|
ALUM, AMMONIUM (BULK) POWDER
|
Facility
|
IP
|
$343.57
|
|
|
Service Code
|
NDC 00395004912
|
| Hospital Charge Code |
345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.17 |
| Max. Negotiated Rate |
$309.21 |
| Rate for Payer: Aetna American Axle |
$223.32
|
| Rate for Payer: Aetna Commercial |
$292.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.32
|
| Rate for Payer: Cash Price |
$274.86
|
| Rate for Payer: Cofinity Commercial |
$240.50
|
| Rate for Payer: Cofinity Commercial |
$295.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$240.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.86
|
| Rate for Payer: Healthscope Commercial |
$309.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$240.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$257.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$292.03
|
| Rate for Payer: PHP Commercial |
$292.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.32
|
| Rate for Payer: Priority Health SBD |
$216.45
|
| Rate for Payer: UMR Bronson Commercial |
$151.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$257.68
|
|
|
ALUM, AMMONIUM (BULK) POWDER
|
Facility
|
IP
|
$143.82
|
|
|
Service Code
|
NDC 00395004996
|
| Hospital Charge Code |
345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.28 |
| Max. Negotiated Rate |
$129.44 |
| Rate for Payer: Aetna American Axle |
$93.48
|
| Rate for Payer: Aetna Commercial |
$122.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.48
|
| Rate for Payer: Cash Price |
$115.06
|
| Rate for Payer: Cofinity Commercial |
$100.67
|
| Rate for Payer: Cofinity Commercial |
$123.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$100.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.06
|
| Rate for Payer: Healthscope Commercial |
$129.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$100.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.25
|
| Rate for Payer: PHP Commercial |
$122.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.48
|
| Rate for Payer: Priority Health SBD |
$90.61
|
| Rate for Payer: UMR Bronson Commercial |
$63.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.86
|
|
|
ALUM, AMMONIUM (BULK) POWDER
|
Facility
|
OP
|
$143.82
|
|
|
Service Code
|
NDC 00395004996
|
| Hospital Charge Code |
345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.21 |
| Max. Negotiated Rate |
$129.44 |
| Rate for Payer: Aetna American Axle |
$93.48
|
| Rate for Payer: Aetna Commercial |
$122.25
|
| Rate for Payer: Aetna Medicare |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.48
|
| Rate for Payer: BCBS Complete |
$57.53
|
| Rate for Payer: Cash Price |
$115.06
|
| Rate for Payer: Cofinity Commercial |
$100.67
|
| Rate for Payer: Cofinity Commercial |
$123.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$100.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.06
|
| Rate for Payer: Healthscope Commercial |
$129.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$100.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.25
|
| Rate for Payer: PHP Commercial |
$122.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.48
|
| Rate for Payer: Priority Health SBD |
$90.61
|
| Rate for Payer: UMR Bronson Commercial |
$53.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.86
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$122.79
|
|
|
Service Code
|
NDC 00536009185
|
| Hospital Charge Code |
353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.03 |
| Max. Negotiated Rate |
$110.51 |
| Rate for Payer: Aetna American Axle |
$79.81
|
| Rate for Payer: Aetna Commercial |
$104.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.81
|
| Rate for Payer: Cash Price |
$98.23
|
| Rate for Payer: Cofinity Commercial |
$105.60
|
| Rate for Payer: Cofinity Commercial |
$85.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$85.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.23
|
| Rate for Payer: Healthscope Commercial |
$110.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.37
|
| Rate for Payer: PHP Commercial |
$104.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.81
|
| Rate for Payer: Priority Health SBD |
$77.36
|
| Rate for Payer: UMR Bronson Commercial |
$54.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.09
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$122.79
|
|
|
Service Code
|
NDC 00536009185
|
| Hospital Charge Code |
353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$110.51 |
| Rate for Payer: Aetna American Axle |
$79.81
|
| Rate for Payer: Aetna Commercial |
$104.37
|
| Rate for Payer: Aetna Medicare |
$61.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.81
|
| Rate for Payer: BCBS Complete |
$49.12
|
| Rate for Payer: Cash Price |
$98.23
|
| Rate for Payer: Cofinity Commercial |
$105.60
|
| Rate for Payer: Cofinity Commercial |
$85.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$85.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.23
|
| Rate for Payer: Healthscope Commercial |
$110.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.37
|
| Rate for Payer: PHP Commercial |
$104.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.81
|
| Rate for Payer: Priority Health SBD |
$77.36
|
| Rate for Payer: UMR Bronson Commercial |
$45.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.09
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 00904683873
