|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.50
|
|
|
Service Code
|
NDC 0143-9784-01
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$16.65 |
| Rate for Payer: Aetna American Axle |
$12.02
|
| Rate for Payer: Aetna Commercial |
$15.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.02
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$15.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$16.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.72
|
| Rate for Payer: PHP Commercial |
$15.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.95
|
| Rate for Payer: Priority Health SBD |
$11.66
|
| Rate for Payer: UMR Bronson Commercial |
$8.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.88
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18.50
|
|
|
Service Code
|
NDC 0143-9784-10
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$16.65 |
| Rate for Payer: Aetna American Axle |
$12.02
|
| Rate for Payer: Aetna Commercial |
$15.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.02
|
| Rate for Payer: BCBS Complete |
$7.40
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$15.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$16.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.72
|
| Rate for Payer: PHP Commercial |
$15.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.95
|
| Rate for Payer: Priority Health SBD |
$11.66
|
| Rate for Payer: UMR Bronson Commercial |
$6.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.88
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.50
|
|
|
Service Code
|
NDC 0143-9784-10
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$16.65 |
| Rate for Payer: Aetna American Axle |
$12.02
|
| Rate for Payer: Aetna Commercial |
$15.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.02
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$15.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$16.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.72
|
| Rate for Payer: PHP Commercial |
$15.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.95
|
| Rate for Payer: Priority Health SBD |
$11.66
|
| Rate for Payer: UMR Bronson Commercial |
$8.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.88
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.76
|
|
|
Service Code
|
NDC 36000-148-10
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$18.68 |
| Rate for Payer: Aetna American Axle |
$13.49
|
| Rate for Payer: Aetna Commercial |
$17.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.49
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cofinity Commercial |
$14.53
|
| Rate for Payer: Cofinity Commercial |
$17.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.61
|
| Rate for Payer: Healthscope Commercial |
$18.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.65
|
| Rate for Payer: PHP Commercial |
$17.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.53
|
| Rate for Payer: Priority Health SBD |
$13.08
|
| Rate for Payer: UMR Bronson Commercial |
$9.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.57
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$30.67
|
|
|
Service Code
|
NDC 63323-424-05
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.49 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna American Axle |
$19.94
|
| Rate for Payer: Aetna Commercial |
$26.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.94
|
| Rate for Payer: Cash Price |
$24.54
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Cofinity Commercial |
$26.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.54
|
| Rate for Payer: Healthscope Commercial |
$27.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.07
|
| Rate for Payer: PHP Commercial |
$26.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.47
|
| Rate for Payer: Priority Health SBD |
$19.32
|
| Rate for Payer: UMR Bronson Commercial |
$13.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.00
|
|
|
FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.76
|
|
|
Service Code
|
NDC 36000-148-01
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$18.68 |
| Rate for Payer: Aetna American Axle |
$13.49
|
| Rate for Payer: Aetna Commercial |
$17.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.49
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cofinity Commercial |
$14.53
|
| Rate for Payer: Cofinity Commercial |
$17.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.61
|
| Rate for Payer: Healthscope Commercial |
$18.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.65
|
| Rate for Payer: PHP Commercial |
$17.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.53
|
| Rate for Payer: Priority Health SBD |
$13.08
|
| Rate for Payer: UMR Bronson Commercial |
$9.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.57
|
|
|
FLUMAZENIL 0.1 MG/ML IV (CODE)
|
Facility
|
IP
|
$18.50
|
|
|
Service Code
|
NDC 0143-9784-10
|
| Hospital Charge Code |
163712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$16.65 |
| Rate for Payer: Aetna American Axle |
$12.02
|
| Rate for Payer: Aetna Commercial |
$15.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.02
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$15.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$16.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.72
|
| Rate for Payer: PHP Commercial |
$15.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.95
|
