network |
$52.72
|
| Rate for Payer: Priority Health SBD |
$11,120.81
|
| Rate for Payer: Railroad Medicare Medicare |
$23.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.17
|
| Rate for Payer: UHC Exchange |
$44.28
|
| Rate for Payer: UHC Medicare Advantage |
$23.17
|
| Rate for Payer: UHCCP Medicaid |
$12.42
|
| Rate for Payer: UMR Bronson Commercial |
$6,531.27
|
| Rate for Payer: VA VA |
$23.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,239.06
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER
|
Facility
|
IP
|
$17,652.08
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,766.92 |
| Max. Negotiated Rate |
$15,886.87 |
| Rate for Payer: Aetna American Axle |
$11,473.85
|
| Rate for Payer: Aetna Commercial |
$15,004.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,473.85
|
| Rate for Payer: Cash Price |
$14,121.66
|
| Rate for Payer: Cofinity Commercial |
$12,356.46
|
| Rate for Payer: Cofinity Commercial |
$15,180.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,356.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,121.66
|
| Rate for Payer: Healthscope Commercial |
$15,886.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,356.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,239.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,004.27
|
| Rate for Payer: PHP Commercial |
$15,004.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,473.85
|
| Rate for Payer: Priority Health SBD |
$11,120.81
|
| Rate for Payer: UMR Bronson Commercial |
$7,766.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,239.06
|
|
|
CAFFEINE 200 MG TABLET
|
Facility
|
IP
|
$33.47
|
|
|
Service Code
|
NDC 09629596325
|
| Hospital Charge Code |
1259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$30.12 |
| Rate for Payer: Aetna American Axle |
$21.76
|
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.76
|
| Rate for Payer: Cash Price |
$26.78
|
| Rate for Payer: Cofinity Commercial |
$23.43
|
| Rate for Payer: Cofinity Commercial |
$28.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.78
|
| Rate for Payer: Healthscope Commercial |
$30.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.45
|
| Rate for Payer: PHP Commercial |
$28.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.76
|
| Rate for Payer: Priority Health SBD |
$21.09
|
| Rate for Payer: UMR Bronson Commercial |
$14.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.10
|
|
|
CAFFEINE 200 MG TABLET
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
NDC 09900000881
|
| Hospital Charge Code |
1259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna American Axle |
$1.06
|
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Aetna Medicare |
$0.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.06
|
| Rate for Payer: BCBS Complete |
$0.65
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cofinity Commercial |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.30
|
| Rate for Payer: Healthscope Commercial |
$1.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.39
|
| Rate for Payer: PHP Commercial |
$1.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.06
|
| Rate for Payer: Priority Health SBD |
$1.03
|
| Rate for Payer: UMR Bronson Commercial |
$0.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.22
|
|
|
CAFFEINE 200 MG TABLET
|
Facility
|
OP
|
$33.47
|
|
|
Service Code
|
NDC 09629596325
|
| Hospital Charge Code |
1259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$30.12 |
| Rate for Payer: Aetna American Axle |
$21.76
|
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna Medicare |
$16.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.76
|
| Rate for Payer: BCBS Complete |
$13.39
|
| Rate for Payer: Cash Price |
$26.78
|
| Rate for Payer: Cofinity Commercial |
$23.43
|
| Rate for Payer: Cofinity Commercial |
$28.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.78
|
| Rate for Payer: Healthscope Commercial |
$30.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.45
|
| Rate for Payer: PHP Commercial |
$28.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.76
|
| Rate for Payer: Priority Health SBD |
$21.09
|
| Rate for Payer: UMR Bronson Commercial |
$12.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.10
|
|
|
CAFFEINE 200 MG TABLET
|
Facility
|
IP
|
$1.63
|
|
|
Service Code
|
NDC 09900000881
|
| Hospital Charge Code |
1259
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna American Axle |
$1.06
|
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.06
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cofinity Commercial |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.30
|
| Rate for Payer: Healthscope Commercial |
$1.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.39
|
| Rate for Payer: PHP Commercial |
$1.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.06
|
| Rate for Payer: Priority Health SBD |
$1.03
|
| Rate for Payer: UMR Bronson Commercial |
$0.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.22
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) BOLUS/LOAD IV SOLUTION CUSTOM
|
Facility
|
IP
|
$44.78
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
163560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$40.30 |
| Rate for Payer: Aetna American Axle |
