|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.58 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna American Axle |
$250.51
|
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Advantage |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health SBD |
$242.80
|
| Rate for Payer: UMR Bronson Commercial |
$169.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$176.25
|
|
|
Service Code
|
NDC 43547025310
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.21 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna American Axle |
$114.56
|
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna Medicare |
$88.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: BCBS Complete |
$70.50
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Advantage |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$151.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$158.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$141.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$132.19
|
| Rate for Payer: PHP Commercial |
$149.81
|
| Rate for Payer: Priority Health SBD |
$111.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$114.56
|
| Rate for Payer: UHC Core |
$91.83
|
| Rate for Payer: UHC Exchange |
$69.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.19
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$1,880.00
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$827.20 |
| Max. Negotiated Rate |
$1,692.00 |
| Rate for Payer: Aetna American Axle |
$1,222.00
|
| Rate for Payer: Aetna Commercial |
$1,598.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,222.00
|
| Rate for Payer: Cash Price |
$1,504.00
|
| Rate for Payer: Cofinity Advantage |
$1,316.00
|
| Rate for Payer: Cofinity Commercial |
$1,616.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,504.00
|
| Rate for Payer: Healthscope Commercial |
$1,692.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,316.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,410.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,598.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,410.00
|
| Rate for Payer: PHP Commercial |
$1,598.00
|
| Rate for Payer: Priority Health SBD |
$1,184.40
|
| Rate for Payer: UMR Bronson Commercial |
$827.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,410.00
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$1,880.00
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$695.60 |
| Max. Negotiated Rate |
$1,692.00 |
| Rate for Payer: Aetna American Axle |
$1,222.00
|
| Rate for Payer: Aetna Commercial |
$1,598.00
|
| Rate for Payer: Aetna Medicare |
$940.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,222.00
|
| Rate for Payer: BCBS Complete |
$752.00
|
| Rate for Payer: Cash Price |
$1,504.00
|
| Rate for Payer: Cofinity Advantage |
$1,316.00
|
| Rate for Payer: Cofinity Commercial |
$1,616.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,504.00
|
| Rate for Payer: Healthscope Commercial |
$1,692.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,316.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,410.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,504.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,598.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,410.00
|
| Rate for Payer: PHP Commercial |
$1,598.00
|
| Rate for Payer: Priority Health SBD |
$1,184.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,222.00
|
| Rate for Payer: UHC Core |
$979.48
|
| Rate for Payer: UHC Exchange |
$738.84
|
| Rate for Payer: UMR Bronson Commercial |
$695.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,410.00
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$385.40
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.60 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna American Axle |
$250.51
|
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna Medicare |
$192.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: BCBS Complete |
$154.16
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Advantage |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health SBD |
$242.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.51
|
| Rate for Payer: UHC Core |
$200.79
|
| Rate for Payer: UHC Exchange |
$151.46
|
| Rate for Payer: UMR Bronson Commercial |
$142.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
IP
|
$465.30
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.73 |
| Max. Negotiated Rate |
$418.77 |
| Rate for Payer: Aetna American Axle |
$302.44
|
| Rate for Payer: Aetna Commercial |
$395.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.44
|
| Rate for Payer: Cash Price |
$372.24
|
| Rate for Payer: Cofinity Advantage |
$325.71
|
| Rate for Payer: Cofinity Commercial |
$400.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.24
|
| Rate for Payer: Healthscope Commercial |
$418.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$325.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$348.98
|
| Rate for Payer: PHP Commercial |
$395.50
|
| Rate for Payer: Priority Health SBD |
$293.14
|
| Rate for Payer: UMR Bronson Commercial |