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.67
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$11.33
|
|
|
Service Code
|
NDC 09900000191
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Aetna American Axle |
$7.36
|
| Rate for Payer: Aetna Commercial |
$9.63
|
| Rate for Payer: Aetna Medicare |
$5.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.36
|
| Rate for Payer: BCBS Complete |
$4.53
|
| Rate for Payer: Cash Price |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$7.93
|
| Rate for Payer: Cofinity Commercial |
$9.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.06
|
| Rate for Payer: Healthscope Commercial |
$10.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.63
|
| Rate for Payer: PHP Commercial |
$9.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.36
|
| Rate for Payer: Priority Health SBD |
$7.14
|
| Rate for Payer: UMR Bronson Commercial |
$4.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.50
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 57896062912
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna American Axle |
$10.39
|
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.39
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Commercial |
$11.19
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.78
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.58
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.39
|
| Rate for Payer: Priority Health SBD |
$10.07
|
| Rate for Payer: UMR Bronson Commercial |
$7.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.98
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$13.77
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.09 |
| Max. Negotiated Rate |
$12.39 |
| Rate for Payer: Aetna American Axle |
$8.95
|
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: Aetna Medicare |
$6.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.95
|
| Rate for Payer: BCBS Complete |
$5.51
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Healthscope Commercial |
$12.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.70
|
| Rate for Payer: PHP Commercial |
$11.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health SBD |
$8.68
|
| Rate for Payer: UMR Bronson Commercial |
$5.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.33
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$13.77
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$12.39 |
| Rate for Payer: Aetna American Axle |
$8.95
|
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.95
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Healthscope Commercial |
$12.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.70
|
| Rate for Payer: PHP Commercial |
$11.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health SBD |
$8.68
|
| Rate for Payer: UMR Bronson Commercial |
$6.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.33
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$11.33
|
|
|
Service Code
|
NDC 09900000191
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Aetna American Axle |
$7.36
|
| Rate for Payer: Aetna Commercial |
$9.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.36
|
| Rate for Payer: Cash Price |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$7.93
|
| Rate for Payer: Cofinity Commercial |
$9.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.06
|
| Rate for Payer: Healthscope Commercial |
$10.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.63
|
| Rate for Payer: PHP Commercial |
$9.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.36
|
| Rate for Payer: Priority Health SBD |
$7.14
|
| Rate for Payer: UMR Bronson Commercial |
$4.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.50
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 57896062912
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna American Axle |
$10.39
|
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: Aetna Medicare |
$7.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.39
|
| Rate for Payer: BCBS Complete |
$6.39
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Commercial |
$11.19
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.78
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.58
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.39
|
| Rate for Payer: Priority Health SBD |
$10.07
|
| Rate for Payer: UMR Bronson Commercial |
$5.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.98
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 00904683873
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna Medicare |
$5.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: BCBS Complete |
$4.10
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.67
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$79.67
|
|
|
Service Code
|
NDC 00121176230
|
| Hospital Charge Code |
9015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.05 |
| Max. Negotiated Rate |
$71.70 |
| Rate for Payer: Aetna American Axle |
$51.79
|
| Rate for Payer: Aetna Commercial |
$67.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.79
|
| Rate for Payer: Cash Price |
$63.74
|
| Rate for Payer: Cofinity Commercial |
$55.77
|
| Rate for Payer: Cofinity Commercial |
$68.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.74
|
| Rate for Payer: Healthscope Commercial |
$71.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.72
