|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$11,284.45
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$10,156.00 |
| Rate for Payer: Aetna American Axle |
$7,334.89
|
| Rate for Payer: Aetna Commercial |
$9,591.78
|
| Rate for Payer: Aetna Medicare |
$36.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,334.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$44.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$44.30
|
| Rate for Payer: BCBS Complete |
$19.95
|
| Rate for Payer: BCBS MAPPO |
$35.44
|
| Rate for Payer: BCBS Trust/PPO |
$95.54
|
| Rate for Payer: BCN Commercial |
$95.54
|
| Rate for Payer: BCN Medicare Advantage |
$35.44
|
| Rate for Payer: Cash Price |
$9,027.56
|
| Rate for Payer: Cash Price |
$9,027.56
|
| Rate for Payer: Cofinity Commercial |
$9,704.63
|
| Rate for Payer: Cofinity Commercial |
$7,899.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,899.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,027.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35.44
|
| Rate for Payer: Healthscope Commercial |
$10,156.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,899.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,463.34
|
| Rate for Payer: Mclaren Medicaid |
$19.00
|
| Rate for Payer: Mclaren Medicare |
$35.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$37.21
|
| Rate for Payer: Meridian Medicaid |
$19.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,591.78
|
| Rate for Payer: Nomi Health Commercial |
$106.32
|
| Rate for Payer: PACE Medicare |
$33.67
|
| Rate for Payer: PACE SWMI |
$35.44
|
| Rate for Payer: PHP Commercial |
$9,591.78
|
| Rate for Payer: PHP Medicare Advantage |
$35.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,334.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$99.78
|
| Rate for Payer: Priority Health Medicare |
$35.44
|
| Rate for Payer: Priority Health Narrow Network |
$79.82
|
| Rate for Payer: Priority Health SBD |
$7,109.20
|
| Rate for Payer: Railroad Medicare Medicare |
$35.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$35.44
|
| Rate for Payer: UHC Exchange |
$67.73
|
| Rate for Payer: UHC Medicare Advantage |
$35.44
|
| Rate for Payer: UHCCP Medicaid |
$19.00
|
| Rate for Payer: UMR Bronson Commercial |
$4,175.25
|
| Rate for Payer: VA VA |
$35.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,463.34
|
|
|
SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$11,284.45
|
|
|
Service Code
|
HCPCS J9317
|
| Hospital Charge Code |
193479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,965.16 |
| Max. Negotiated Rate |
$10,156.00 |
| Rate for Payer: Aetna American Axle |
$7,334.89
|
| Rate for Payer: Aetna Commercial |
$9,591.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,334.89
|
| Rate for Payer: Cash Price |
$9,027.56
|
| Rate for Payer: Cofinity Commercial |
$7,899.12
|
| Rate for Payer: Cofinity Commercial |
$9,704.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,899.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,027.56
|
| Rate for Payer: Healthscope Commercial |
$10,156.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,899.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,463.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,591.78
|
| Rate for Payer: PHP Commercial |
$9,591.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,334.89
|
| Rate for Payer: Priority Health SBD |
$7,109.20
|
| Rate for Payer: UMR Bronson Commercial |
$4,965.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,463.34
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
OP
|
$7,031.63
|
|
|
Service Code
|
NDC 00078065967
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,601.70 |
| Max. Negotiated Rate |
$6,328.47 |
| Rate for Payer: Aetna American Axle |
$4,570.56
|
| Rate for Payer: Aetna Commercial |
$5,976.89
|
| Rate for Payer: Aetna Medicare |
$3,515.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,570.56
|
| Rate for Payer: BCBS Complete |
$2,812.65
|
| Rate for Payer: Cash Price |
$5,625.30
|
| Rate for Payer: Cofinity Commercial |
$4,922.14
|
| Rate for Payer: Cofinity Commercial |
$6,047.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,922.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,625.30
|
| Rate for Payer: Healthscope Commercial |
$6,328.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,922.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,273.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,976.89
|
| Rate for Payer: PHP Commercial |
$5,976.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,570.56
|
| Rate for Payer: Priority Health SBD |
$4,429.93
|
| Rate for Payer: UMR Bronson Commercial |
$2,601.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,273.72
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$2,343.88
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,031.31 |
| Max. Negotiated Rate |
$2,109.49 |
| Rate for Payer: Aetna American Axle |
$1,523.52
|
| Rate for Payer: Aetna Commercial |
$1,992.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,523.52
|
| Rate for Payer: Cash Price |
$1,875.10
|
| Rate for Payer: Cofinity Commercial |
$1,640.72
|
| Rate for Payer: Cofinity Commercial |
$2,015.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,640.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,875.10
|
| Rate for Payer: Healthscope Commercial |
$2,109.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,640.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,757.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,992.30
|
| Rate for Payer: PHP Commercial |
$1,992.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,523.52
|
| Rate for Payer: Priority Health SBD |
$1,476.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,031.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,757.91
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
IP
|
$7,031.63
|
|
|
Service Code
|