| Rate for Payer: Priority Health SBD |
$11.66
|
| Rate for Payer: UMR Bronson Commercial |
$8.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.88
|
|
|
FLUOCINOLONE 0.01 % TOPICAL SOLUTION
|
Facility
|
IP
|
$261.03
|
|
|
Service Code
|
NDC 52565-012-59
|
| Hospital Charge Code |
3186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.85 |
| Max. Negotiated Rate |
$234.93 |
| Rate for Payer: Aetna American Axle |
$169.67
|
| Rate for Payer: Aetna Commercial |
$221.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.67
|
| Rate for Payer: Cash Price |
$208.82
|
| Rate for Payer: Cofinity Commercial |
$182.72
|
| Rate for Payer: Cofinity Commercial |
$224.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.82
|
| Rate for Payer: Healthscope Commercial |
$234.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.88
|
| Rate for Payer: PHP Commercial |
$221.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.72
|
| Rate for Payer: Priority Health SBD |
$164.45
|
| Rate for Payer: UMR Bronson Commercial |
$114.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.77
|
|
|
FLUOCINOLONE 0.01 % TOPICAL SOLUTION
|
Facility
|
IP
|
$65.10
|
|
|
Service Code
|
NDC 51672-1365-4
|
| Hospital Charge Code |
3186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.64 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna American Axle |
$42.32
|
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.32
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$45.57
|
| Rate for Payer: Cofinity Commercial |
$55.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.34
|
| Rate for Payer: PHP Commercial |
$55.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.57
|
| Rate for Payer: Priority Health SBD |
$41.01
|
| Rate for Payer: UMR Bronson Commercial |
$28.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.82
|
|
|
FLUOCINOLONE 0.01 % TOPICAL SOLUTION
|
Facility
|
IP
|
$108.78
|
|
|
Service Code
|
NDC 0168-0059-60
|
| Hospital Charge Code |
3186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.86 |
| Max. Negotiated Rate |
$97.90 |
| Rate for Payer: Aetna American Axle |
$70.71
|
| Rate for Payer: Aetna Commercial |
$92.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.71
|
| Rate for Payer: Cash Price |
$87.02
|
| Rate for Payer: Cofinity Commercial |
$76.15
|
| Rate for Payer: Cofinity Commercial |
$93.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.02
|
| Rate for Payer: Healthscope Commercial |
$97.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.46
|
| Rate for Payer: PHP Commercial |
$92.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.15
|
| Rate for Payer: Priority Health SBD |
$68.53
|
| Rate for Payer: UMR Bronson Commercial |
$47.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.58
|
|
|
FLUOCINOLONE 0.01 % TOPICAL SOLUTION
|
Facility
|
IP
|
$65.10
|
|
|
Service Code
|
NDC 21922-003-01
|
| Hospital Charge Code |
3186
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.64 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna American Axle |
$42.32
|
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.32
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$45.57
|
| Rate for Payer: Cofinity Commercial |
$55.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.34
|
| Rate for Payer: PHP Commercial |
$55.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.57
|
| Rate for Payer: Priority Health SBD |
$41.01
|
| Rate for Payer: UMR Bronson Commercial |
$28.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.82
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT
|
Facility
|
IP
|
$133.62
|
|
|
Service Code
|
NDC 47781-569-72
|
| Hospital Charge Code |
3189
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.79 |
| Max. Negotiated Rate |
$120.26 |
| Rate for Payer: Aetna American Axle |
$86.85
|
| Rate for Payer: Aetna Commercial |
$113.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.85
|
| Rate for Payer: Cash Price |
$106.90
|
| Rate for Payer: Cofinity Commercial |
$114.91
|
| Rate for Payer: Cofinity Commercial |
$93.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.90
|
| Rate for Payer: Healthscope Commercial |
$120.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.58
|
| Rate for Payer: PHP Commercial |
$113.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.53
|
| Rate for Payer: Priority Health SBD |
$84.18
|
| Rate for Payer: UMR Bronson Commercial |
$58.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.22
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT
|
Facility
|
IP
|
$25.47
|
|
|
Service Code
|
NDC 51672-1264-1
|
| Hospital Charge Code |
3189
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$22.92 |
| Rate for Payer: Aetna American Axle |
$16.56
|
| Rate for Payer: Aetna Commercial |
$21.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.56
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Cofinity Commercial |
$17.83
|
| Rate for Payer: Cofinity Commercial |
$21.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.38
|
| Rate for Payer: Healthscope Commercial |
$22.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.65
|
| Rate for Payer: PHP Commercial |
$21.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.83
|
| Rate for Payer: Priority Health SBD |
$16.05
|
| Rate for Payer: UMR Bronson Commercial |
$11.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.10
|
|
|
FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$125.43
