|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$61.42
|
|
|
Service Code
|
NDC 58468013101
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.73 |
| Max. Negotiated Rate |
$55.28 |
| Rate for Payer: Aetna American Axle |
$39.92
|
| Rate for Payer: Aetna Commercial |
$52.21
|
| Rate for Payer: Aetna Medicare |
$30.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.92
|
| Rate for Payer: BCBS Complete |
$24.57
|
| Rate for Payer: Cash Price |
$49.14
|
| Rate for Payer: Cofinity Commercial |
$42.99
|
| Rate for Payer: Cofinity Commercial |
$52.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.14
|
| Rate for Payer: Healthscope Commercial |
$55.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.21
|
| Rate for Payer: PHP Commercial |
$52.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.92
|
| Rate for Payer: Priority Health SBD |
$38.69
|
| Rate for Payer: UMR Bronson Commercial |
$22.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.06
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$9.07
|
|
|
Service Code
|
NDC 65862093108
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Aetna American Axle |
$5.90
|
| Rate for Payer: Aetna Commercial |
$7.71
|
| Rate for Payer: Aetna Medicare |
$4.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.90
|
| Rate for Payer: BCBS Complete |
$3.63
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cofinity Commercial |
$6.35
|
| Rate for Payer: Cofinity Commercial |
$7.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.26
|
| Rate for Payer: Healthscope Commercial |
$8.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.71
|
| Rate for Payer: PHP Commercial |
$7.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.90
|
| Rate for Payer: Priority Health SBD |
$5.71
|
| Rate for Payer: UMR Bronson Commercial |
$3.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.80
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$9.07
|
|
|
Service Code
|
NDC 65862093108
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Aetna American Axle |
$5.90
|
| Rate for Payer: Aetna Commercial |
$7.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.90
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cofinity Commercial |
$6.35
|
| Rate for Payer: Cofinity Commercial |
$7.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.26
|
| Rate for Payer: Healthscope Commercial |
$8.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.71
|
| Rate for Payer: PHP Commercial |
$7.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.90
|
| Rate for Payer: Priority Health SBD |
$5.71
|
| Rate for Payer: UMR Bronson Commercial |
$3.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.80
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$816.05
|
|
|
Service Code
|
NDC 65862093190
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$359.06 |
| Max. Negotiated Rate |
$734.44 |
| Rate for Payer: Aetna American Axle |
$530.43
|
| Rate for Payer: Aetna Commercial |
$693.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$530.43
|
| Rate for Payer: Cash Price |
$652.84
|
| Rate for Payer: Cofinity Commercial |
$571.24
|
| Rate for Payer: Cofinity Commercial |
$701.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$571.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$652.84
|
| Rate for Payer: Healthscope Commercial |
$734.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$571.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$612.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$693.64
|
| Rate for Payer: PHP Commercial |
$693.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.43
|
| Rate for Payer: Priority Health SBD |
$514.11
|
| Rate for Payer: UMR Bronson Commercial |
$359.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$612.04
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$61.42
|
|
|
Service Code
|
NDC 58468013101
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.02 |
| Max. Negotiated Rate |
$55.28 |
| Rate for Payer: Aetna American Axle |
$39.92
|
| Rate for Payer: Aetna Commercial |
$52.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.92
|
| Rate for Payer: Cash Price |
$49.14
|
| Rate for Payer: Cofinity Commercial |
$42.99
|
| Rate for Payer: Cofinity Commercial |
$52.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.14
|
| Rate for Payer: Healthscope Commercial |
$55.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.21
|
| Rate for Payer: PHP Commercial |
$52.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.92
|
| Rate for Payer: Priority Health SBD |
$38.69
|
| Rate for Payer: UMR Bronson Commercial |
$27.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.06
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$816.05
|
|
|
Service Code
|
NDC 65862093190
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.94 |