NDC 00078065967
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,093.92 |
| Max. Negotiated Rate |
$6,328.47 |
| Rate for Payer: Aetna American Axle |
$4,570.56
|
| Rate for Payer: Aetna Commercial |
$5,976.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,570.56
|
| Rate for Payer: Cash Price |
$5,625.30
|
| Rate for Payer: Cofinity Commercial |
$4,922.14
|
| Rate for Payer: Cofinity Commercial |
$6,047.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,922.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,625.30
|
| Rate for Payer: Healthscope Commercial |
$6,328.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,922.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,273.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,976.89
|
| Rate for Payer: PHP Commercial |
$5,976.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,570.56
|
| Rate for Payer: Priority Health SBD |
$4,429.93
|
| Rate for Payer: UMR Bronson Commercial |
$3,093.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,273.72
|
|
|
SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET
|
Facility
|
OP
|
$2,343.88
|
|
|
Service Code
|
NDC 00078065920
|
| Hospital Charge Code |
174639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$867.24 |
| Max. Negotiated Rate |
$2,109.49 |
| Rate for Payer: Aetna American Axle |
$1,523.52
|
| Rate for Payer: Aetna Commercial |
$1,992.30
|
| Rate for Payer: Aetna Medicare |
$1,171.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,523.52
|
| Rate for Payer: BCBS Complete |
$937.55
|
| Rate for Payer: Cash Price |
$1,875.10
|
| Rate for Payer: Cofinity Commercial |
$1,640.72
|
| Rate for Payer: Cofinity Commercial |
$2,015.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,640.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,875.10
|
| Rate for Payer: Healthscope Commercial |
$2,109.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,640.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,757.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,992.30
|
| Rate for Payer: PHP Commercial |
$1,992.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,523.52
|
| Rate for Payer: Priority Health SBD |
$1,476.64
|
| Rate for Payer: UMR Bronson Commercial |
$867.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,757.91
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
OP
|
$2,343.88
|
|
|
Service Code
|
NDC 00078077720
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$867.24 |
| Max. Negotiated Rate |
$2,109.49 |
| Rate for Payer: Aetna American Axle |
$1,523.52
|
| Rate for Payer: Aetna Commercial |
$1,992.30
|
| Rate for Payer: Aetna Medicare |
$1,171.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,523.52
|
| Rate for Payer: BCBS Complete |
$937.55
|
| Rate for Payer: Cash Price |
$1,875.10
|
| Rate for Payer: Cofinity Commercial |
$1,640.72
|
| Rate for Payer: Cofinity Commercial |
$2,015.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,640.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,875.10
|
| Rate for Payer: Healthscope Commercial |
$2,109.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,640.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,757.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,992.30
|
| Rate for Payer: PHP Commercial |
$1,992.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,523.52
|
| Rate for Payer: Priority Health SBD |
$1,476.64
|
| Rate for Payer: UMR Bronson Commercial |
$867.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,757.91
|
|
|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
|
IP
|
$2,343.88
|
|
|
Service Code
|
NDC 00078077720
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,031.31 |
| Max. Negotiated Rate |
$2,109.49 |
| Rate for Payer: Aetna American Axle |
$1,523.52
|
| Rate for Payer: Aetna Commercial |
$1,992.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,523.52
|
| Rate for Payer: Cash Price |
$1,875.10
|
| Rate for Payer: Cofinity Commercial |
$1,640.72
|
| Rate for Payer: Cofinity Commercial |
$2,015.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,640.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,875.10
|
| Rate for Payer: Healthscope Commercial |
$2,109.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,640.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,757.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,992.30
|
| Rate for Payer: PHP Commercial |
$1,992.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,523.52
|
| Rate for Payer: Priority Health SBD |
$1,476.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,031.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,757.91
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
OP
|
$2,343.88
|
|
|
Service Code
|
NDC 00078069620
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$867.24 |
| Max. Negotiated Rate |
$2,109.49 |
| Rate for Payer: Aetna American Axle |
$1,523.52
|
| Rate for Payer: Aetna Commercial |
$1,992.30
|
| Rate for Payer: Aetna Medicare |
$1,171.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,523.52
|
| Rate for Payer: BCBS Complete |
$937.55
|
| Rate for Payer: Cash Price |
$1,875.10
|
| Rate for Payer: Cofinity Commercial |
$1,640.72
|
| Rate for Payer: Cofinity Commercial |
$2,015.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,640.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,875.10
|
| Rate for Payer: Healthscope Commercial |
$2,109.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,640.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,757.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,992.30
|
| Rate for Payer: PHP Commercial |
$1,992.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,523.52
|
| Rate for Payer: Priority Health SBD |
$1,476.64
|
| Rate for Payer: UMR Bronson Commercial |
$867.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,757.91
|
|
|
SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET
