|
URIDINE TRIACETATE 10 GRAM ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$16,371.58
|
|
|
Service Code
|
NDC 50633022010
|
| Hospital Charge Code |
177130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,203.50 |
| Max. Negotiated Rate |
$14,734.42 |
| Rate for Payer: Aetna American Axle |
$10,641.53
|
| Rate for Payer: Aetna Commercial |
$13,915.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,641.53
|
| Rate for Payer: Cash Price |
$13,097.26
|
| Rate for Payer: Cofinity Commercial |
$11,460.11
|
| Rate for Payer: Cofinity Commercial |
$14,079.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,460.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,097.26
|
| Rate for Payer: Healthscope Commercial |
$14,734.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11,460.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,278.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,915.84
|
| Rate for Payer: PHP Commercial |
$13,915.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,641.53
|
| Rate for Payer: Priority Health SBD |
$10,314.10
|
| Rate for Payer: UMR Bronson Commercial |
$7,203.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,278.68
|
|
|
URIDINE TRIACETATE 10 GRAM ORAL GRANULES IN PACKET
|
Facility
|
OP
|
$16,371.58
|
|
|
Service Code
|
NDC 50633022010
|
| Hospital Charge Code |
177130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,057.48 |
| Max. Negotiated Rate |
$14,734.42 |
| Rate for Payer: Aetna American Axle |
$10,641.53
|
| Rate for Payer: Aetna Commercial |
$13,915.84
|
| Rate for Payer: Aetna Medicare |
$8,185.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,641.53
|
| Rate for Payer: BCBS Complete |
$6,548.63
|
| Rate for Payer: Cash Price |
$13,097.26
|
| Rate for Payer: Cofinity Commercial |
$11,460.11
|
| Rate for Payer: Cofinity Commercial |
$14,079.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,460.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,097.26
|
| Rate for Payer: Healthscope Commercial |
$14,734.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11,460.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,278.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,915.84
|
| Rate for Payer: PHP Commercial |
$13,915.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,641.53
|
| Rate for Payer: Priority Health SBD |
$10,314.10
|
| Rate for Payer: UMR Bronson Commercial |
$6,057.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,278.68
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
OP
|
$632.64
|
|
|
Service Code
|
NDC 70710112701
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.08 |
| Max. Negotiated Rate |
$569.38 |
| Rate for Payer: Aetna American Axle |
$411.22
|
| Rate for Payer: Aetna Commercial |
$537.74
|
| Rate for Payer: Aetna Medicare |
$316.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.22
|
| Rate for Payer: BCBS Complete |
$253.06
|
| Rate for Payer: Cash Price |
$506.11
|
| Rate for Payer: Cofinity Commercial |
$442.85
|
| Rate for Payer: Cofinity Commercial |
$544.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$442.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$506.11
|
| Rate for Payer: Healthscope Commercial |
$569.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$442.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$474.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$537.74
|
| Rate for Payer: PHP Commercial |
$537.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$411.22
|
| Rate for Payer: Priority Health SBD |
$398.56
|
| Rate for Payer: UMR Bronson Commercial |
$234.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$474.48
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
IP
|
$632.64
|
|
|
Service Code
|
NDC 70710112701
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.36 |
| Max. Negotiated Rate |
$569.38 |
| Rate for Payer: Aetna American Axle |
$411.22
|
| Rate for Payer: Aetna Commercial |
$537.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.22
|
| Rate for Payer: Cash Price |
$506.11
|
| Rate for Payer: Cofinity Commercial |
$442.85
|
| Rate for Payer: Cofinity Commercial |
$544.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$442.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$506.11
|
| Rate for Payer: Healthscope Commercial |
$569.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$442.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$474.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$537.74
|
| Rate for Payer: PHP Commercial |
$537.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$411.22
|
| Rate for Payer: Priority Health SBD |
$398.56
|
| Rate for Payer: UMR Bronson Commercial |
$278.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$474.48
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
OP
|
$632.64
|
|
|
Service Code
|
NDC 49884041201
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.08 |
| Max. Negotiated Rate |
$569.38 |
| Rate for Payer: Aetna American Axle |
$411.22
|
| Rate for Payer: Aetna Commercial |
$537.74
|
| Rate for Payer: Aetna Medicare |
$316.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.22
|
| Rate for Payer: BCBS Complete |
$253.06
|
| Rate for Payer: Cash Price |
$506.11
|
| Rate for Payer: Cofinity Commercial |
$442.85
|
| Rate for Payer: Cofinity Commercial |
$544.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$442.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$506.11
|
| Rate for Payer: Healthscope Commercial |
$569.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$442.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$474.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$537.74
|
