|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 0049-0174-02
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.36 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.40
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
GLOSSECTOMY; LESS THAN ONE-HALF TONGUE
|
Facility
|
OP
|
$16,386.90
|
|
|
Service Code
|
CPT 41120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,037.99 |
| Max. Negotiated Rate |
$16,386.90 |
| Rate for Payer: Aetna Medicare |
$5,413.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,506.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,506.78
|
| Rate for Payer: BCBS Complete |
$2,989.99
|
| Rate for Payer: BCBS MAPPO |
$5,205.42
|
| Rate for Payer: BCBS Trust/PPO |
$4,481.61
|
| Rate for Payer: BCN Medicare Advantage |
$5,205.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,205.42
|
| Rate for Payer: Mclaren Medicaid |
$2,847.36
|
| Rate for Payer: Mclaren Medicare |
$5,205.42
|
| Rate for Payer: Meridian Medicaid |
$2,989.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,465.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,986.23
|
| Rate for Payer: PACE Medicare |
$4,945.15
|
| Rate for Payer: PACE SWMI |
$5,205.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,205.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,847.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,386.90
|
| Rate for Payer: Priority Health Medicare |
$5,205.42
|
| Rate for Payer: Priority Health Narrow Network |
$13,109.52
|
| Rate for Payer: Railroad Medicare Medicare |
$5,205.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,141.79
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,205.42
|
| Rate for Payer: UHC Exchange |
$1,037.99
|
| Rate for Payer: UHC Medicare Advantage |
$5,361.58
|
| Rate for Payer: VA VA |
$5,205.42
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$983.53
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
109673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$432.75 |
| Max. Negotiated Rate |
$885.18 |
| Rate for Payer: Aetna American Axle |
$639.29
|
| Rate for Payer: Aetna American Axle |
$660.32
|
| Rate for Payer: Aetna Commercial |
$863.49
|
| Rate for Payer: Aetna Commercial |
$836.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$660.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.29
|
| Rate for Payer: Cash Price |
$812.70
|
| Rate for Payer: Cash Price |
$786.82
|
| Rate for Payer: Cofinity Commercial |
$873.65
|
| Rate for Payer: Cofinity Commercial |
$711.11
|
| Rate for Payer: Cofinity Commercial |
$688.47
|
| Rate for Payer: Cofinity Commercial |
$845.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$812.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.82
|
| Rate for Payer: Healthscope Commercial |
$914.28
|
| Rate for Payer: Healthscope Commercial |
$885.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$711.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$688.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$761.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$737.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$863.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$836.00
|
| Rate for Payer: PHP Commercial |
$863.49
|
| Rate for Payer: PHP Commercial |
$836.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$688.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$711.11
|
| Rate for Payer: Priority Health SBD |
$640.00
|
| Rate for Payer: Priority Health SBD |
$619.62
|
| Rate for Payer: UMR Bronson Commercial |
$432.75
|
| Rate for Payer: UMR Bronson Commercial |
$446.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$761.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$737.65
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION
|
Facility
|
IP
|
$407.28
|
|
|
Service Code
|
HCPCS J1611
|
| Hospital Charge Code |
168350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$366.55 |
| Rate for Payer: Aetna American Axle |
$264.73
|
| Rate for Payer: Aetna American Axle |
$264.72
|
| Rate for Payer: Aetna Commercial |
$346.17
|
| Rate for Payer: Aetna Commercial |
$346.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.72
|
| Rate for Payer: Cash Price |
$325.81
|
| Rate for Payer: Cash Price |
$325.82
|
| Rate for Payer: Cofinity Commercial |
$350.26
|
| Rate for Payer: Cofinity Commercial |
$285.10
|
| Rate for Payer: Cofinity Commercial |
$350.24
|
| Rate for Payer: Cofinity Commercial |
$285.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.81
|
| Rate for Payer: Healthscope Commercial |
$366.53
|
| Rate for Payer: Healthscope Commercial |
$366.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$285.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$285.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$346.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$346.17
|
| Rate for Payer: PHP Commercial |
$346.19
|
| Rate for Payer: PHP Commercial |
$346.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.10
|
| Rate for Payer: Priority Health SBD |
$256.57
|
| Rate for Payer: Priority Health SBD |
$256.59
|
| Rate for Payer: UMR Bronson Commercial |
$179.19