$204.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.98
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
OP
|
$465.30
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.16 |
| Max. Negotiated Rate |
$418.77 |
| Rate for Payer: Aetna American Axle |
$302.44
|
| Rate for Payer: Aetna Commercial |
$395.50
|
| Rate for Payer: Aetna Medicare |
$232.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.44
|
| Rate for Payer: BCBS Complete |
$186.12
|
| Rate for Payer: Cash Price |
$372.24
|
| Rate for Payer: Cofinity Advantage |
$325.71
|
| Rate for Payer: Cofinity Commercial |
$400.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.24
|
| Rate for Payer: Healthscope Commercial |
$418.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$325.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$372.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$348.98
|
| Rate for Payer: PHP Commercial |
$395.50
|
| Rate for Payer: Priority Health SBD |
$293.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$302.44
|
| Rate for Payer: UHC Core |
$242.42
|
| Rate for Payer: UHC Exchange |
$182.86
|
| Rate for Payer: UMR Bronson Commercial |
$172.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.98
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$21.15
|
|
|
Service Code
|
NDC 00121089340
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$19.04 |
| Rate for Payer: Aetna American Axle |
$13.75
|
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.75
|
| Rate for Payer: Cash Price |
$16.92
|
| Rate for Payer: Cofinity Advantage |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$18.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.92
|
| Rate for Payer: Healthscope Commercial |
$19.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.86
|
| Rate for Payer: PHP Commercial |
$17.98
|
| Rate for Payer: Priority Health SBD |
$13.32
|
| Rate for Payer: UMR Bronson Commercial |
$9.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.86
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$88.93
|
|
|
Service Code
|
NDC 00116200116
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna American Axle |
$57.80
|
| Rate for Payer: Aetna Commercial |
$75.59
|
| Rate for Payer: Aetna Medicare |
$44.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.80
|
| Rate for Payer: BCBS Complete |
$35.57
|
| Rate for Payer: Cash Price |
$71.14
|
| Rate for Payer: Cofinity Advantage |
$62.25
|
| Rate for Payer: Cofinity Commercial |
$76.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.14
|
| Rate for Payer: Healthscope Commercial |
$80.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.70
|
| Rate for Payer: PHP Commercial |
$75.59
|
| Rate for Payer: Priority Health SBD |
$56.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.80
|
| Rate for Payer: UHC Core |
$46.33
|
| Rate for Payer: UHC Exchange |
$34.95
|
| Rate for Payer: UMR Bronson Commercial |
$32.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.70
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$44.77
|
|
|
Service Code
|
NDC 60687061644
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$40.29 |
| Rate for Payer: Aetna American Axle |
$29.10
|
| Rate for Payer: Aetna Commercial |
$38.05
|
| Rate for Payer: Aetna Medicare |
$22.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.10
|
| Rate for Payer: BCBS Complete |
$17.91
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Advantage |
$31.34
|
| Rate for Payer: Cofinity Commercial |
$38.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.58
|
| Rate for Payer: PHP Commercial |
$38.05
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.10
|
| Rate for Payer: UHC Core |
$23.33
|
| Rate for Payer: UHC Exchange |
$17.59
|
| Rate for Payer: UMR Bronson Commercial |
$16.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$21.51
|
|
|
Service Code
|
NDC 00116200106
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$19.36 |
| Rate for Payer: Aetna American Axle |
$13.98
|
| Rate for Payer: Aetna Commercial |
$18.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.98
|
| Rate for Payer: Cash Price |
$17.21
|
| Rate for Payer: Cofinity Advantage |
$15.06
|
| Rate for Payer: Cofinity Commercial |
$18.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.21
|
| Rate for Payer: Healthscope Commercial |
$19.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.13
|
| Rate for Payer: PHP Commercial |
$18.28
|
| Rate for Payer: Priority Health SBD |
$13.55
|
| Rate for Payer: UMR Bronson Commercial |
$9.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.13
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$100.04
|
|
|
Service Code
|
NDC 52376002102
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.02 |
| Max. Negotiated Rate |
$90.04 |
| Rate for Payer: Aetna American Axle |
$65.03
|
| Rate for Payer: Aetna Commercial |
$85.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.03
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cofinity Advantage |
$70.03
|
| Rate for Payer: Cofinity Commercial |
$86.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.03
|
| Rate for Payer: Healthscope Commercial |