|
|
|
Service Code
|
NDC 51672-1254-1
|
| Hospital Charge Code |
115137
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.19 |
| Max. Negotiated Rate |
$112.89 |
| Rate for Payer: Aetna American Axle |
$81.53
|
| Rate for Payer: Aetna Commercial |
$106.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.53
|
| Rate for Payer: Cash Price |
$100.34
|
| Rate for Payer: Cofinity Commercial |
$107.87
|
| Rate for Payer: Cofinity Commercial |
$87.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.34
|
| Rate for Payer: Healthscope Commercial |
$112.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$106.62
|
| Rate for Payer: PHP Commercial |
$106.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.80
|
| Rate for Payer: Priority Health SBD |
$79.02
|
| Rate for Payer: UMR Bronson Commercial |
$55.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.07
|
|
|
FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$49.41
|
|
|
Service Code
|
NDC 0093-0263-15
|
| Hospital Charge Code |
115137
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$44.47 |
| Rate for Payer: Aetna American Axle |
$32.12
|
| Rate for Payer: Aetna Commercial |
$42.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.12
|
| Rate for Payer: Cash Price |
$39.53
|
| Rate for Payer: Cofinity Commercial |
$34.59
|
| Rate for Payer: Cofinity Commercial |
$42.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.53
|
| Rate for Payer: Healthscope Commercial |
$44.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$42.00
|
| Rate for Payer: PHP Commercial |
$42.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.59
|
| Rate for Payer: Priority Health SBD |
$31.13
|
| Rate for Payer: UMR Bronson Commercial |
$21.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.06
|
|
|
FLUORESCEIN 0.6 MG EYE STRIPS
|
Facility
|
IP
|
$571.05
|
|
|
Service Code
|
NDC 17478-403-03
|
| Hospital Charge Code |
27662
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$251.26 |
| Max. Negotiated Rate |
$513.94 |
| Rate for Payer: Aetna American Axle |
$371.18
|
| Rate for Payer: Aetna Commercial |
$485.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$371.18
|
| Rate for Payer: Cash Price |
$456.84
|
| Rate for Payer: Cofinity Commercial |
$399.74
|
| Rate for Payer: Cofinity Commercial |
$491.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$456.84
|
| Rate for Payer: Healthscope Commercial |
$513.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$399.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$428.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$485.39
|
| Rate for Payer: PHP Commercial |
$485.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$399.74
|
| Rate for Payer: Priority Health SBD |
$359.76
|
| Rate for Payer: UMR Bronson Commercial |
$251.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$428.29
|
|
|
FLUORESCEIN 1 MG EYE STRIPS
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 17478-404-01
|
| Hospital Charge Code |
27663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna American Axle |
$1.51
|
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.51
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cofinity Commercial |
$1.63
|
| Rate for Payer: Cofinity Commercial |
$2.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.86
|
| Rate for Payer: Healthscope Commercial |
$2.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.98
|
| Rate for Payer: PHP Commercial |
$1.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health SBD |
$1.47
|
| Rate for Payer: UMR Bronson Commercial |
$1.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.75
|
|
|
FLUORESCEIN 1 MG EYE STRIPS
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 17238-900-99
|
| Hospital Charge Code |
27663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna American Axle |
$2.98
|
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.98
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cofinity Commercial |
$3.21
|
| Rate for Payer: Cofinity Commercial |
$3.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.67
|
| Rate for Payer: Healthscope Commercial |
$4.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.90
|
| Rate for Payer: PHP Commercial |
$3.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.21
|
| Rate for Payer: Priority Health SBD |
$2.89
|
| Rate for Payer: UMR Bronson Commercial |
$2.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.44
|
|
|
FLUORESCEIN 1 MG EYE STRIPS
|
Facility
|
IP
|
$458.25
|
|
|
Service Code
|
NDC 17238-900-11
|
| Hospital Charge Code |
27663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$201.63 |
| Max. Negotiated Rate |
$412.42 |
| Rate for Payer: Aetna American Axle |
$297.86
|
| Rate for Payer: Aetna Commercial |
$389.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.86
|
| Rate for Payer: Cash Price |
$366.60
|
| Rate for Payer: Cofinity Commercial |
$320.78
|
| Rate for Payer: Cofinity Commercial |
$394.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.60
|
| Rate for Payer: Healthscope Commercial |
$412.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$320.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$343.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$389.51
|
| Rate for Payer: PHP Commercial |
$389.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.78
|
| Rate for Payer: Priority Health SBD |
$288.70
|
| Rate for Payer: UMR Bronson Commercial |