|
| Rate for Payer: UMR Bronson Commercial |
$179.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.46
|
|
|
GLUCAGON HCL 1 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$709.79
|
|
|
Service Code
|
HCPCS J1611
|
| Hospital Charge Code |
192635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$312.31 |
| Max. Negotiated Rate |
$638.81 |
| Rate for Payer: Aetna American Axle |
$461.36
|
| Rate for Payer: Aetna Commercial |
$603.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$461.36
|
| Rate for Payer: Cash Price |
$567.83
|
| Rate for Payer: Cofinity Commercial |
$496.85
|
| Rate for Payer: Cofinity Commercial |
$610.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$567.83
|
| Rate for Payer: Healthscope Commercial |
$638.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$496.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$532.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$603.32
|
| Rate for Payer: PHP Commercial |
$603.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$496.85
|
| Rate for Payer: Priority Health SBD |
$447.17
|
| Rate for Payer: UMR Bronson Commercial |
$312.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$532.34
|
|
|
GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML SOLUTION FOR INJECTION VIAL
|
Facility
|
OP
|
$569.77
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
119849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.04 |
| Max. Negotiated Rate |
$608.71 |
| Rate for Payer: Aetna American Axle |
$370.35
|
| Rate for Payer: Aetna American Axle |
$370.36
|
| Rate for Payer: Aetna Commercial |
$484.31
|
| Rate for Payer: Aetna Commercial |
$484.30
|
| Rate for Payer: Aetna Medicare |
$195.90
|
| Rate for Payer: Aetna Medicare |
$195.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$370.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$370.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$235.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$235.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$235.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$235.46
|
| Rate for Payer: BCBS Complete |
$108.20
|
| Rate for Payer: BCBS Complete |
$108.20
|
| Rate for Payer: BCBS MAPPO |
$188.37
|
| Rate for Payer: BCBS MAPPO |
$188.37
|
| Rate for Payer: BCBS Trust/PPO |
$608.71
|
| Rate for Payer: BCBS Trust/PPO |
$608.71
|
| Rate for Payer: BCN Medicare Advantage |
$188.37
|
| Rate for Payer: BCN Medicare Advantage |
$188.37
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cofinity Commercial |
$398.84
|
| Rate for Payer: Cofinity Commercial |
$398.85
|
| Rate for Payer: Cofinity Commercial |
$490.00
|
| Rate for Payer: Cofinity Commercial |
$490.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$188.37
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$188.37
|
| Rate for Payer: Healthscope Commercial |
$512.80
|
| Rate for Payer: Healthscope Commercial |
$512.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$398.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$398.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$427.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$427.34
|
| Rate for Payer: Mclaren Medicaid |
$103.04
|
| Rate for Payer: Mclaren Medicaid |
$103.04
|
| Rate for Payer: Mclaren Medicare |
$188.37
|
| Rate for Payer: Mclaren Medicare |
$188.37
|
| Rate for Payer: Meridian Medicaid |
$108.20
|
| Rate for Payer: Meridian Medicaid |
$108.20
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$197.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$197.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$216.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$216.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$484.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$484.31
|
| Rate for Payer: PACE Medicare |
$178.95
|
| Rate for Payer: PACE Medicare |
$178.95
|
| Rate for Payer: PACE SWMI |
$188.37
|
| Rate for Payer: PACE SWMI |
$188.37
|
| Rate for Payer: PHP Commercial |
$484.31
|
| Rate for Payer: PHP Commercial |
$484.30
|
| Rate for Payer: PHP Medicare Advantage |
$188.37
|
| Rate for Payer: PHP Medicare Advantage |
$188.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$103.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$103.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$550.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$550.68
|
| Rate for Payer: Priority Health Medicare |
$188.37
|
| Rate for Payer: Priority Health Medicare |
$188.37
|
| Rate for Payer: Priority Health Narrow Network |
$440.54
|
| Rate for Payer: Priority Health Narrow Network |
$440.54
|
| Rate for Payer: Priority Health SBD |
$358.96
|
| Rate for Payer: Priority Health SBD |
$358.96
|
| Rate for Payer: Railroad Medicare Medicare |
$188.37
|
| Rate for Payer: Railroad Medicare Medicare |
$188.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$188.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$188.37
|
| Rate for Payer: UHC Medicare Advantage |
$194.02
|
| Rate for Payer: UHC Medicare Advantage |
$194.02
|
| Rate for Payer: UMR Bronson Commercial |
$210.81
|
| Rate for Payer: UMR Bronson Commercial |