$90.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.03
|
| Rate for Payer: PHP Commercial |
$85.03
|
| Rate for Payer: Priority Health SBD |
$63.03
|
| Rate for Payer: UMR Bronson Commercial |
$44.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.03
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$25.03
|
|
|
Service Code
|
NDC 00904703588
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.01 |
| Max. Negotiated Rate |
$22.53 |
| Rate for Payer: Aetna American Axle |
$16.27
|
| Rate for Payer: Aetna Commercial |
$21.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.27
|
| Rate for Payer: Cash Price |
$20.02
|
| Rate for Payer: Cofinity Advantage |
$17.52
|
| Rate for Payer: Cofinity Commercial |
$21.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$22.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.77
|
| Rate for Payer: PHP Commercial |
$21.28
|
| Rate for Payer: Priority Health SBD |
$15.77
|
| Rate for Payer: UMR Bronson Commercial |
$11.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.77
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$25.03
|
|
|
Service Code
|
NDC 00904703588
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$22.53 |
| Rate for Payer: Aetna American Axle |
$16.27
|
| Rate for Payer: Aetna Commercial |
$21.28
|
| Rate for Payer: Aetna Medicare |
$12.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.27
|
| Rate for Payer: BCBS Complete |
$10.01
|
| Rate for Payer: Cash Price |
$20.02
|
| Rate for Payer: Cofinity Advantage |
$17.52
|
| Rate for Payer: Cofinity Commercial |
$21.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$22.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.77
|
| Rate for Payer: PHP Commercial |
$21.28
|
| Rate for Payer: Priority Health SBD |
$15.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.27
|
| Rate for Payer: UHC Core |
$13.04
|
| Rate for Payer: UHC Exchange |
$9.84
|
| Rate for Payer: UMR Bronson Commercial |
$9.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.77
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$3.88
|
|
|
Service Code
|
NDC 09900000023
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna Medicare |
$1.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: BCBS Complete |
$1.55
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Advantage |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.91
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.52
|
| Rate for Payer: UHC Core |
$2.02
|
| Rate for Payer: UHC Exchange |
$1.52
|
| Rate for Payer: UMR Bronson Commercial |
$1.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$100.04
|
|
|
Service Code
|
NDC 52376002102
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$90.04 |
| Rate for Payer: Aetna American Axle |
$65.03
|
| Rate for Payer: Aetna Commercial |
$85.03
|
| Rate for Payer: Aetna Medicare |
$50.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.03
|
| Rate for Payer: BCBS Complete |
$40.02
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cofinity Advantage |
$70.03
|
| Rate for Payer: Cofinity Commercial |
$86.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.03
|
| Rate for Payer: Healthscope Commercial |
$90.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.03
|
| Rate for Payer: PHP Commercial |
$85.03
|
| Rate for Payer: Priority Health SBD |
$63.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.03
|
| Rate for Payer: UHC Core |
$52.12
|
| Rate for Payer: UHC Exchange |
$39.32
|
| Rate for Payer: UMR Bronson Commercial |
$37.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.03
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 00116200115
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Advantage |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.12
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$25.38
|
|
|
Service Code
|
NDC 48878062004
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$22.84 |
| Rate for Payer: Aetna American Axle |
$16.50
|
| Rate for Payer: Aetna Commercial |
$21.57
|
| Rate for Payer: Aetna Medicare |
$12.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.50
|
| Rate for Payer: BCBS Complete |
$10.15
|
| Rate for Payer: Cash Price |
$20.30
|
| Rate for Payer: Cofinity Advantage |
$17.77
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.30
|
| Rate for Payer: Healthscope Commercial |
$22.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.04
|
| Rate for Payer: PHP Commercial |
$21.57
|
| Rate for Payer: Priority Health SBD |
$15.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.50
|
| Rate for Payer: UHC Core |
$13.22
|
| Rate for Payer: UHC Exchange |
$9.97
|
| Rate for Payer: UMR Bronson Commercial |
$9.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.04
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$22.56
|
|
|
Service Code
|
NDC 00121089315
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$20.30 |
| Rate for Payer: Aetna American Axle |
$14.66
|
| Rate for Payer: Aetna Commercial |
$19.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.66
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cofinity Advantage |
$15.79
|
| Rate for Payer: Cofinity Commercial |