|
Facility
|
IP
|
$2,343.88
|
|
|
Service Code
|
NDC 00078069620
|
| Hospital Charge Code |
174641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,031.31 |
| Max. Negotiated Rate |
$2,109.49 |
| Rate for Payer: Aetna American Axle |
$1,523.52
|
| Rate for Payer: Aetna Commercial |
$1,992.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,523.52
|
| Rate for Payer: Cash Price |
$1,875.10
|
| Rate for Payer: Cofinity Commercial |
$1,640.72
|
| Rate for Payer: Cofinity Commercial |
$2,015.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,640.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,875.10
|
| Rate for Payer: Healthscope Commercial |
$2,109.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,640.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,757.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,992.30
|
| Rate for Payer: PHP Commercial |
$1,992.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,523.52
|
| Rate for Payer: Priority Health SBD |
$1,476.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,031.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,757.91
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
IP
|
$24.97
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna American Axle |
$16.23
|
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.23
|
| Rate for Payer: Priority Health SBD |
$15.73
|
| Rate for Payer: UMR Bronson Commercial |
$10.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.73
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
OP
|
$24.97
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna American Axle |
$16.23
|
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna Medicare |
$12.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: BCBS Complete |
$9.99
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.23
|
| Rate for Payer: Priority Health SBD |
$15.73
|
| Rate for Payer: UMR Bronson Commercial |
$9.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.73
|
|
|
SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION
|
Facility
|
OP
|
$1,378.37
|
|
|
Service Code
|
NDC 00173052100
|
| Hospital Charge Code |
28246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$1,240.53 |
| Rate for Payer: Aetna American Axle |
$895.94
|
| Rate for Payer: Aetna Commercial |
$1,171.61
|
| Rate for Payer: Aetna Medicare |
$689.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$895.94
|
| Rate for Payer: BCBS Complete |
$551.35
|
| Rate for Payer: Cash Price |
$1,102.70
|
| Rate for Payer: Cofinity Commercial |
$1,185.40
|
| Rate for Payer: Cofinity Commercial |
$964.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$964.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,102.70
|
| Rate for Payer: Healthscope Commercial |
$1,240.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$964.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,033.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,171.61
|
| Rate for Payer: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$895.94
|
| Rate for Payer: Priority Health SBD |
$868.37
|
| Rate for Payer: UMR Bronson Commercial |
$510.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,033.78
|
|
|
SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$1,378.37
|
|
|
Service Code
|
NDC 00173052100
|
| Hospital Charge Code |
28246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$606.48 |
| Max. Negotiated Rate |
$1,240.53 |
| Rate for Payer: Aetna American Axle |
$895.94
|
| Rate for Payer: Aetna Commercial |
$1,171.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$895.94
|
| Rate for Payer: Cash Price |
$1,102.70
|
| Rate for Payer: Cofinity Commercial |
$1,185.40
|
| Rate for Payer: Cofinity Commercial |
$964.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$964.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,102.70
|
| Rate for Payer: Healthscope Commercial |
$1,240.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$964.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,033.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,171.61
|
| Rate for Payer: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$895.94
|
| Rate for Payer: Priority Health SBD |
$868.37
|
| Rate for Payer: UMR Bronson Commercial |
$606.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,033.78
|
|
|
SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$6,395.00
|
|
|
Service Code
|
CPT 58720
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$738.78 |
| Max. Negotiated Rate |
$6,395.00 |
| Rate for Payer: BCBS Trust/PPO |
$2,652.03
|
| Rate for Payer: BCN Commercial |
$2,652.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$812.66
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Exchange |
$738.78
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
OP
|
$385.70
|
|
|
Service Code
|
NDC 69367016004
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.70
|
| Rate for Payer: Aetna Commercial |
$327.84
|
| Rate for Payer: Aetna Medicare |
$192.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.70
|
| Rate for Payer: BCBS Complete |
$154.28
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.84
|
| Rate for Payer: PHP Commercial |
$327.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.70
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$142.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.28
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$444.60
|
|
|
Service Code
|
NDC 13273020903
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.62 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna American Axle |
$288.99
|
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$311.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.99
|
| Rate for Payer: Priority Health SBD |
$280.10
|
| Rate for Payer: UMR Bronson Commercial |
$195.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.45
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$265.05