|
| Rate for Payer: PHP Commercial |
$67.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.79
|
| Rate for Payer: Priority Health SBD |
$50.19
|
| Rate for Payer: UMR Bronson Commercial |
$35.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.75
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$79.67
|
|
|
Service Code
|
NDC 00121176230
|
| Hospital Charge Code |
9015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$71.70 |
| Rate for Payer: Aetna American Axle |
$51.79
|
| Rate for Payer: Aetna Commercial |
$67.72
|
| Rate for Payer: Aetna Medicare |
$39.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.79
|
| Rate for Payer: BCBS Complete |
$31.87
|
| Rate for Payer: Cash Price |
$63.74
|
| Rate for Payer: Cofinity Commercial |
$55.77
|
| Rate for Payer: Cofinity Commercial |
$68.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.74
|
| Rate for Payer: Healthscope Commercial |
$71.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.72
|
| Rate for Payer: PHP Commercial |
$67.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.79
|
| Rate for Payer: Priority Health SBD |
$50.19
|
| Rate for Payer: UMR Bronson Commercial |
$29.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.75
|
|
|
ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 41874
|
|
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
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
IP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919002010
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8,881.07 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna American Axle |
$13,119.76
|
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,119.76
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$14,128.97
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$14,128.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,128.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,138.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,156.60
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,119.76
|
| Rate for Payer: Priority Health SBD |
$12,716.07
|
| Rate for Payer: UMR Bronson Commercial |
$8,881.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,138.18
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
OP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919002010
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,468.17 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna American Axle |
$13,119.76
|
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna Medicare |
$10,092.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,119.76
|
| Rate for Payer: BCBS Complete |
$8,073.70
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$14,128.97
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$14,128.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,128.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,138.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,156.60
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,119.76
|
| Rate for Payer: Priority Health SBD |
$12,716.07
|
| Rate for Payer: UMR Bronson Commercial |
$7,468.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,138.18
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
OP
|
$16,044.61
|
|
|
Service Code
|
NDC 00054066882
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,936.51 |
| Max. Negotiated Rate |
$14,440.15 |
| Rate for Payer: Aetna American Axle |
$10,429.00
|
| Rate for Payer: Aetna Commercial |
$13,637.92
|
| Rate for Payer: Aetna Medicare |
$8,022.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,429.00
|
| Rate for Payer: BCBS Complete |
$6,417.84
|
| Rate for Payer: Cash Price |
$12,835.69
|
| Rate for Payer: Cofinity Commercial |
$11,231.23
|
| Rate for Payer: Cofinity Commercial |
$13,798.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,231.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,835.69
|
| Rate for Payer: Healthscope Commercial |
$14,440.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11,231.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,033.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,637.92
|
| Rate for Payer: PHP Commercial |
$13,637.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,429.00
|
| Rate for Payer: Priority Health SBD |
$10,108.10
|
| Rate for Payer: UMR Bronson Commercial |
$5,936.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,033.46
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
IP
|
$16,044.61
|
|
|
Service Code
|
NDC 00054066882
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,059.63 |
| Max. Negotiated Rate |
$14,440.15 |
| Rate for Payer: Aetna American Axle |
$10,429.00
|
| Rate for Payer: Aetna Commercial |
$13,637.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,429.00
|
| Rate for Payer: Cash Price |
$12,835.69
|
| Rate for Payer: Cofinity Commercial |
$11,231.23
|
| Rate for Payer: Cofinity Commercial |
$13,798.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,231.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,835.69
|
| Rate for Payer: Healthscope Commercial |
$14,440.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11,231.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,033.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,637.92
|
| Rate for Payer: PHP Commercial |