| Rate for Payer: PHP Commercial |
$537.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$411.22
|
| Rate for Payer: Priority Health SBD |
$398.56
|
| Rate for Payer: UMR Bronson Commercial |
$234.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$474.48
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
OP
|
$467.40
|
|
|
Service Code
|
NDC 64380091806
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.94 |
| Max. Negotiated Rate |
$420.66 |
| Rate for Payer: Aetna American Axle |
$303.81
|
| Rate for Payer: Aetna Commercial |
$397.29
|
| Rate for Payer: Aetna Medicare |
$233.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$303.81
|
| Rate for Payer: BCBS Complete |
$186.96
|
| Rate for Payer: Cash Price |
$373.92
|
| Rate for Payer: Cofinity Commercial |
$327.18
|
| Rate for Payer: Cofinity Commercial |
$401.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$327.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.92
|
| Rate for Payer: Healthscope Commercial |
$420.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$327.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$350.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$397.29
|
| Rate for Payer: PHP Commercial |
$397.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.81
|
| Rate for Payer: Priority Health SBD |
$294.46
|
| Rate for Payer: UMR Bronson Commercial |
$172.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$350.55
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
IP
|
$467.40
|
|
|
Service Code
|
NDC 64380091806
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.66 |
| Max. Negotiated Rate |
$420.66 |
| Rate for Payer: Aetna American Axle |
$303.81
|
| Rate for Payer: Aetna Commercial |
$397.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$303.81
|
| Rate for Payer: Cash Price |
$373.92
|
| Rate for Payer: Cofinity Commercial |
$327.18
|
| Rate for Payer: Cofinity Commercial |
$401.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$327.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.92
|
| Rate for Payer: Healthscope Commercial |
$420.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$327.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$350.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$397.29
|
| Rate for Payer: PHP Commercial |
$397.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.81
|
| Rate for Payer: Priority Health SBD |
$294.46
|
| Rate for Payer: UMR Bronson Commercial |
$205.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$350.55
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
IP
|
$632.64
|
|
|
Service Code
|
NDC 49884041201
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.36 |
| Max. Negotiated Rate |
$569.38 |
| Rate for Payer: Aetna American Axle |
$411.22
|
| Rate for Payer: Aetna Commercial |
$537.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.22
|
| Rate for Payer: Cash Price |
$506.11
|
| Rate for Payer: Cofinity Commercial |
$442.85
|
| Rate for Payer: Cofinity Commercial |
$544.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$442.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$506.11
|
| Rate for Payer: Healthscope Commercial |
$569.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$442.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$474.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$537.74
|
| Rate for Payer: PHP Commercial |
$537.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$411.22
|
| Rate for Payer: Priority Health SBD |
$398.56
|
| Rate for Payer: UMR Bronson Commercial |
$278.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$474.48
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
IP
|
$754.43
|
|
|
Service Code
|
NDC 00591299801
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.95 |
| Max. Negotiated Rate |
$678.99 |
| Rate for Payer: Aetna American Axle |
$490.38
|
| Rate for Payer: Aetna Commercial |
$641.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$490.38
|
| Rate for Payer: Cash Price |
$603.54
|
| Rate for Payer: Cofinity Commercial |
$528.10
|
| Rate for Payer: Cofinity Commercial |
$648.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$528.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$603.54
|
| Rate for Payer: Healthscope Commercial |
$678.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$528.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$565.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$641.27
|
| Rate for Payer: PHP Commercial |
$641.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$490.38
|
| Rate for Payer: Priority Health SBD |
$475.29
|
| Rate for Payer: UMR Bronson Commercial |
$331.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$565.82
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
OP
|
$754.43
|
|
|
Service Code
|
NDC 00591299801
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$279.14 |
| Max. Negotiated Rate |
$678.99 |
| Rate for Payer: Aetna American Axle |
$490.38
|
| Rate for Payer: Aetna Commercial |
$641.27
|
| Rate for Payer: Aetna Medicare |
$377.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$490.38
|
| Rate for Payer: BCBS Complete |
$301.77
|
| Rate for Payer: Cash Price |
$603.54
|
| Rate for Payer: Cofinity Commercial |
$528.10
|
| Rate for Payer: Cofinity Commercial |
$648.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$528.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$603.54
|
| Rate for Payer: Healthscope Commercial |
$678.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$528.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$565.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$641.27
|
| Rate for Payer: PHP Commercial |
