|
SILDENAFIL (PULMONARY HYPERTENSION) 10 MG/ML ORAL POWDR FOR SUSPENSION
|
Facility
|
OP
|
$535.45
|
|
|
Service Code
|
NDC 69238157401
|
| Hospital Charge Code |
172285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.12 |
| Max. Negotiated Rate |
$481.90 |
| Rate for Payer: Aetna American Axle |
$348.04
|
| Rate for Payer: Aetna Commercial |
$455.13
|
| Rate for Payer: Aetna Medicare |
$267.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.04
|
| Rate for Payer: BCBS Complete |
$214.18
|
| Rate for Payer: Cash Price |
$428.36
|
| Rate for Payer: Cofinity Commercial |
$374.82
|
| Rate for Payer: Cofinity Commercial |
$460.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$374.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$428.36
|
| Rate for Payer: Healthscope Commercial |
$481.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$374.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$401.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.13
|
| Rate for Payer: PHP Commercial |
$455.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.04
|
| Rate for Payer: Priority Health SBD |
$337.33
|
| Rate for Payer: UMR Bronson Commercial |
$198.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$401.59
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 10 MG/ML ORAL POWDR FOR SUSPENSION
|
Facility
|
IP
|
$535.45
|
|
|
Service Code
|
NDC 69238157401
|
| Hospital Charge Code |
172285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.60 |
| Max. Negotiated Rate |
$481.90 |
| Rate for Payer: Aetna American Axle |
$348.04
|
| Rate for Payer: Aetna Commercial |
$455.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.04
|
| Rate for Payer: Cash Price |
$428.36
|
| Rate for Payer: Cofinity Commercial |
$374.82
|
| Rate for Payer: Cofinity Commercial |
$460.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$374.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$428.36
|
| Rate for Payer: Healthscope Commercial |
$481.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$374.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$401.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.13
|
| Rate for Payer: PHP Commercial |
$455.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.04
|
| Rate for Payer: Priority Health SBD |
$337.33
|
| Rate for Payer: UMR Bronson Commercial |
$235.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$401.59
|
|
|
SILDENAFIL (PULMONARY HYPERTENSION) 10 MG/ML ORAL POWDR FOR SUSPENSION
|
Facility
|
IP
|
$340.48
|
|
|
Service Code
|
NDC 69543041972
|
| Hospital Charge Code |
172285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.81 |
| Max. Negotiated Rate |
$306.43 |
| Rate for Payer: Aetna American Axle |
$221.31
|
| Rate for Payer: Aetna Commercial |
$289.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.31
|
| Rate for Payer: Cash Price |
$272.38
|
| Rate for Payer: Cofinity Commercial |
$238.34
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.38
|
| Rate for Payer: Healthscope Commercial |
$306.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.41
|
| Rate for Payer: PHP Commercial |
$289.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.31
|
| Rate for Payer: Priority Health SBD |
$214.50
|
| Rate for Payer: UMR Bronson Commercial |
$149.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.36
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$176.99
|
|
|
Service Code
|
NDC 00093551798
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.49 |
| Max. Negotiated Rate |
$159.29 |
| Rate for Payer: Aetna American Axle |
$115.04
|
| Rate for Payer: Aetna Commercial |
$150.44
|
| Rate for Payer: Aetna Medicare |
$88.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.04
|
| Rate for Payer: BCBS Complete |
$70.80
|
| Rate for Payer: Cash Price |
$141.59
|
| Rate for Payer: Cofinity Commercial |
$123.89
|
| Rate for Payer: Cofinity Commercial |
$152.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.59
|
| Rate for Payer: Healthscope Commercial |
$159.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.44
|
| Rate for Payer: PHP Commercial |
$150.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.04
|
| Rate for Payer: Priority Health SBD |
$111.50
|
| Rate for Payer: UMR Bronson Commercial |
$65.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.74
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$410.40
|
|
|
Service Code
|
NDC 59762003301
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.85 |
| Max. Negotiated Rate |
$369.36 |
| Rate for Payer: Aetna American Axle |
$266.76
|
| Rate for Payer: Aetna Commercial |
$348.84
|
| Rate for Payer: Aetna Medicare |
$205.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.76
|
| Rate for Payer: BCBS Complete |
$164.16
|
| Rate for Payer: Cash Price |
$328.32
|
| Rate for Payer: Cofinity Commercial |
$287.28
|
| Rate for Payer: Cofinity Commercial |
$352.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.32
|
| Rate for Payer: Healthscope Commercial |
$369.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$348.84
|
| Rate for Payer: PHP Commercial |
$348.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.76
|
| Rate for Payer: Priority Health SBD |
$258.55
|
| Rate for Payer: UMR Bronson Commercial |
$151.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.80
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$19,155.83
|
|
|
Service Code
|
NDC 00069419068
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,087.66 |
| Max. Negotiated Rate |
$17,240.25 |
| Rate for Payer: Aetna American Axle |
$12,451.29
|
| Rate for Payer: Aetna Commercial |
$16,282.46
|
| Rate for Payer: Aetna Medicare |
$9,577.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,451.29
|
| Rate for Payer: BCBS Complete |
$7,662.33
|
| Rate for Payer: Cash Price |
$15,324.66
|
| Rate for Payer: Cofinity Commercial |
$13,409.08
|
| Rate for Payer: Cofinity Commercial |
$16,474.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,409.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,324.66
|
| Rate for Payer: Healthscope Commercial |
$17,240.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,409.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,366.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,282.46
|