$29.11
|
| Rate for Payer: Aetna Commercial |
$38.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.11
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$31.35
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.11
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UMR Bronson Commercial |
$19.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) BOLUS/LOAD IV SOLUTION CUSTOM
|
Facility
|
OP
|
$44.78
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
163560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$40.30 |
| Rate for Payer: Aetna American Axle |
$29.11
|
| Rate for Payer: Aetna Commercial |
$38.06
|
| Rate for Payer: Aetna Medicare |
$22.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.11
|
| Rate for Payer: BCBS Complete |
$17.91
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$31.35
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.11
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UMR Bronson Commercial |
$16.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) BOLUS/LOAD ORAL SOLUTION CUSTOM
|
Facility
|
OP
|
$37.76
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
301512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna American Axle |
$24.54
|
| Rate for Payer: Aetna Commercial |
$32.10
|
| Rate for Payer: Aetna Medicare |
$18.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.54
|
| Rate for Payer: BCBS Complete |
$15.10
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cofinity Commercial |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.21
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.10
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.54
|
| Rate for Payer: Priority Health SBD |
$23.79
|
| Rate for Payer: UMR Bronson Commercial |
$13.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.32
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) BOLUS/LOAD ORAL SOLUTION CUSTOM
|
Facility
|
IP
|
$37.76
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
301512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna American Axle |
$24.54
|
| Rate for Payer: Aetna Commercial |
$32.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.54
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cofinity Commercial |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.21
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.10
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.54
|
| Rate for Payer: Priority Health SBD |
$23.79
|
| Rate for Payer: UMR Bronson Commercial |
$16.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.32
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$80.04
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.22 |
| Max. Negotiated Rate |
$72.04 |
| Rate for Payer: Aetna American Axle |
$52.03
|
| Rate for Payer: Aetna American Axle |
$29.11
|
| Rate for Payer: Aetna American Axle |
$38.26
|
| Rate for Payer: Aetna American Axle |
$56.82
|
| Rate for Payer: Aetna American Axle |
$47.50
|
| Rate for Payer: Aetna Commercial |
$68.03
|
| Rate for Payer: Aetna Commercial |
$50.03
|
| Rate for Payer: Aetna Commercial |
$38.06
|
| Rate for Payer: Aetna Commercial |
$74.30
|
| Rate for Payer: Aetna Commercial |
$62.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.26
|
| Rate for Payer: Cash Price |
$64.03
|
| Rate for Payer: Cash Price |
$69.93
|
| Rate for Payer: Cash Price |
$47.09
|
| Rate for Payer: Cash Price |
$58.46
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$31.35
|
| Rate for Payer: Cofinity Commercial |
$68.83
|
| Rate for Payer: Cofinity Commercial |
$56.03
|
| Rate for Payer: Cofinity Commercial |
$51.16
|
| Rate for Payer: Cofinity Commercial |
$41.20
|
| Rate for Payer: Cofinity Commercial |
$50.62
|
| Rate for Payer: Cofinity Commercial |
$62.85
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Cofinity Commercial |
$75.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.46
|
| Rate for Payer: Healthscope Commercial |
$52.97
|
| Rate for Payer: Healthscope Commercial |
$72.04
|
| Rate for Payer: Healthscope Commercial |
$65.77
|
| Rate for Payer: Healthscope Commercial |
$78.67
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$74.30
|
| Rate for Payer: PHP Commercial |
$62.12
|
| Rate for Payer: PHP Commercial |
$68.03
|
| Rate for Payer: PHP Commercial |
$50.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.11
|
| Rate for Payer: Priority Health SBD |
$55.07
|
| Rate for Payer: Priority Health SBD |
$46.04
|
| Rate for Payer: Priority Health SBD |
$37.08
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: Priority Health SBD |
$50.43
|
| Rate for Payer: UMR Bronson Commercial |
$19.70
|
| Rate for Payer: UMR Bronson Commercial |
$25.90
|
| Rate for Payer: UMR Bronson Commercial |
$35.22
|
| Rate for Payer: UMR Bronson Commercial |
$38.46
|
| Rate for Payer: UMR Bronson Commercial |
$32.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.03
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$58.86
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$52.97 |
| Rate for Payer: Aetna American Axle |
$38.26
|
| Rate for Payer: Aetna American Axle |
$52.03
|
| Rate for Payer: Aetna American Axle |
$47.50
|
| Rate for Payer: Aetna American Axle |
$29.11
|
| Rate for Payer: Aetna American Axle |
$56.82