| Max. Negotiated Rate |
$734.44 |
| Rate for Payer: Aetna American Axle |
$530.43
|
| Rate for Payer: Aetna Commercial |
$693.64
|
| Rate for Payer: Aetna Medicare |
$408.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$530.43
|
| Rate for Payer: BCBS Complete |
$326.42
|
| Rate for Payer: Cash Price |
$652.84
|
| Rate for Payer: Cofinity Commercial |
$571.24
|
| Rate for Payer: Cofinity Commercial |
$701.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$571.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$652.84
|
| Rate for Payer: Healthscope Commercial |
$734.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$571.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$612.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$693.64
|
| Rate for Payer: PHP Commercial |
$693.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.43
|
| Rate for Payer: Priority Health SBD |
$514.11
|
| Rate for Payer: UMR Bronson Commercial |
$301.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$612.04
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$61.42
|
|
|
Service Code
|
NDC 58468013102
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.02 |
| Max. Negotiated Rate |
$55.28 |
| Rate for Payer: Aetna American Axle |
$39.92
|
| Rate for Payer: Aetna Commercial |
$52.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.92
|
| Rate for Payer: Cash Price |
$49.14
|
| Rate for Payer: Cofinity Commercial |
$42.99
|
| Rate for Payer: Cofinity Commercial |
$52.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.14
|
| Rate for Payer: Healthscope Commercial |
$55.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.21
|
| Rate for Payer: PHP Commercial |
$52.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.92
|
| Rate for Payer: Priority Health SBD |
$38.69
|
| Rate for Payer: UMR Bronson Commercial |
$27.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.06
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$61.42
|
|
|
Service Code
|
NDC 58468013102
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.73 |
| Max. Negotiated Rate |
$55.28 |
| Rate for Payer: Aetna American Axle |
$39.92
|
| Rate for Payer: Aetna Commercial |
$52.21
|
| Rate for Payer: Aetna Medicare |
$30.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.92
|
| Rate for Payer: BCBS Complete |
$24.57
|
| Rate for Payer: Cash Price |
$49.14
|
| Rate for Payer: Cofinity Commercial |
$42.99
|
| Rate for Payer: Cofinity Commercial |
$52.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.14
|
| Rate for Payer: Healthscope Commercial |
$55.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.21
|
| Rate for Payer: PHP Commercial |
$52.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.92
|
| Rate for Payer: Priority Health SBD |
$38.69
|
| Rate for Payer: UMR Bronson Commercial |
$22.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.06
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$928.53
|
|
|
Service Code
|
NDC 65162005827
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$408.55 |
| Max. Negotiated Rate |
$835.68 |
| Rate for Payer: Aetna American Axle |
$603.54
|
| Rate for Payer: Aetna Commercial |
$789.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$603.54
|
| Rate for Payer: Cash Price |
$742.82
|
| Rate for Payer: Cofinity Commercial |
$649.97
|
| Rate for Payer: Cofinity Commercial |
$798.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$649.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$742.82
|
| Rate for Payer: Healthscope Commercial |
$835.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$649.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$696.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$789.25
|
| Rate for Payer: PHP Commercial |
$789.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$603.54
|
| Rate for Payer: Priority Health SBD |
$584.97
|
| Rate for Payer: UMR Bronson Commercial |
$408.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$696.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$5,499.50
|
|
|
Service Code
|
NDC 58468013001
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,034.82 |
| Max. Negotiated Rate |
$4,949.55 |
| Rate for Payer: Aetna American Axle |
$3,574.68
|
| Rate for Payer: Aetna Commercial |
$4,674.58
|
| Rate for Payer: Aetna Medicare |
$2,749.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,574.68
|
| Rate for Payer: BCBS Complete |
$2,199.80
|
| Rate for Payer: Cash Price |
$4,399.60
|
| Rate for Payer: Cofinity Commercial |
$3,849.65
|
| Rate for Payer: Cofinity Commercial |
$4,729.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,849.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,399.60
|
| Rate for Payer: Healthscope Commercial |
