|
CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 28261
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$815.48 |
| Max. Negotiated Rate |
$4,928.37 |
| Rate for Payer: Aetna Medicare |
$1,630.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,960.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,960.06
|
| Rate for Payer: BCBS Complete |
$882.50
|
| Rate for Payer: BCBS MAPPO |
$1,568.05
|
| Rate for Payer: BCBS Trust/PPO |
$2,214.78
|
| Rate for Payer: BCN Commercial |
$2,214.78
|
| Rate for Payer: BCN Medicare Advantage |
$1,568.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,568.05
|
| Rate for Payer: Mclaren Medicaid |
$840.47
|
| Rate for Payer: Mclaren Medicare |
$1,568.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,646.45
|
| Rate for Payer: Meridian Medicaid |
$882.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,803.26
|
| Rate for Payer: Nomi Health Commercial |
$3,292.90
|
| Rate for Payer: PACE Medicare |
$1,489.65
|
| Rate for Payer: PACE SWMI |
$1,568.05
|
| Rate for Payer: PHP Medicare Advantage |
$1,568.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$840.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,928.37
|
| Rate for Payer: Priority Health Medicare |
$1,568.05
|
| Rate for Payer: Priority Health Narrow Network |
$3,942.70
|
| Rate for Payer: Railroad Medicare Medicare |
$1,568.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$897.03
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,568.05
|
| Rate for Payer: UHC Exchange |
$815.48
|
| Rate for Payer: UHC Medicare Advantage |
$1,568.05
|
| Rate for Payer: UHCCP Medicaid |
$840.47
|
| Rate for Payer: VA VA |
$1,568.05
|
|
|
CAPSULOTOMY, WRIST (EG, CONTRACTURE)
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 25085
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$436.67 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$2,214.78
|
| Rate for Payer: BCN Commercial |
$2,214.78
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$480.34
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$436.67
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,703.94
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
|
OP
|
$579.84
|
|
|
Service Code
|
NDC 51079086320
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.54 |
| Max. Negotiated Rate |
$521.86 |
| Rate for Payer: Aetna American Axle |
$376.90
|
| Rate for Payer: Aetna Commercial |
$492.86
|
| Rate for Payer: Aetna Medicare |
$289.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.90
|
| Rate for Payer: BCBS Complete |
$231.94
|
| Rate for Payer: Cash Price |
$463.87
|
| Rate for Payer: Cofinity Commercial |
$405.89
|
| Rate for Payer: Cofinity Commercial |
$498.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$405.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.87
|
| Rate for Payer: Healthscope Commercial |
$521.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$405.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.86
|
| Rate for Payer: PHP Commercial |
$492.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.90
|
| Rate for Payer: Priority Health SBD |
$365.30
|
| Rate for Payer: UMR Bronson Commercial |
$214.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.88
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
|
OP
|
$533.76
|
|
|
Service Code
|
NDC 00904710561
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.49 |
| Max. Negotiated Rate |
$480.38 |
| Rate for Payer: Aetna American Axle |
$346.94
|
| Rate for Payer: Aetna Commercial |
$453.70
|
| Rate for Payer: Aetna Medicare |
$266.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.94
|
| Rate for Payer: BCBS Complete |
$213.50
|
| Rate for Payer: Cash Price |
$427.01
|
| Rate for Payer: Cofinity Commercial |
$373.63
|
| Rate for Payer: Cofinity Commercial |
$459.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$373.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$427.01
|
| Rate for Payer: Healthscope Commercial |
$480.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$373.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$400.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$453.70
|
| Rate for Payer: PHP Commercial |
$453.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$346.94
|
| Rate for Payer: Priority Health SBD |
$336.27
|
| Rate for Payer: UMR Bronson Commercial |
$197.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$400.32
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
|
IP
|
$5.80
|
|
|
Service Code
|
NDC 51079086301
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna American Axle |
$3.77
|
| Rate for Payer: Aetna Commercial |
$4.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.77
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cofinity Commercial |
$4.06
|
| Rate for Payer: Cofinity Commercial |
$4.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.64
|
| Rate for Payer: Healthscope Commercial |
$5.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.93
|
| Rate for Payer: PHP Commercial |