| Rate for Payer: PHP Commercial |
$16,282.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,451.29
|
| Rate for Payer: Priority Health SBD |
$12,068.17
|
| Rate for Payer: UMR Bronson Commercial |
$7,087.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,366.87
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$176.99
|
|
|
Service Code
|
NDC 00093551798
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$159.29 |
| Rate for Payer: Aetna American Axle |
$115.04
|
| Rate for Payer: Aetna Commercial |
$150.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.04
|
| Rate for Payer: Cash Price |
$141.59
|
| Rate for Payer: Cofinity Commercial |
$123.89
|
| Rate for Payer: Cofinity Commercial |
$152.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.59
|
| Rate for Payer: Healthscope Commercial |
$159.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.44
|
| Rate for Payer: PHP Commercial |
$150.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.04
|
| Rate for Payer: Priority Health SBD |
$111.50
|
| Rate for Payer: UMR Bronson Commercial |
$77.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.74
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$410.40
|
|
|
Service Code
|
NDC 59762003301
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.58 |
| Max. Negotiated Rate |
$369.36 |
| Rate for Payer: Aetna American Axle |
$266.76
|
| Rate for Payer: Aetna Commercial |
$348.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.76
|
| Rate for Payer: Cash Price |
$328.32
|
| Rate for Payer: Cofinity Commercial |
$287.28
|
| Rate for Payer: Cofinity Commercial |
$352.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.32
|
| Rate for Payer: Healthscope Commercial |
$369.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$348.84
|
| Rate for Payer: PHP Commercial |
$348.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.76
|
| Rate for Payer: Priority Health SBD |
$258.55
|
| Rate for Payer: UMR Bronson Commercial |
$180.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.80
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$188.24
|
|
|
Service Code
|
NDC 65162035109
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.83 |
| Max. Negotiated Rate |
$169.42 |
| Rate for Payer: PHP Commercial |
$160.00
|
| Rate for Payer: Aetna American Axle |
$122.36
|
| Rate for Payer: Aetna Commercial |
$160.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.36
|
| Rate for Payer: Cash Price |
$150.59
|
| Rate for Payer: Cofinity Commercial |
$131.77
|
| Rate for Payer: Cofinity Commercial |
$161.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.59
|
| Rate for Payer: Healthscope Commercial |
$169.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.36
|
| Rate for Payer: Priority Health SBD |
$118.59
|
| Rate for Payer: UMR Bronson Commercial |
$82.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.18
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$123.12
|
|
|
Service Code
|
NDC 00904667104
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.55 |
| Max. Negotiated Rate |
$110.81 |
| Rate for Payer: Aetna American Axle |
$80.03
|
| Rate for Payer: Aetna Commercial |
$104.65
|
| Rate for Payer: Aetna Medicare |
$61.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.03
|
| Rate for Payer: BCBS Complete |
$49.25
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Cofinity Commercial |
$105.88
|
| Rate for Payer: Cofinity Commercial |
$86.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.50
|
| Rate for Payer: Healthscope Commercial |
$110.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.65
|
| Rate for Payer: PHP Commercial |
$104.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.03
|
| Rate for Payer: Priority Health SBD |
$77.57
|
| Rate for Payer: UMR Bronson Commercial |
$45.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.34
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
OP
|
$188.24
|
|
|
Service Code
|
NDC 65162035109
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.65 |
| Max. Negotiated Rate |
$169.42 |
| Rate for Payer: Aetna American Axle |
$122.36
|
| Rate for Payer: Aetna Commercial |
$160.00
|
| Rate for Payer: Aetna Medicare |
$94.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.36
|
| Rate for Payer: BCBS Complete |
$75.30
|
| Rate for Payer: Cash Price |
$150.59
|
| Rate for Payer: Cofinity Commercial |
$131.77
|
| Rate for Payer: Cofinity Commercial |
$161.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.59
|
| Rate for Payer: Healthscope Commercial |
$169.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.00
|
| Rate for Payer: PHP Commercial |
$160.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.36
|
| Rate for Payer: Priority Health SBD |
$118.59
|
| Rate for Payer: UMR Bronson Commercial |
$69.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.18
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$123.12
|
|
|
Service Code
|
NDC 00904667104
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.17 |
| Max. Negotiated Rate |
$110.81 |
| Rate for Payer: Aetna American Axle |
$80.03
|
| Rate for Payer: Aetna Commercial |
$104.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.03
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Cofinity Commercial |
$105.88
|
| Rate for Payer: Cofinity Commercial |
$86.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.50
|
| Rate for Payer: Healthscope Commercial |
$110.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.65
|
| Rate for Payer: PHP Commercial |
$104.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.03
|
| Rate for Payer: Priority Health SBD |
$77.57
|
| Rate for Payer: UMR Bronson Commercial |
$54.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.34
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
|
IP
|
$19,155.83
|
|
|
Service Code
|
NDC 00069419068
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8,428.57 |
| Max. Negotiated Rate |
$17,240.25 |
| Rate for Payer: Aetna American Axle |
$12,451.29
|
| Rate for Payer: Aetna Commercial |
$16,282.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,451.29
|
| Rate for Payer: Cash Price |
$15,324.66
|
| Rate for Payer: Cofinity Commercial |
$13,409.08
|
| Rate for Payer: Cofinity Commercial |