$4,949.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,849.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,124.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,674.58
|
| Rate for Payer: PHP Commercial |
$4,674.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,574.68
|
| Rate for Payer: Priority Health SBD |
$3,464.68
|
| Rate for Payer: UMR Bronson Commercial |
$2,034.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,124.62
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$928.53
|
|
|
Service Code
|
NDC 65162005827
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$343.56 |
| Max. Negotiated Rate |
$835.68 |
| Rate for Payer: Aetna American Axle |
$603.54
|
| Rate for Payer: Aetna Commercial |
$789.25
|
| Rate for Payer: Aetna Medicare |
$464.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$603.54
|
| Rate for Payer: BCBS Complete |
$371.41
|
| Rate for Payer: Cash Price |
$742.82
|
| Rate for Payer: Cofinity Commercial |
$649.97
|
| Rate for Payer: Cofinity Commercial |
$798.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$649.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$742.82
|
| Rate for Payer: Healthscope Commercial |
$835.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$649.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$696.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$789.25
|
| Rate for Payer: PHP Commercial |
$789.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$603.54
|
| Rate for Payer: Priority Health SBD |
$584.97
|
| Rate for Payer: UMR Bronson Commercial |
$343.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$696.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$2,051.57
|
|
|
Service Code
|
NDC 00955105027
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$759.08 |
| Max. Negotiated Rate |
$1,846.41 |
| Rate for Payer: Aetna American Axle |
$1,333.52
|
| Rate for Payer: Aetna Commercial |
$1,743.83
|
| Rate for Payer: Aetna Medicare |
$1,025.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,333.52
|
| Rate for Payer: BCBS Complete |
$820.63
|
| Rate for Payer: Cash Price |
$1,641.26
|
| Rate for Payer: Cofinity Commercial |
$1,436.10
|
| Rate for Payer: Cofinity Commercial |
$1,764.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,436.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,641.26
|
| Rate for Payer: Healthscope Commercial |
$1,846.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,436.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,538.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,743.83
|
| Rate for Payer: PHP Commercial |
$1,743.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,333.52
|
| Rate for Payer: Priority Health SBD |
$1,292.49
|
| Rate for Payer: UMR Bronson Commercial |
$759.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,538.68
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$5,499.50
|
|
|
Service Code
|
NDC 58468013001
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,419.78 |
| Max. Negotiated Rate |
$4,949.55 |
| Rate for Payer: Aetna American Axle |
$3,574.68
|
| Rate for Payer: Aetna Commercial |
$4,674.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,574.68
|
| Rate for Payer: Cash Price |
$4,399.60
|
| Rate for Payer: Cofinity Commercial |
$3,849.65
|
| Rate for Payer: Cofinity Commercial |
$4,729.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,849.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,399.60
|
| Rate for Payer: Healthscope Commercial |
$4,949.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,849.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,124.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,674.58
|
| Rate for Payer: PHP Commercial |
$4,674.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,574.68
|
| Rate for Payer: Priority Health SBD |
$3,464.68
|
| Rate for Payer: UMR Bronson Commercial |
$2,419.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,124.62
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$232.32
|
|
|
Service Code
|
NDC 00904670706
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.96 |
| Max. Negotiated Rate |
$209.09 |
| Rate for Payer: Aetna American Axle |
$151.01
|
| Rate for Payer: Aetna Commercial |
$197.47
|
| Rate for Payer: Aetna Medicare |
$116.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.01
|
| Rate for Payer: BCBS Complete |
$92.93
|
| Rate for Payer: Cash Price |
$185.86
|
| Rate for Payer: Cofinity Commercial |
$162.62
|
| Rate for Payer: Cofinity Commercial |
$199.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.86
|
| Rate for Payer: Healthscope Commercial |
$209.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.47
|
| Rate for Payer: PHP Commercial |
$197.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.01
|
| Rate for Payer: Priority Health SBD |
$146.36
|