$4.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.77
|
| Rate for Payer: Priority Health SBD |
$3.65
|
| Rate for Payer: UMR Bronson Commercial |
$2.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.35
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
|
OP
|
$5.80
|
|
|
Service Code
|
NDC 51079086301
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna American Axle |
$3.77
|
| Rate for Payer: Aetna Commercial |
$4.93
|
| Rate for Payer: Aetna Medicare |
$2.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.77
|
| Rate for Payer: BCBS Complete |
$2.32
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cofinity Commercial |
$4.06
|
| Rate for Payer: Cofinity Commercial |
$4.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.64
|
| Rate for Payer: Healthscope Commercial |
$5.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.93
|
| Rate for Payer: PHP Commercial |
$4.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.77
|
| Rate for Payer: Priority Health SBD |
$3.65
|
| Rate for Payer: UMR Bronson Commercial |
$2.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.35
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
|
IP
|
$533.76
|
|
|
Service Code
|
NDC 00904710561
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.85 |
| Max. Negotiated Rate |
$480.38 |
| Rate for Payer: Aetna American Axle |
$346.94
|
| Rate for Payer: Aetna Commercial |
$453.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.94
|
| Rate for Payer: Cash Price |
$427.01
|
| Rate for Payer: Cofinity Commercial |
$373.63
|
| Rate for Payer: Cofinity Commercial |
$459.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$373.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$427.01
|
| Rate for Payer: Healthscope Commercial |
$480.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$373.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$400.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$453.70
|
| Rate for Payer: PHP Commercial |
$453.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$346.94
|
| Rate for Payer: Priority Health SBD |
$336.27
|
| Rate for Payer: UMR Bronson Commercial |
$234.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$400.32
|
|
|
CAPTOPRIL 12.5 MG TABLET
|
Facility
|
IP
|
$579.84
|
|
|
Service Code
|
NDC 51079086320
|
| Hospital Charge Code |
9401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$255.13 |
| Max. Negotiated Rate |
$521.86 |
| Rate for Payer: Aetna American Axle |
$376.90
|
| Rate for Payer: Aetna Commercial |
$492.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.90
|
| Rate for Payer: Cash Price |
$463.87
|
| Rate for Payer: Cofinity Commercial |
$405.89
|
| Rate for Payer: Cofinity Commercial |
$498.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$405.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.87
|
| Rate for Payer: Healthscope Commercial |
$521.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$405.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.86
|
| Rate for Payer: PHP Commercial |
$492.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.90
|
| Rate for Payer: Priority Health SBD |
$365.30
|
| Rate for Payer: UMR Bronson Commercial |
$255.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.88
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$595.20
|
|
|
Service Code
|
NDC 51079086420
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.22 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna American Axle |
$386.88
|
| Rate for Payer: Aetna Commercial |
$505.92
|
| Rate for Payer: Aetna Medicare |
$297.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.88
|
| Rate for Payer: BCBS Complete |
$238.08
|
| Rate for Payer: Cash Price |
$476.16
|
| Rate for Payer: Cofinity Commercial |
$416.64
|
| Rate for Payer: Cofinity Commercial |
$511.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.16
|
| Rate for Payer: Healthscope Commercial |
$535.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$505.92
|
| Rate for Payer: PHP Commercial |
$505.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$386.88
|
| Rate for Payer: Priority Health SBD |
$374.98
|
| Rate for Payer: UMR Bronson Commercial |
$220.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.40
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$598.56
|
|
|
Service Code
|
NDC 00904710661
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$263.37 |
| Max. Negotiated Rate |
$538.70 |
| Rate for Payer: Aetna American Axle |
$389.06
|
| Rate for Payer: Aetna Commercial |
$508.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$389.06
|
| Rate for Payer: Cash Price |
$478.85
|
| Rate for Payer: Cofinity Commercial |
$418.99
|
| Rate for Payer: Cofinity Commercial |
$514.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$418.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$478.85
|
| Rate for Payer: Healthscope Commercial |
$538.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$418.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$448.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$508.78