|
| Rate for Payer: Aetna Commercial |
$50.03
|
| Rate for Payer: Aetna Commercial |
$38.06
|
| Rate for Payer: Aetna Commercial |
$74.30
|
| Rate for Payer: Aetna Commercial |
$62.12
|
| Rate for Payer: Aetna Commercial |
$68.03
|
| Rate for Payer: Aetna Medicare |
$36.54
|
| Rate for Payer: Aetna Medicare |
$40.02
|
| Rate for Payer: Aetna Medicare |
$29.43
|
| Rate for Payer: Aetna Medicare |
$22.39
|
| Rate for Payer: Aetna Medicare |
$43.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.50
|
| Rate for Payer: BCBS Complete |
$23.54
|
| Rate for Payer: BCBS Complete |
$17.91
|
| Rate for Payer: BCBS Complete |
$32.02
|
| Rate for Payer: BCBS Complete |
$34.96
|
| Rate for Payer: BCBS Complete |
$29.23
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: Cash Price |
$47.09
|
| Rate for Payer: Cash Price |
$58.46
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cash Price |
$47.09
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cash Price |
$58.46
|
| Rate for Payer: Cash Price |
$69.93
|
| Rate for Payer: Cash Price |
$69.93
|
| Rate for Payer: Cash Price |
$64.03
|
| Rate for Payer: Cash Price |
$64.03
|
| Rate for Payer: Cofinity Commercial |
$41.20
|
| Rate for Payer: Cofinity Commercial |
$75.17
|
| Rate for Payer: Cofinity Commercial |
$31.35
|
| Rate for Payer: Cofinity Commercial |
$62.85
|
| Rate for Payer: Cofinity Commercial |
$51.16
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$68.83
|
| Rate for Payer: Cofinity Commercial |
$56.03
|
| Rate for Payer: Cofinity Commercial |
$50.62
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.03
|
| Rate for Payer: Healthscope Commercial |
$72.04
|
| Rate for Payer: Healthscope Commercial |
$40.30
|
| Rate for Payer: Healthscope Commercial |
$52.97
|
| Rate for Payer: Healthscope Commercial |
$65.77
|
| Rate for Payer: Healthscope Commercial |
$78.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$74.30
|
| Rate for Payer: PHP Commercial |
$68.03
|
| Rate for Payer: PHP Commercial |
$50.03
|
| Rate for Payer: PHP Commercial |
$38.06
|
| Rate for Payer: PHP Commercial |
$62.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.26
|
| Rate for Payer: Priority Health SBD |
$37.08
|
| Rate for Payer: Priority Health SBD |
$55.07
|
| Rate for Payer: Priority Health SBD |
$50.43
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: Priority Health SBD |
$46.04
|
| Rate for Payer: UMR Bronson Commercial |
$16.57
|
| Rate for Payer: UMR Bronson Commercial |
$27.04
|
| Rate for Payer: UMR Bronson Commercial |
$21.78
|
| Rate for Payer: UMR Bronson Commercial |
$29.61
|
| Rate for Payer: UMR Bronson Commercial |
$32.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE ORAL SOLUTION
|
Facility
|
OP
|
$37.76
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna American Axle |
$24.54
|
| Rate for Payer: Aetna Commercial |
$32.10
|
| Rate for Payer: Aetna Medicare |
$18.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.54
|
| Rate for Payer: BCBS Complete |
$15.10
|
| Rate for Payer: BCBS Trust/PPO |
$4.37
|
| Rate for Payer: BCN Commercial |
$4.37
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cofinity Commercial |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.21
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.10
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.54
|
| Rate for Payer: Priority Health SBD |
$23.79
|
| Rate for Payer: UMR Bronson Commercial |
$13.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.32
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE ORAL SOLUTION
|
Facility
|
IP
|
$37.76
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
77411
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna American Axle |
$24.54
|
| Rate for Payer: Aetna Commercial |
$32.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.54
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cofinity Commercial |
$26.43
|
| Rate for Payer: Cofinity Commercial |
$32.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.21
|
| Rate for Payer: Healthscope Commercial |
$33.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.10
|
| Rate for Payer: PHP Commercial |
$32.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.54
|
| Rate for Payer: Priority Health SBD |
$23.79
|
| Rate for Payer: UMR Bronson Commercial |
$16.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.32
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
OP
|
$124.20
|
|
|
Service Code
|
NDC 00517250210
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.95 |
| Max. Negotiated Rate |
$111.78 |
| Rate for Payer: Aetna American Axle |
$80.73
|
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.73
|
| Rate for Payer: BCBS Complete |
$49.68
|
| Rate for Payer: Cash Price |
$99.36
|
| Rate for Payer: Cofinity Commercial |
$106.81
|
| Rate for Payer: Cofinity Commercial |
$86.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$111.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.57
|
| Rate for Payer: PHP Commercial |
$105.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.73
|
| Rate for Payer: Priority Health SBD |
$78.25
|
| Rate for Payer: UMR Bronson Commercial |
$45.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.15
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