$641.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$490.38
|
| Rate for Payer: Priority Health SBD |
$475.29
|
| Rate for Payer: UMR Bronson Commercial |
$279.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$565.82
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$558.24
|
|
|
Service Code
|
NDC 00527132601
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.63 |
| Max. Negotiated Rate |
$502.42 |
| Rate for Payer: Aetna American Axle |
$362.86
|
| Rate for Payer: Aetna Commercial |
$474.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$362.86
|
| Rate for Payer: Cash Price |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$390.77
|
| Rate for Payer: Cofinity Commercial |
$480.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$390.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$446.59
|
| Rate for Payer: Healthscope Commercial |
$502.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$390.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$418.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$474.50
|
| Rate for Payer: PHP Commercial |
$474.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.86
|
| Rate for Payer: Priority Health SBD |
$351.69
|
| Rate for Payer: UMR Bronson Commercial |
$245.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$418.68
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$558.24
|
|
|
Service Code
|
NDC 00527132601
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.55 |
| Max. Negotiated Rate |
$502.42 |
| Rate for Payer: Aetna American Axle |
$362.86
|
| Rate for Payer: Aetna Commercial |
$474.50
|
| Rate for Payer: Aetna Medicare |
$279.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$362.86
|
| Rate for Payer: BCBS Complete |
$223.30
|
| Rate for Payer: Cash Price |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$390.77
|
| Rate for Payer: Cofinity Commercial |
$480.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$390.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$446.59
|
| Rate for Payer: Healthscope Commercial |
$502.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$390.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$418.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$474.50
|
| Rate for Payer: PHP Commercial |
$474.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.86
|
| Rate for Payer: Priority Health SBD |
$351.69
|
| Rate for Payer: UMR Bronson Commercial |
$206.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$418.68
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$468.96
|
|
|
Service Code
|
NDC 69238154001
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.52 |
| Max. Negotiated Rate |
$422.06 |
| Rate for Payer: Aetna American Axle |
$304.82
|
| Rate for Payer: Aetna Commercial |
$398.62
|
| Rate for Payer: Aetna Medicare |
$234.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$304.82
|
| Rate for Payer: BCBS Complete |
$187.58
|
| Rate for Payer: Cash Price |
$375.17
|
| Rate for Payer: Cofinity Commercial |
$328.27
|
| Rate for Payer: Cofinity Commercial |
$403.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$328.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.17
|
| Rate for Payer: Healthscope Commercial |
$422.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$328.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$351.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$398.62
|
| Rate for Payer: PHP Commercial |
$398.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$304.82
|
| Rate for Payer: Priority Health SBD |
$295.44
|
| Rate for Payer: UMR Bronson Commercial |
$173.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$351.72
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
NDC 00591315901
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.64 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna American Axle |
$296.40
|
| Rate for Payer: Aetna Commercial |
$387.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.40
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cofinity Commercial |
$319.20
|
| Rate for Payer: Cofinity Commercial |
$392.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$319.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.80
|
| Rate for Payer: Healthscope Commercial |
$410.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$342.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.60
|
| Rate for Payer: PHP Commercial |
$387.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.40
|
| Rate for Payer: Priority Health SBD |
$287.28
|
| Rate for Payer: UMR Bronson Commercial |
$200.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$342.00
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$468.96
|
|
|
Service Code
|
NDC 69238154001
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.34 |
| Max. Negotiated Rate |
$422.06 |
| Rate for Payer: Aetna American Axle |
$304.82
|
| Rate for Payer: Aetna Commercial |
$398.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$304.82
|
| Rate for Payer: Cash Price |
$375.17
|
| Rate for Payer: Cofinity Commercial |
$328.27
|
| Rate for Payer: Cofinity Commercial |
$403.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$328.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.17
|
| Rate for Payer: Healthscope Commercial |
$422.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$328.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$351.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$398.62
|
| Rate for Payer: PHP Commercial |
$398.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$304.82
|
| Rate for Payer: Priority Health SBD |
$295.44
|
| Rate for Payer: UMR Bronson Commercial |