|
| Rate for Payer: PHP Commercial |
$508.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.06
|
| Rate for Payer: Priority Health SBD |
$377.09
|
| Rate for Payer: UMR Bronson Commercial |
$263.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$448.92
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
NDC 60687031511
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$5.91 |
| Rate for Payer: Aetna American Axle |
$4.27
|
| Rate for Payer: Aetna Commercial |
$5.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.27
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Cofinity Commercial |
$4.60
|
| Rate for Payer: Cofinity Commercial |
$5.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.26
|
| Rate for Payer: Healthscope Commercial |
$5.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.58
|
| Rate for Payer: PHP Commercial |
$5.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.27
|
| Rate for Payer: Priority Health SBD |
$4.14
|
| Rate for Payer: UMR Bronson Commercial |
$2.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.93
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$281.28
|
|
|
Service Code
|
NDC 27241016101
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$253.15 |
| Rate for Payer: Aetna American Axle |
$182.83
|
| Rate for Payer: Aetna Commercial |
$239.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.83
|
| Rate for Payer: Cash Price |
$225.02
|
| Rate for Payer: Cofinity Commercial |
$196.90
|
| Rate for Payer: Cofinity Commercial |
$241.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.02
|
| Rate for Payer: Healthscope Commercial |
$253.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.09
|
| Rate for Payer: PHP Commercial |
$239.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.83
|
| Rate for Payer: Priority Health SBD |
$177.21
|
| Rate for Payer: UMR Bronson Commercial |
$123.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.96
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$598.56
|
|
|
Service Code
|
NDC 00904710661
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.47 |
| Max. Negotiated Rate |
$538.70 |
| Rate for Payer: Aetna American Axle |
$389.06
|
| Rate for Payer: Aetna Commercial |
$508.78
|
| Rate for Payer: Aetna Medicare |
$299.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$389.06
|
| Rate for Payer: BCBS Complete |
$239.42
|
| Rate for Payer: Cash Price |
$478.85
|
| Rate for Payer: Cofinity Commercial |
$418.99
|
| Rate for Payer: Cofinity Commercial |
$514.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$418.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$478.85
|
| Rate for Payer: Healthscope Commercial |
$538.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$418.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$448.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$508.78
|
| Rate for Payer: PHP Commercial |
$508.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.06
|
| Rate for Payer: Priority Health SBD |
$377.09
|
| Rate for Payer: UMR Bronson Commercial |
$221.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$448.92
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
NDC 60687031511
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$5.91 |
| Rate for Payer: Aetna American Axle |
$4.27
|
| Rate for Payer: Aetna Commercial |
$5.58
|
| Rate for Payer: Aetna Medicare |
$3.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.27
|
| Rate for Payer: BCBS Complete |
$2.63
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Cofinity Commercial |
$4.60
|
| Rate for Payer: Cofinity Commercial |
$5.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.26
|
| Rate for Payer: Healthscope Commercial |
$5.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.58
|
| Rate for Payer: PHP Commercial |
$5.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.27
|
| Rate for Payer: Priority Health SBD |
$4.14
|
| Rate for Payer: UMR Bronson Commercial |
$2.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.93
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$5.96
|
|
|
Service Code
|
NDC 51079086401
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna American Axle |
$3.87
|
| Rate for Payer: Aetna Commercial |
$5.07
|
| Rate for Payer: Aetna Medicare |
$2.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.87
|
| Rate for Payer: BCBS Complete |
$2.38
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cofinity Commercial |
$4.17
|
| Rate for Payer: Cofinity Commercial |
$5.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.77
|
| Rate for Payer: Healthscope Commercial |
$5.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.07
|
| Rate for Payer: PHP Commercial |
$5.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.87
|
| Rate for Payer: Priority Health SBD |
$3.75
|
| Rate for Payer: UMR Bronson Commercial |
$2.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.47
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