$201.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$343.69
|
|
|
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$199.57
|
|
|
Service Code
|
NDC 0065-0092-65
|
| Hospital Charge Code |
10059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.81 |
| Max. Negotiated Rate |
$179.61 |
| Rate for Payer: Aetna American Axle |
$129.72
|
| Rate for Payer: Aetna Commercial |
$169.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.72
|
| Rate for Payer: Cash Price |
$159.66
|
| Rate for Payer: Cofinity Commercial |
$171.63
|
| Rate for Payer: Cofinity Commercial |
$139.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.66
|
| Rate for Payer: Healthscope Commercial |
$179.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$169.63
|
| Rate for Payer: PHP Commercial |
$169.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.70
|
| Rate for Payer: Priority Health SBD |
$125.73
|
| Rate for Payer: UMR Bronson Commercial |
$87.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.68
|
|
|
FLUORIDE 0.5 MG (1.1 MG SODIUM FLUORIDE)/ML ORAL DROPS
|
Facility
|
IP
|
$149.23
|
|
|
Service Code
|
NDC 4494610328
|
| Hospital Charge Code |
11406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.66 |
| Max. Negotiated Rate |
$134.31 |
| Rate for Payer: Aetna American Axle |
$97.00
|
| Rate for Payer: Aetna Commercial |
$126.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.00
|
| Rate for Payer: Cash Price |
$119.38
|
| Rate for Payer: Cofinity Commercial |
$104.46
|
| Rate for Payer: Cofinity Commercial |
$128.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.38
|
| Rate for Payer: Healthscope Commercial |
$134.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.85
|
| Rate for Payer: PHP Commercial |
$126.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.46
|
| Rate for Payer: Priority Health SBD |
$94.01
|
| Rate for Payer: UMR Bronson Commercial |
$65.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.92
|
|
|
FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$548.21
|
|
|
Service Code
|
NDC 11980-211-05
|
| Hospital Charge Code |
3208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.21 |
| Max. Negotiated Rate |
$493.39 |
| Rate for Payer: Aetna American Axle |
$356.34
|
| Rate for Payer: Aetna Commercial |
$465.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$356.34
|
| Rate for Payer: Cash Price |
$438.57
|
| Rate for Payer: Cofinity Commercial |
$383.75
|
| Rate for Payer: Cofinity Commercial |
$471.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$438.57
|
| Rate for Payer: Healthscope Commercial |
$493.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$383.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$411.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$465.98
|
| Rate for Payer: PHP Commercial |
$465.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$383.75
|
| Rate for Payer: Priority Health SBD |
$345.37
|
| Rate for Payer: UMR Bronson Commercial |
$241.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$411.16
|
|
|
FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$252.07
|
|
|
Service Code
|
NDC 60758-880-05
|
| Hospital Charge Code |
3208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.91 |
| Max. Negotiated Rate |
$226.86 |
| Rate for Payer: Aetna American Axle |
$163.85
|
| Rate for Payer: Aetna Commercial |
$214.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.85
|
| Rate for Payer: Cash Price |
$201.66
|
| Rate for Payer: Cofinity Commercial |
$176.45
|
| Rate for Payer: Cofinity Commercial |
$216.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.66
|
| Rate for Payer: Healthscope Commercial |
$226.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$189.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$214.26
|
| Rate for Payer: PHP Commercial |
$214.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.45
|
| Rate for Payer: Priority Health SBD |
$158.80
|
| Rate for Payer: UMR Bronson Commercial |
$110.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$189.05
|
|
|
FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$171.04
|
|
|
Service Code
|
CPT 77002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$113.95 |
| Max. Negotiated Rate |
$171.04 |
| Rate for Payer: BCBS Trust/PPO |
$171.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.34
|
| Rate for Payer: UHC Exchange |
$113.95
|
|
|
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$124.88
|
|
|
Service Code
|
HCPCS J9190
|
| Hospital Charge Code |
82204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$112.39 |
| Rate for Payer: Aetna American Axle |
$81.17
|
| Rate for Payer: Aetna Commercial |
$106.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.17
|
| Rate for Payer: BCBS Complete |
$49.95
|
| Rate for Payer: BCBS Trust/PPO |
$10.37
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cash Price |
$99.90
|
| Rate for Payer: Cofinity Commercial |
$107.40
|
| Rate for Payer: Cofinity Commercial |
$87.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$99.90
|
| Rate for Payer: Healthscope Commercial |
$112.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$106.15
|
| Rate for Payer: PHP Commercial |
$106.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.42
|
| Rate for Payer: Priority Health SBD |
$78.67
|
| Rate for Payer: UMR Bronson Commercial |
$46.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.66
|
|