| Rate for Payer: UMR Bronson Commercial |
$85.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.24
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$2,051.57
|
|
|
Service Code
|
NDC 00955105027
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$902.69 |
| Max. Negotiated Rate |
$1,846.41 |
| Rate for Payer: Aetna American Axle |
$1,333.52
|
| Rate for Payer: Aetna Commercial |
$1,743.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,333.52
|
| Rate for Payer: Cash Price |
$1,641.26
|
| Rate for Payer: Cofinity Commercial |
$1,436.10
|
| Rate for Payer: Cofinity Commercial |
$1,764.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,436.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,641.26
|
| Rate for Payer: Healthscope Commercial |
$1,846.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,436.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,538.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,743.83
|
| Rate for Payer: PHP Commercial |
$1,743.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,333.52
|
| Rate for Payer: Priority Health SBD |
$1,292.49
|
| Rate for Payer: UMR Bronson Commercial |
$902.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,538.68
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$232.32
|
|
|
Service Code
|
NDC 00904670706
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.22 |
| Max. Negotiated Rate |
$209.09 |
| Rate for Payer: Aetna American Axle |
$151.01
|
| Rate for Payer: Aetna Commercial |
$197.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.01
|
| Rate for Payer: Cash Price |
$185.86
|
| Rate for Payer: Cofinity Commercial |
$162.62
|
| Rate for Payer: Cofinity Commercial |
$199.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.86
|
| Rate for Payer: Healthscope Commercial |
$209.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.47
|
| Rate for Payer: PHP Commercial |
$197.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.01
|
| Rate for Payer: Priority Health SBD |
$146.36
|
| Rate for Payer: UMR Bronson Commercial |
$102.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.24
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$707.94
|
|
|
Service Code
|
NDC 65862092127
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$311.49 |
| Max. Negotiated Rate |
$637.15 |
| Rate for Payer: Aetna American Axle |
$460.16
|
| Rate for Payer: Aetna Commercial |
$601.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$460.16
|
| Rate for Payer: Cash Price |
$566.35
|
| Rate for Payer: Cofinity Commercial |
$495.56
|
| Rate for Payer: Cofinity Commercial |
$608.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$495.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$566.35
|
| Rate for Payer: Healthscope Commercial |
$637.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$495.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$530.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$601.75
|
| Rate for Payer: PHP Commercial |
$601.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$460.16
|
| Rate for Payer: Priority Health SBD |
$446.00
|
| Rate for Payer: UMR Bronson Commercial |
$311.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$530.96
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$707.94
|
|
|
Service Code
|
NDC 65862092127
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.94 |
| Max. Negotiated Rate |
$637.15 |
| Rate for Payer: Aetna American Axle |
$460.16
|
| Rate for Payer: Aetna Commercial |
$601.75
|
| Rate for Payer: Aetna Medicare |
$353.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$460.16
|
| Rate for Payer: BCBS Complete |
$283.18
|
| Rate for Payer: Cash Price |
$566.35
|
| Rate for Payer: Cofinity Commercial |
$495.56
|
| Rate for Payer: Cofinity Commercial |
$608.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$495.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$566.35
|
| Rate for Payer: Healthscope Commercial |
$637.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$495.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$530.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$601.75
|
| Rate for Payer: PHP Commercial |
$601.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$460.16
|
| Rate for Payer: Priority Health SBD |
$446.00
|
| Rate for Payer: UMR Bronson Commercial |
$261.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$530.96
|
|
|
SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); ANTERIOR SYNECHIAE, EXCEPT GONIOSYNECHIAE
|
Facility
|
OP
|
$7,023.35
|
|
|
Service Code
|
CPT 65870
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$554.12 |
| Max. Negotiated Rate |
$7,023.35 |
| Rate for Payer: Aetna Medicare |
$2,323.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,793.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,793.26