OP
|
$124.20
|
|
|
Service Code
|
NDC 00517250201
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.95 |
| Max. Negotiated Rate |
$111.78 |
| Rate for Payer: Aetna American Axle |
$80.73
|
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Aetna Medicare |
$62.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.73
|
| Rate for Payer: BCBS Complete |
$49.68
|
| Rate for Payer: Cash Price |
$99.36
|
| Rate for Payer: Cofinity Commercial |
$106.81
|
| Rate for Payer: Cofinity Commercial |
$86.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$111.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.57
|
| Rate for Payer: PHP Commercial |
$105.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.73
|
| Rate for Payer: Priority Health SBD |
$78.25
|
| Rate for Payer: UMR Bronson Commercial |
$45.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.15
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
IP
|
$124.20
|
|
|
Service Code
|
NDC 00517250210
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.65 |
| Max. Negotiated Rate |
$111.78 |
| Rate for Payer: Aetna American Axle |
$80.73
|
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.73
|
| Rate for Payer: Cash Price |
$99.36
|
| Rate for Payer: Cofinity Commercial |
$106.81
|
| Rate for Payer: Cofinity Commercial |
$86.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$111.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.57
|
| Rate for Payer: PHP Commercial |
$105.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.73
|
| Rate for Payer: Priority Health SBD |
$78.25
|
| Rate for Payer: UMR Bronson Commercial |
$54.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.15
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN
|
Facility
|
IP
|
$124.20
|
|
|
Service Code
|
NDC 00517250201
|
| Hospital Charge Code |
1262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.65 |
| Max. Negotiated Rate |
$111.78 |
| Rate for Payer: Aetna American Axle |
$80.73
|
| Rate for Payer: Aetna Commercial |
$105.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.73
|
| Rate for Payer: Cash Price |
$99.36
|
| Rate for Payer: Cofinity Commercial |
$106.81
|
| Rate for Payer: Cofinity Commercial |
$86.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$111.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.57
|
| Rate for Payer: PHP Commercial |
$105.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.73
|
| Rate for Payer: Priority Health SBD |
$78.25
|
| Rate for Payer: UMR Bronson Commercial |
$54.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.15
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
|
OP
|
$8.50
|
|
|
Service Code
|
NDC 00904253321
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna American Axle |
$5.52
|
| Rate for Payer: Aetna Commercial |
$7.22
|
| Rate for Payer: Aetna Medicare |
$4.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.52
|
| Rate for Payer: BCBS Complete |
$3.40
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cofinity Commercial |
$5.95
|
| Rate for Payer: Cofinity Commercial |
$7.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.80
|
| Rate for Payer: Healthscope Commercial |
$7.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.22
|
| Rate for Payer: PHP Commercial |
$7.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.52
|
| Rate for Payer: Priority Health SBD |
$5.36
|
| Rate for Payer: UMR Bronson Commercial |
$3.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.38
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
|
OP
|
$14.34
|
|
|
Service Code
|
NDC 00395041396
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$12.91 |
| Rate for Payer: BCBS Complete |
$5.74
|
| Rate for Payer: Aetna American Axle |
$9.32
|
| Rate for Payer: Aetna Commercial |
$12.19
|
| Rate for Payer: Aetna Medicare |
$7.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.32
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cofinity Commercial |
$10.04
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.47
|
| Rate for Payer: Healthscope Commercial |
$12.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.19
|
| Rate for Payer: PHP Commercial |
$12.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.32
|
| Rate for Payer: Priority Health SBD |
$9.03
|
| Rate for Payer: UMR Bronson Commercial |
$5.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.76
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION
|
Facility
|
IP
|
$8.50
|
|
|
Service Code
|
NDC 00904253321
|
| Hospital Charge Code |
78879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna American Axle |
$5.52
|
| Rate for Payer: Aetna Commercial |
$7.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.52
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cofinity Commercial |
$5.95
|
| Rate for Payer: Cofinity Commercial |
$7.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.80
|
| Rate for Payer: Healthscope Commercial |
$7.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.22
|
| Rate for Payer: PHP Commercial |
$7.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.52
|
| Rate for Payer: Priority Health SBD |
$5.36
|
| Rate for Payer: UMR Bronson Commercial |
$3.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.38
|
|