NDC 60687031521
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.68 |
| Max. Negotiated Rate |
$177.30 |
| Rate for Payer: Aetna American Axle |
$128.05
|
| Rate for Payer: Aetna Commercial |
$167.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.05
|
| Rate for Payer: Cash Price |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$137.90
|
| Rate for Payer: Cofinity Commercial |
$169.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$137.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.60
|
| Rate for Payer: Healthscope Commercial |
$177.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$137.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.45
|
| Rate for Payer: PHP Commercial |
$167.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.05
|
| Rate for Payer: Priority Health SBD |
$124.11
|
| Rate for Payer: UMR Bronson Commercial |
$86.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.75
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$5.96
|
|
|
Service Code
|
NDC 51079086401
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna American Axle |
$3.87
|
| Rate for Payer: Aetna Commercial |
$5.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.87
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cofinity Commercial |
$4.17
|
| Rate for Payer: Cofinity Commercial |
$5.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.77
|
| Rate for Payer: Healthscope Commercial |
$5.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.07
|
| Rate for Payer: PHP Commercial |
$5.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.87
|
| Rate for Payer: Priority Health SBD |
$3.75
|
| Rate for Payer: UMR Bronson Commercial |
$2.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.47
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$281.28
|
|
|
Service Code
|
NDC 27241016101
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.07 |
| Max. Negotiated Rate |
$253.15 |
| Rate for Payer: Aetna American Axle |
$182.83
|
| Rate for Payer: Aetna Commercial |
$239.09
|
| Rate for Payer: Aetna Medicare |
$140.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.83
|
| Rate for Payer: BCBS Complete |
$112.51
|
| Rate for Payer: Cash Price |
$225.02
|
| Rate for Payer: Cofinity Commercial |
$196.90
|
| Rate for Payer: Cofinity Commercial |
$241.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.02
|
| Rate for Payer: Healthscope Commercial |
$253.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.09
|
| Rate for Payer: PHP Commercial |
$239.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.83
|
| Rate for Payer: Priority Health SBD |
$177.21
|
| Rate for Payer: UMR Bronson Commercial |
$104.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.96
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$595.20
|
|
|
Service Code
|
NDC 51079086420
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.89 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna American Axle |
$386.88
|
| Rate for Payer: Aetna Commercial |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.88
|
| Rate for Payer: Cash Price |
$476.16
|
| Rate for Payer: Cofinity Commercial |
$416.64
|
| Rate for Payer: Cofinity Commercial |
$511.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.16
|
| Rate for Payer: Healthscope Commercial |
$535.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$505.92
|
| Rate for Payer: PHP Commercial |
$505.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$386.88
|
| Rate for Payer: Priority Health SBD |
$374.98
|
| Rate for Payer: UMR Bronson Commercial |
$261.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.40
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
NDC 60687031521
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.89 |
| Max. Negotiated Rate |
$177.30 |
| Rate for Payer: Aetna American Axle |
$128.05
|
| Rate for Payer: Aetna Commercial |
$167.45
|
| Rate for Payer: Aetna Medicare |
$98.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.05
|
| Rate for Payer: BCBS Complete |
$78.80
|
| Rate for Payer: Cash Price |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$137.90
|
| Rate for Payer: Cofinity Commercial |
$169.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$137.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.60
|
| Rate for Payer: Healthscope Commercial |
$177.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$137.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.45
|
| Rate for Payer: PHP Commercial |
$167.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.05
|
| Rate for Payer: Priority Health SBD |
$124.11
|
| Rate for Payer: UMR Bronson Commercial |
$72.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.75
|
|
|
CARBACHOL 0.01 % INTRAOCULAR SOLUTION
|
Facility
|
IP
|
$41.89
|
|
|
Service Code
|
NDC 00065002315
|
| Hospital Charge Code |
19704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.43 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna American Axle |
$27.23
|
| Rate for Payer: Aetna Commercial |