|
| Rate for Payer: BCBS Complete |
$1,257.64
|
| Rate for Payer: BCBS MAPPO |
$2,234.61
|
| Rate for Payer: BCBS Trust/PPO |
$1,776.49
|
| Rate for Payer: BCN Commercial |
$1,776.49
|
| Rate for Payer: BCN Medicare Advantage |
$2,234.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,234.61
|
| Rate for Payer: Mclaren Medicaid |
$1,197.75
|
| Rate for Payer: Mclaren Medicare |
$2,234.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,346.34
|
| Rate for Payer: Meridian Medicaid |
$1,257.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,569.80
|
| Rate for Payer: Nomi Health Commercial |
$4,692.68
|
| Rate for Payer: PACE Medicare |
$2,122.88
|
| Rate for Payer: PACE SWMI |
$2,234.61
|
| Rate for Payer: PHP Medicare Advantage |
$2,234.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,197.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,023.35
|
| Rate for Payer: Priority Health Medicare |
$2,234.61
|
| Rate for Payer: Priority Health Narrow Network |
$5,618.68
|
| Rate for Payer: Railroad Medicare Medicare |
$2,234.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$609.53
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,234.61
|
| Rate for Payer: UHC Exchange |
$554.12
|
| Rate for Payer: UHC Medicare Advantage |
$2,234.61
|
| Rate for Payer: UHCCP Medicaid |
$1,197.75
|
| Rate for Payer: VA VA |
$2,234.61
|
|
|
SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); CORNEOVITREAL ADHESIONS
|
Facility
|
OP
|
$12,388.13
|
|
|
Service Code
|
CPT 65880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$621.85 |
| Max. Negotiated Rate |
$12,388.13 |
| Rate for Payer: Aetna Medicare |
$4,099.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,926.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,926.90
|
| Rate for Payer: BCBS Complete |
$2,218.29
|
| Rate for Payer: BCBS MAPPO |
$3,941.52
|
| Rate for Payer: BCBS Trust/PPO |
$2,724.13
|
| Rate for Payer: BCN Commercial |
$2,724.13
|
| Rate for Payer: BCN Medicare Advantage |
$3,941.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,941.52
|
| Rate for Payer: Mclaren Medicaid |
$2,112.65
|
| Rate for Payer: Mclaren Medicare |
$3,941.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4,138.60
|
| Rate for Payer: Meridian Medicaid |
$2,218.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,532.75
|
| Rate for Payer: Nomi Health Commercial |
$8,277.19
|
| Rate for Payer: PACE Medicare |
$3,744.44
|
| Rate for Payer: PACE SWMI |
$3,941.52
|
| Rate for Payer: PHP Medicare Advantage |
$3,941.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,112.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,388.13
|
| Rate for Payer: Priority Health Medicare |
$3,941.52
|
| Rate for Payer: Priority Health Narrow Network |
$9,910.50
|
| Rate for Payer: Railroad Medicare Medicare |
$3,941.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$684.04
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,941.52
|
| Rate for Payer: UHC Exchange |
$621.85
|
| Rate for Payer: UHC Medicare Advantage |
$3,941.52
|
| Rate for Payer: UHCCP Medicaid |
$2,112.65
|
| Rate for Payer: VA VA |
$3,941.52
|
|
|
SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE
|
Facility
|
OP
|
$7,023.35
|
|
|
Service Code
|
CPT 65865
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$445.75 |
| Max. Negotiated Rate |
$7,023.35 |
| Rate for Payer: Aetna Medicare |
$2,323.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,793.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,793.26
|
| Rate for Payer: BCBS Complete |
$1,257.64
|
| Rate for Payer: BCBS MAPPO |
$2,234.61
|
| Rate for Payer: BCBS Trust/PPO |
$1,522.72
|
| Rate for Payer: BCN Commercial |
$1,522.72
|
| Rate for Payer: BCN Medicare Advantage |
$2,234.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,234.61
|
| Rate for Payer: Mclaren Medicaid |
$1,197.75
|
| Rate for Payer: Mclaren Medicare |
$2,234.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,346.34
|
| Rate for Payer: Meridian Medicaid |
$1,257.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,569.80
|
| Rate for Payer: Nomi Health Commercial |
$4,692.68
|
| Rate for Payer: PACE Medicare |
$2,122.88
|
| Rate for Payer: PACE SWMI |
$2,234.61
|
| Rate for Payer: PHP Medicare Advantage |
$2,234.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,197.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,023.35
|
| Rate for Payer: Priority Health Medicare |
$2,234.61
|
| Rate for Payer: Priority Health Narrow Network |
$5,618.68
|
| Rate for Payer: Railroad Medicare Medicare |
$2,234.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$490.32
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,234.61
|
| Rate for Payer: UHC Exchange |
$445.75
|
| Rate for Payer: UHC Medicare Advantage |
$2,234.61
|
| Rate for Payer: UHCCP Medicaid |