$16,474.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,409.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,324.66
|
| Rate for Payer: Healthscope Commercial |
$17,240.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,409.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,366.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,282.46
|
| Rate for Payer: PHP Commercial |
$16,282.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,451.29
|
| Rate for Payer: Priority Health SBD |
$12,068.17
|
| Rate for Payer: UMR Bronson Commercial |
$8,428.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,366.87
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$81.90
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.04 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna American Axle |
$53.24
|
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
| Rate for Payer: UMR Bronson Commercial |
$36.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.42
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna American Axle |
$3.35
|
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna Medicare |
$2.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.35
|
| Rate for Payer: BCBS Complete |
$2.06
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: Priority Health SBD |
$3.25
|
| Rate for Payer: UMR Bronson Commercial |
$1.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.87
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna American Axle |
$3.35
|
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.35
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: Priority Health SBD |
$3.25
|
| Rate for Payer: UMR Bronson Commercial |
$2.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.87
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna American Axle |
$53.24
|
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna Medicare |
$40.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: BCBS Complete |
$32.76
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
| Rate for Payer: UMR Bronson Commercial |
$30.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.42
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.04 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna American Axle |
$53.24
|
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
| Rate for Payer: UMR Bronson Commercial |
$36.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.42
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$81.90
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$73.71 |
| Rate for Payer: Aetna American Axle |
$53.24
|
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Aetna Medicare |
$40.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.24
|
| Rate for Payer: BCBS Complete |
$32.76
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$57.33
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$73.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: PHP Commercial |
$69.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health SBD |
$51.60
|
| Rate for Payer: UMR Bronson Commercial |
$30.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.42
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.81 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna American Axle |
$57.33
|
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.33
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$61.74
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health SBD |
$55.57
|
| Rate for Payer: UMR Bronson Commercial |
$38.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$88.20
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.63 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna American Axle |
$57.33
|
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna Medicare |
$44.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.33
|
| Rate for Payer: BCBS Complete |
$35.28
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$61.74
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health SBD |
$55.57
|
| Rate for Payer: UMR Bronson Commercial |
$32.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$141.40
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.32 |
| Max. Negotiated Rate |
$127.26 |
| Rate for Payer: Aetna American Axle |
$91.91
|
| Rate for Payer: Aetna Commercial |
$120.19
|
| Rate for Payer: Aetna Medicare |
$70.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.91
|
| Rate for Payer: BCBS Complete |
$56.56
|
| Rate for Payer: Cash Price |
$113.12
|
| Rate for Payer: Cofinity Commercial |
$121.60
|
| Rate for Payer: Cofinity Commercial |
$98.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.12
|
| Rate for Payer: Healthscope Commercial |
$127.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.19
|
| Rate for Payer: PHP Commercial |
$120.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.91
|
| Rate for Payer: Priority Health SBD |
$89.08
|
| Rate for Payer: UMR Bronson Commercial |
$52.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.05
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 61570013150
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.62 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna Medicare |
$14.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: BCBS Complete |
$11.48
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 61570013150
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.08
|
| Rate for Payer: UMR Bronson Commercial |
$12.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$141.40
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.22 |
| Max. Negotiated Rate |
$127.26 |
| Rate for Payer: Aetna American Axle |
$91.91
|
| Rate for Payer: Aetna Commercial |
$120.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.91
|
| Rate for Payer: Cash Price |
$113.12
|
| Rate for Payer: Cofinity Commercial |
$121.60
|
| Rate for Payer: Cofinity Commercial |
$98.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.12
|
| Rate for Payer: Healthscope Commercial |
$127.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.19
|
| Rate for Payer: PHP Commercial |
$120.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.91
|
| Rate for Payer: Priority Health SBD |
$89.08
|
| Rate for Payer: UMR Bronson Commercial |
$62.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.05
|
|