$35.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.23
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cofinity Commercial |
$29.32
|
| Rate for Payer: Cofinity Commercial |
$36.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.51
|
| Rate for Payer: Healthscope Commercial |
$37.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.61
|
| Rate for Payer: PHP Commercial |
$35.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.23
|
| Rate for Payer: Priority Health SBD |
$26.39
|
| Rate for Payer: UMR Bronson Commercial |
$18.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.42
|
|
|
CARBACHOL 0.01 % INTRAOCULAR SOLUTION
|
Facility
|
OP
|
$41.89
|
|
|
Service Code
|
NDC 00065002315
|
| Hospital Charge Code |
19704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna American Axle |
$27.23
|
| Rate for Payer: Aetna Commercial |
$35.61
|
| Rate for Payer: Aetna Medicare |
$20.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.23
|
| Rate for Payer: BCBS Complete |
$16.76
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cofinity Commercial |
$29.32
|
| Rate for Payer: Cofinity Commercial |
$36.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.51
|
| Rate for Payer: Healthscope Commercial |
$37.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.61
|
| Rate for Payer: PHP Commercial |
$35.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.23
|
| Rate for Payer: Priority Health SBD |
$26.39
|
| Rate for Payer: UMR Bronson Commercial |
$15.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.42
|
|
|
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,290.15
|
|
|
Service Code
|
NDC 51672404709
|
| Hospital Charge Code |
109663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$477.36 |
| Max. Negotiated Rate |
$1,161.14 |
| Rate for Payer: Aetna American Axle |
$838.60
|
| Rate for Payer: Aetna Commercial |
$1,096.63
|
| Rate for Payer: Aetna Medicare |
$645.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$838.60
|
| Rate for Payer: BCBS Complete |
$516.06
|
| Rate for Payer: Cash Price |
$1,032.12
|
| Rate for Payer: Cofinity Commercial |
$1,109.53
|
| Rate for Payer: Cofinity Commercial |
$903.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$903.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,032.12
|
| Rate for Payer: Healthscope Commercial |
$1,161.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$903.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$967.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,096.63
|
| Rate for Payer: PHP Commercial |
$1,096.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$838.60
|
| Rate for Payer: Priority Health SBD |
$812.79
|
| Rate for Payer: UMR Bronson Commercial |
$477.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$967.61
|
|
|
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,290.15
|
|
|
Service Code
|
NDC 51672404709
|
| Hospital Charge Code |
109663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$567.67 |
| Max. Negotiated Rate |
$1,161.14 |
| Rate for Payer: Aetna American Axle |
$838.60
|
| Rate for Payer: Aetna Commercial |
$1,096.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$838.60
|
| Rate for Payer: Cash Price |
$1,032.12
|
| Rate for Payer: Cofinity Commercial |
$1,109.53
|
| Rate for Payer: Cofinity Commercial |
$903.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$903.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,032.12
|
| Rate for Payer: Healthscope Commercial |
$1,161.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$903.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$967.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,096.63
|
| Rate for Payer: PHP Commercial |
$1,096.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$838.60
|
| Rate for Payer: Priority Health SBD |
$812.79
|
| Rate for Payer: UMR Bronson Commercial |
$567.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$967.61
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
IP
|
$320.15
|
|
|
Service Code
|
NDC 00904385461
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.87 |
| Max. Negotiated Rate |
$288.14 |
| Rate for Payer: Aetna American Axle |
$208.10
|
| Rate for Payer: Aetna Commercial |
$272.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.10
|
| Rate for Payer: Cash Price |
$256.12
|
| Rate for Payer: Cofinity Commercial |
$224.10
|
| Rate for Payer: Cofinity Commercial |
$275.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$224.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.12
|
| Rate for Payer: Healthscope Commercial |
$288.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$224.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$240.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$272.13
|
| Rate for Payer: PHP Commercial |
$272.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.10
|
| Rate for Payer: Priority Health SBD |
$201.69
|
| Rate for Payer: UMR Bronson Commercial |
$140.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$240.11
|
|