$19.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.05
|
| Rate for Payer: Healthscope Commercial |
$20.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.92
|
| Rate for Payer: PHP Commercial |
$19.18
|
| Rate for Payer: Priority Health SBD |
$14.21
|
| Rate for Payer: UMR Bronson Commercial |
$9.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.92
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$21.51
|
|
|
Service Code
|
NDC 00116200105
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$19.36 |
| Rate for Payer: Aetna American Axle |
$13.98
|
| Rate for Payer: Aetna Commercial |
$18.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.98
|
| Rate for Payer: Cash Price |
$17.21
|
| Rate for Payer: Cofinity Advantage |
$15.06
|
| Rate for Payer: Cofinity Commercial |
$18.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.21
|
| Rate for Payer: Healthscope Commercial |
$19.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.13
|
| Rate for Payer: PHP Commercial |
$18.28
|
| Rate for Payer: Priority Health SBD |
$13.55
|
| Rate for Payer: UMR Bronson Commercial |
$9.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.13
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 09900000023
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Advantage |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.91
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$21.15
|
|
|
Service Code
|
NDC 00121089340
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$19.04 |
| Rate for Payer: Aetna American Axle |
$13.75
|
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Aetna Medicare |
$10.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.75
|
| Rate for Payer: BCBS Complete |
$8.46
|
| Rate for Payer: Cash Price |
$16.92
|
| Rate for Payer: Cofinity Advantage |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$18.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.92
|
| Rate for Payer: Healthscope Commercial |
$19.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.86
|
| Rate for Payer: PHP Commercial |
$17.98
|
| Rate for Payer: Priority Health SBD |
$13.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.75
|
| Rate for Payer: UHC Core |
$11.02
|
| Rate for Payer: UHC Exchange |
$8.31
|
| Rate for Payer: UMR Bronson Commercial |
$7.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.86
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$21.51
|
|
|
Service Code
|
NDC 00116200106
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$19.36 |
| Rate for Payer: Aetna American Axle |
$13.98
|
| Rate for Payer: Aetna Commercial |
$18.28
|
| Rate for Payer: Aetna Medicare |
$10.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.98
|
| Rate for Payer: BCBS Complete |
$8.60
|
| Rate for Payer: Cash Price |
$17.21
|
| Rate for Payer: Cofinity Advantage |
$15.06
|
| Rate for Payer: Cofinity Commercial |
$18.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.21
|
| Rate for Payer: Healthscope Commercial |
$19.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.13
|
| Rate for Payer: PHP Commercial |
$18.28
|
| Rate for Payer: Priority Health SBD |
$13.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.98
|
| Rate for Payer: UHC Core |
$11.21
|
| Rate for Payer: UHC Exchange |
$8.45
|
| Rate for Payer: UMR Bronson Commercial |
$7.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.13
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$21.51
|
|
|
Service Code
|
NDC 00116200105
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$19.36 |
| Rate for Payer: Aetna American Axle |
$13.98
|
| Rate for Payer: Aetna Commercial |
$18.28
|
| Rate for Payer: Aetna Medicare |
$10.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.98
|
| Rate for Payer: BCBS Complete |
$8.60
|
| Rate for Payer: Cash Price |
$17.21
|
| Rate for Payer: Cofinity Advantage |
$15.06
|
| Rate for Payer: Cofinity Commercial |
$18.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.21
|
| Rate for Payer: Healthscope Commercial |
$19.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.13
|
| Rate for Payer: PHP Commercial |
$18.28
|
| Rate for Payer: Priority Health SBD |
$13.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.98
|
| Rate for Payer: UHC Core |
$11.21
|
| Rate for Payer: UHC Exchange |
$8.45
|
| Rate for Payer: UMR Bronson Commercial |
$7.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.13
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$88.93
|
|
|
Service Code
|
NDC 00116200116
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna American Axle |
$57.80
|
| Rate for Payer: Aetna Commercial |
$75.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.80
|
| Rate for Payer: Cash Price |
$71.14
|
| Rate for Payer: Cofinity Advantage |
$62.25
|
| Rate for Payer: Cofinity Commercial |
$76.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.14
|
| Rate for Payer: Healthscope Commercial |
$80.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.70
|
| Rate for Payer: PHP Commercial |
$75.59
|
| Rate for Payer: Priority Health SBD |
$56.03
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.70
|
|