|
|
|
Service Code
|
NDC 65162051210
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna American Axle |
$172.28
|
| Rate for Payer: Aetna Commercial |
$225.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.28
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cofinity Commercial |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$227.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.04
|
| Rate for Payer: Healthscope Commercial |
$238.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.29
|
| Rate for Payer: PHP Commercial |
$225.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.28
|
| Rate for Payer: Priority Health SBD |
$166.98
|
| Rate for Payer: UMR Bronson Commercial |
$116.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.79
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
OP
|
$265.05
|
|
|
Service Code
|
NDC 65162051210
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.07 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna American Axle |
$172.28
|
| Rate for Payer: Aetna Commercial |
$225.29
|
| Rate for Payer: Aetna Medicare |
$132.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.28
|
| Rate for Payer: BCBS Complete |
$106.02
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cofinity Commercial |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$227.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.04
|
| Rate for Payer: Healthscope Commercial |
$238.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.29
|
| Rate for Payer: PHP Commercial |
$225.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.28
|
| Rate for Payer: Priority Health SBD |
$166.98
|
| Rate for Payer: UMR Bronson Commercial |
$98.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.79
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
OP
|
$444.60
|
|
|
Service Code
|
NDC 13273020903
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.50 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna American Axle |
$288.99
|
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna Medicare |
$222.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: BCBS Complete |
$177.84
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$311.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.99
|
| Rate for Payer: Priority Health SBD |
$280.10
|
| Rate for Payer: UMR Bronson Commercial |
$164.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.45
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 69367016004
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.70
|
| Rate for Payer: Aetna Commercial |
$327.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.70
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.84
|
| Rate for Payer: PHP Commercial |
$327.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.70
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$169.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.28
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
OP
|
$291.84
|
|
|
Service Code
|
NDC 13273021003
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.98 |
| Max. Negotiated Rate |
$262.66 |
| Rate for Payer: Aetna American Axle |
$189.70
|
| Rate for Payer: Aetna Commercial |
$248.06
|
| Rate for Payer: Aetna Medicare |
$145.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: BCBS Complete |
$116.74
|
| Rate for Payer: Cash Price |
$233.47
|
| Rate for Payer: Cofinity Commercial |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$250.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.47
|
| Rate for Payer: Healthscope Commercial |
$262.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: PHP Commercial |
$248.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.70
|
| Rate for Payer: Priority Health SBD |
$183.86
|
| Rate for Payer: UMR Bronson Commercial |
$107.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.88
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
IP
|
$379.05
|
|
|
Service Code
|
NDC 69367016104
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.78 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$265.34
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$265.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.19
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.38
|
| Rate for Payer: Priority Health SBD |
$238.80
|
| Rate for Payer: UMR Bronson Commercial |
$166.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
IP
|
$291.84
|
|
|
Service Code
|
NDC 13273021003
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.41 |
| Max. Negotiated Rate |
$262.66 |
| Rate for Payer: Aetna American Axle |
$189.70
|
| Rate for Payer: Aetna Commercial |
$248.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: Cash Price |
$233.47
|
| Rate for Payer: Cofinity Commercial |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$250.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.47
|
| Rate for Payer: Healthscope Commercial |
$262.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: PHP Commercial |
$248.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.70
|
| Rate for Payer: Priority Health SBD |
$183.86
|
| Rate for Payer: UMR Bronson Commercial |
$128.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.88
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
OP
|
$379.05
|
|
|
Service Code
|
NDC 69367016104
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.25 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna Medicare |
$189.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: BCBS Complete |
$151.62
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$265.34
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$265.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.19
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.38
|
| Rate for Payer: Priority Health SBD |
$238.80
|
| Rate for Payer: UMR Bronson Commercial |
$140.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