$1,197.75
|
| Rate for Payer: VA VA |
$2,234.61
|
|
|
SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); POSTERIOR SYNECHIAE
|
Facility
|
OP
|
$7,023.35
|
|
|
Service Code
|
CPT 65875
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$591.48 |
| Max. Negotiated Rate |
$7,023.35 |
| Rate for Payer: Aetna Medicare |
$2,323.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,793.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,793.26
|
| Rate for Payer: BCBS Complete |
$1,257.64
|
| Rate for Payer: BCBS MAPPO |
$2,234.61
|
| Rate for Payer: BCBS Trust/PPO |
$1,776.49
|
| Rate for Payer: BCN Commercial |
$1,776.49
|
| Rate for Payer: BCN Medicare Advantage |
$2,234.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,234.61
|
| Rate for Payer: Mclaren Medicaid |
$1,197.75
|
| Rate for Payer: Mclaren Medicare |
$2,234.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,346.34
|
| Rate for Payer: Meridian Medicaid |
$1,257.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,569.80
|
| Rate for Payer: Nomi Health Commercial |
$4,692.68
|
| Rate for Payer: PACE Medicare |
$2,122.88
|
| Rate for Payer: PACE SWMI |
$2,234.61
|
| Rate for Payer: PHP Medicare Advantage |
$2,234.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,197.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,023.35
|
| Rate for Payer: Priority Health Medicare |
$2,234.61
|
| Rate for Payer: Priority Health Narrow Network |
$5,618.68
|
| Rate for Payer: Railroad Medicare Medicare |
$2,234.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$650.63
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,234.61
|
| Rate for Payer: UHC Exchange |
$591.48
|
| Rate for Payer: UHC Medicare Advantage |
$2,234.61
|
| Rate for Payer: UHCCP Medicaid |
$1,197.75
|
| Rate for Payer: VA VA |
$2,234.61
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
IP
|
$223.13
|
|
|
Service Code
|
NDC 10019065164
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.18 |
| Max. Negotiated Rate |
$200.82 |
| Rate for Payer: Aetna American Axle |
$145.03
|
| Rate for Payer: Aetna Commercial |
$189.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.03
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cofinity Commercial |
$156.19
|
| Rate for Payer: Cofinity Commercial |
$191.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.50
|
| Rate for Payer: Healthscope Commercial |
$200.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.66
|
| Rate for Payer: PHP Commercial |
$189.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.03
|
| Rate for Payer: Priority Health SBD |
$140.57
|
| Rate for Payer: UMR Bronson Commercial |
$98.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.35
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
OP
|
$214.38
|
|
|
Service Code
|
NDC 00074445651
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.32 |
| Max. Negotiated Rate |
$192.94 |
| Rate for Payer: Aetna American Axle |
$139.35
|
| Rate for Payer: Aetna Commercial |
$182.22
|
| Rate for Payer: Aetna Medicare |
$107.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$139.35
|
| Rate for Payer: BCBS Complete |
$85.75
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$150.07
|
| Rate for Payer: Cofinity Commercial |
$184.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$150.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.50
|
| Rate for Payer: Healthscope Commercial |
$192.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$150.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$182.22
|
| Rate for Payer: PHP Commercial |
$182.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.35
|
| Rate for Payer: Priority Health SBD |
$135.06
|
| Rate for Payer: UMR Bronson Commercial |
$79.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.78
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
IP
|
$214.38
|
|
|
Service Code
|
NDC 00074445604
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.33 |
| Max. Negotiated Rate |
$192.94 |
| Rate for Payer: Aetna American Axle |
$139.35
|
| Rate for Payer: Aetna Commercial |
$182.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$139.35
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$150.07
|
| Rate for Payer: Cofinity Commercial |
$184.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$150.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.50
|
| Rate for Payer: Healthscope Commercial |
$192.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$150.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$182.22
|
| Rate for Payer: PHP Commercial |
$182.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.35
|
| Rate for Payer: Priority Health SBD |
$135.06
|
| Rate for Payer: UMR Bronson Commercial |
$94.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.78
|
|