$13,637.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,429.00
|
| Rate for Payer: Priority Health SBD |
$10,108.10
|
| Rate for Payer: UMR Bronson Commercial |
$7,059.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,033.46
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
|
OP
|
$359.52
|
|
|
Service Code
|
NDC 00832101500
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.02 |
| Max. Negotiated Rate |
$323.57 |
| Rate for Payer: Aetna American Axle |
$233.69
|
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: Aetna Medicare |
$179.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.69
|
| Rate for Payer: BCBS Complete |
$143.81
|
| Rate for Payer: Cash Price |
$287.62
|
| Rate for Payer: Cofinity Commercial |
$251.66
|
| Rate for Payer: Cofinity Commercial |
$309.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.62
|
| Rate for Payer: Healthscope Commercial |
$323.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.59
|
| Rate for Payer: PHP Commercial |
$305.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.69
|
| Rate for Payer: Priority Health SBD |
$226.50
|
| Rate for Payer: UMR Bronson Commercial |
$133.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.64
|
|
|
AMANTADINE HCL 100 MG CAPSULE
|
Facility
|
IP
|
$359.52
|
|
|
Service Code
|
NDC 00832101500
|
| Hospital Charge Code |
364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.19 |
| Max. Negotiated Rate |
$323.57 |
| Rate for Payer: Aetna American Axle |
$233.69
|
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.69
|
| Rate for Payer: Cash Price |
$287.62
|
| Rate for Payer: Cofinity Commercial |
$251.66
|
| Rate for Payer: Cofinity Commercial |
$309.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.62
|
| Rate for Payer: Healthscope Commercial |
$323.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.59
|
| Rate for Payer: PHP Commercial |
$305.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.69
|
| Rate for Payer: Priority Health SBD |
$226.50
|
| Rate for Payer: UMR Bronson Commercial |
$158.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.64
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$133.39
|
|
|
Service Code
|
NDC 50383080716
|
| Hospital Charge Code |
365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.69 |
| Max. Negotiated Rate |
$120.05 |
| Rate for Payer: Aetna American Axle |
$86.70
|
| Rate for Payer: Aetna Commercial |
$113.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.70
|
| Rate for Payer: Cash Price |
$106.71
|
| Rate for Payer: Cofinity Commercial |
$114.72
|
| Rate for Payer: Cofinity Commercial |
$93.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.71
|
| Rate for Payer: Healthscope Commercial |
$120.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.38
|
| Rate for Payer: PHP Commercial |
$113.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.70
|
| Rate for Payer: Priority Health SBD |
$84.04
|
| Rate for Payer: UMR Bronson Commercial |
$58.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.04
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$533.55
|
|
|
Service Code
|
NDC 00121064616
|
| Hospital Charge Code |
365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.76 |
| Max. Negotiated Rate |
$480.19 |
| Rate for Payer: Aetna American Axle |
$346.81
|
| Rate for Payer: Aetna Commercial |
$453.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.81
|
| Rate for Payer: Cash Price |
$426.84
|
| Rate for Payer: Cofinity Commercial |
$373.49
|
| Rate for Payer: Cofinity Commercial |
$458.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$373.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$426.84
|
| Rate for Payer: Healthscope Commercial |
$480.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$373.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$400.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$453.52
|
| Rate for Payer: PHP Commercial |
$453.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$346.81
|
| Rate for Payer: Priority Health SBD |
$336.14
|
| Rate for Payer: UMR Bronson Commercial |
$234.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$400.16
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$533.55
|
|
|
Service Code
|
NDC 00121064616
|
| Hospital Charge Code |
365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.41 |
| Max. Negotiated Rate |
$480.19 |
| Rate for Payer: Aetna American Axle |
$346.81
|
| Rate for Payer: Aetna Commercial |
$453.52
|
| Rate for Payer: Aetna Medicare |
$266.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.81
|
| Rate for Payer: BCBS Complete |
$213.42
|
| Rate for Payer: Cash Price |
$426.84
|
| Rate for Payer: Cofinity Commercial |
$373.49
|
| Rate for Payer: Cofinity Commercial |
$458.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$373.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$426.84
|
| Rate for Payer: Healthscope Commercial |
$480.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$373.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$400.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$453.52
|
| Rate for Payer: PHP Commercial |
$453.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$346.81
|
| Rate for Payer: Priority Health SBD |
$336.14
|
| Rate for Payer: UMR Bronson Commercial |
$197.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$400.16
|
|