$206.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$351.72
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$365.75
|
|
|
Service Code
|
NDC 42806050301
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.33 |
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Aetna American Axle |
$237.74
|
| Rate for Payer: Aetna Commercial |
$310.89
|
| Rate for Payer: Aetna Medicare |
$182.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.74
|
| Rate for Payer: BCBS Complete |
$146.30
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$256.02
|
| Rate for Payer: Cofinity Commercial |
$314.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$329.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: PHP Commercial |
$310.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health SBD |
$230.42
|
| Rate for Payer: UMR Bronson Commercial |
$135.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.31
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
NDC 00591315901
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.72 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna American Axle |
$296.40
|
| Rate for Payer: Aetna Commercial |
$387.60
|
| Rate for Payer: Aetna Medicare |
$228.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.40
|
| Rate for Payer: BCBS Complete |
$182.40
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cofinity Commercial |
$319.20
|
| Rate for Payer: Cofinity Commercial |
$392.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$319.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.80
|
| Rate for Payer: Healthscope Commercial |
$410.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$342.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.60
|
| Rate for Payer: PHP Commercial |
$387.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.40
|
| Rate for Payer: Priority Health SBD |
$287.28
|
| Rate for Payer: UMR Bronson Commercial |
$168.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$342.00
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$365.75
|
|
|
Service Code
|
NDC 42806050301
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.93 |
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Aetna American Axle |
$237.74
|
| Rate for Payer: Aetna Commercial |
$310.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.74
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$256.02
|
| Rate for Payer: Cofinity Commercial |
$314.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$329.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: PHP Commercial |
$310.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health SBD |
$230.42
|
| Rate for Payer: UMR Bronson Commercial |
$160.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.31
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,511.09
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
180872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.96 |
| Max. Negotiated Rate |
$4,959.98 |
| Rate for Payer: Aetna American Axle |
$3,582.21
|
| Rate for Payer: Aetna Commercial |
$4,684.43
|
| Rate for Payer: Aetna Medicare |
$13.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,582.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.24
|
| Rate for Payer: BCBS Complete |
$7.31
|
| Rate for Payer: BCBS MAPPO |
$12.99
|
| Rate for Payer: BCN Medicare Advantage |
$12.99
|
| Rate for Payer: Cash Price |
$4,408.87
|
| Rate for Payer: Cash Price |
$4,408.87
|
| Rate for Payer: Cofinity Commercial |
$4,739.54
|
| Rate for Payer: Cofinity Commercial |
$3,857.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,857.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,408.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.99
|
| Rate for Payer: Healthscope Commercial |
$4,959.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,857.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,133.32
|
| Rate for Payer: Mclaren Medicaid |
$6.96
|
| Rate for Payer: Mclaren Medicare |
$12.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.64
|
| Rate for Payer: Meridian Medicaid |
$7.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,684.43
|
| Rate for Payer: PACE Medicare |
$12.34
|
| Rate for Payer: PACE SWMI |
$12.99
|
| Rate for Payer: PHP Commercial |
$4,684.43
|
| Rate for Payer: PHP Medicare Advantage |
$12.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,582.21
|
| Rate for Payer: Priority Health Medicare |
$12.99
|
| Rate for Payer: Priority Health SBD |
$3,471.99
|
| Rate for Payer: Railroad Medicare Medicare |
$12.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.99
|
| Rate for Payer: UHC Exchange |
$24.83
|
| Rate for Payer: UHC Medicare Advantage |
$12.99
|
| Rate for Payer: UHCCP Medicaid |
$6.96
|
| Rate for Payer: UMR Bronson Commercial |
$2,039.10
|
| Rate for Payer: VA VA |
$12.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,133.32
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,511.09
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
180872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,424.88 |
| Max. Negotiated Rate |
$4,959.98 |
| Rate for Payer: Aetna American Axle |
$3,582.21
|
| Rate for Payer: Aetna Commercial |
$4,684.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,582.21
|
| Rate for Payer: Cash Price |
$4,408.87
|
| Rate for Payer: Cofinity Commercial |
$3,857.76
|
| Rate for Payer: Cofinity Commercial |
$4,739.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,857.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,408.87
|
| Rate for Payer: Healthscope Commercial |
$4,959.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,857.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,133.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,684.43
|
| Rate for Payer: PHP Commercial |
$4,684.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,582.21
|
| Rate for Payer: Priority Health SBD |
$3,471.99
|
| Rate for Payer: UMR Bronson Commercial |
$2,424.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,133.32
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$73,898.95
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
119469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.08 |
| Max. Negotiated Rate |
$66,509.05 |
| Rate for Payer: Aetna American Axle |
$48,034.32
|
| Rate for Payer: Aetna Commercial |
$62,814.11
|
| Rate for Payer: Aetna Medicare |
$155.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48,034.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$186.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$186.75
|
| Rate for Payer: BCBS Complete |
$84.08
|
| Rate for Payer: BCBS MAPPO |
$149.40
|
| Rate for Payer: BCN Medicare Advantage |
$149.40
|
| Rate for Payer: Cash Price |
$59,119.16
|
| Rate for Payer: Cash Price |
$59,119.16
|
| Rate for Payer: Cofinity Commercial |
$63,553.10
|
| Rate for Payer: Cofinity Commercial |
$51,729.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$51,729.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59,119.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$149.40
|
| Rate for Payer: Healthscope Commercial |
$66,509.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51,729.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55,424.21
|
| Rate for Payer: Mclaren Medicaid |
$80.08
|
| Rate for Payer: Mclaren Medicare |
$149.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$156.87
|
| Rate for Payer: Meridian Medicaid |
$84.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$171.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62,814.11
|
| Rate for Payer: PACE Medicare |
$141.93
|
| Rate for Payer: PACE SWMI |
$149.40
|
| Rate for Payer: PHP Commercial |
$62,814.11
|
| Rate for Payer: PHP Medicare Advantage |
$149.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$80.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48,034.32
|
| Rate for Payer: Priority Health Medicare |
$149.40
|
| Rate for Payer: Priority Health SBD |
$46,556.34
|
| Rate for Payer: Railroad Medicare Medicare |
$149.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$420.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$149.40
|
| Rate for Payer: UHC Exchange |
$285.52
|
| Rate for Payer: UHC Medicare Advantage |
$149.40
|
| Rate for Payer: UHCCP Medicaid |
$80.08
|
| Rate for Payer: UMR Bronson Commercial |
$27,342.61
|
| Rate for Payer: VA VA |
$149.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55,424.21
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$73,898.95
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
119469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32,515.54 |
| Max. Negotiated Rate |
$66,509.05 |
| Rate for Payer: Aetna American Axle |
$48,034.32
|
| Rate for Payer: Aetna Commercial |
$62,814.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48,034.32
|
| Rate for Payer: Cash Price |
$59,119.16
|
| Rate for Payer: Cofinity Commercial |
$51,729.26
|
| Rate for Payer: Cofinity Commercial |
$63,553.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$51,729.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59,119.16
|
| Rate for Payer: Healthscope Commercial |
$66,509.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51,729.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55,424.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62,814.11
|
| Rate for Payer: PHP Commercial |
$62,814.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48,034.32
|
| Rate for Payer: Priority Health SBD |
$46,556.34
|
| Rate for Payer: UMR Bronson Commercial |
$32,515.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55,424.21
|
|
|
UTERINE EVACUATION AND CURETTAGE FOR HYDATIDIFORM MOLE
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 59870
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
UVULECTOMY, EXCISION OF UVULA
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 42140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,695.31 |
| Max. Negotiated Rate |
$8,903.25 |
| Rate for Payer: Aetna Medicare |
$3,289.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,953.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,953.62
|
| Rate for Payer: BCBS Complete |
$1,780.08
|
| Rate for Payer: BCBS MAPPO |
$3,162.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,162.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,162.90
|
| Rate for Payer: Mclaren Medicaid |
$1,695.31
|
| Rate for Payer: Mclaren Medicare |
$3,162.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,321.05
|
| Rate for Payer: Meridian Medicaid |
$1,780.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,637.34
|
| Rate for Payer: PACE Medicare |
$3,004.76
|
| Rate for Payer: PACE SWMI |
$3,162.90
|
| Rate for Payer: PHP Medicare Advantage |
$3,162.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.31
|
| Rate for Payer: Priority Health Medicare |
$3,162.90
|
| Rate for Payer: Railroad Medicare Medicare |
$3,162.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,903.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,162.90
|
| Rate for Payer: UHC Exchange |
$6,044.62
|
| Rate for Payer: UHC Medicare Advantage |
$3,162.90
|
| Rate for Payer: UHCCP Medicaid |
$1,695.31
|
| Rate for Payer: VA VA |
$3,162.90
|
|
|
VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 58260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