$210.82
|
| Rate for Payer: VA VA |
$188.37
|
| Rate for Payer: VA VA |
$188.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$427.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$427.34
|
|
|
GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML SOLUTION FOR INJECTION VIAL
|
Facility
|
IP
|
$569.78
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
119849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$250.70 |
| Max. Negotiated Rate |
$512.80 |
| Rate for Payer: Aetna American Axle |
$370.36
|
| Rate for Payer: Aetna Commercial |
$484.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$370.36
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cofinity Commercial |
$398.85
|
| Rate for Payer: Cofinity Commercial |
$490.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.82
|
| Rate for Payer: Healthscope Commercial |
$512.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$398.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$427.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$484.31
|
| Rate for Payer: PHP Commercial |
$484.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.85
|
| Rate for Payer: Priority Health SBD |
$358.96
|
| Rate for Payer: UMR Bronson Commercial |
$250.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$427.34
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$39.60
|
|
|
Service Code
|
NDC 56151-1610-11
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Aetna American Axle |
$25.74
|
| Rate for Payer: Aetna Commercial |
$33.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.74
|
| Rate for Payer: Cash Price |
$31.68
|
| Rate for Payer: Cofinity Commercial |
$27.72
|
| Rate for Payer: Cofinity Commercial |
$34.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.68
|
| Rate for Payer: Healthscope Commercial |
$35.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.66
|
| Rate for Payer: PHP Commercial |
$33.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.72
|
| Rate for Payer: Priority Health SBD |
$24.95
|
| Rate for Payer: UMR Bronson Commercial |
$17.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.70
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$3.13
|
|
|
Service Code
|
NDC 3839652363
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.66
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$3.13
|
|
|
Service Code
|
NDC 3839652263
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.66
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$24.21
|
|
|
Service Code
|
NDC 3839650208
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$21.79 |
| Rate for Payer: Aetna American Axle |
$15.74
|
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.74
|
| Rate for Payer: Cash Price |
$19.37
|
| Rate for Payer: Cofinity Commercial |
$16.95
|
| Rate for Payer: Cofinity Commercial |
$20.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.37
|
| Rate for Payer: Healthscope Commercial |
$21.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.58
|
| Rate for Payer: PHP Commercial |
$20.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.95
|
| Rate for Payer: Priority Health SBD |
$15.25
|
| Rate for Payer: UMR Bronson Commercial |
$10.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.16
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$3.13
|
|
|
Service Code
|
NDC 3839650763
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.66
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$23.97
|
|
|
Service Code
|
NDC 3839652163
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$21.57 |
| Rate for Payer: Aetna American Axle |
$15.58
|
| Rate for Payer: Aetna Commercial |
$20.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.58
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cofinity Commercial |
$16.78
|
| Rate for Payer: Cofinity Commercial |
$20.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Healthscope Commercial |
$21.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.37
|
| Rate for Payer: PHP Commercial |
$20.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.78
|
| Rate for Payer: Priority Health SBD |
$15.10
|
| Rate for Payer: UMR Bronson Commercial |
$10.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.98
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 2129200434
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna American Axle |
$1.62
|
| Rate for Payer: Aetna Commercial |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.62
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$2.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.00
|
| Rate for Payer: Healthscope Commercial |
$2.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.12
|
| Rate for Payer: PHP Commercial |
$2.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.75
|
| Rate for Payer: Priority Health SBD |
$1.58
|
| Rate for Payer: UMR Bronson Commercial |
$1.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.88
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$5.60
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
170096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna American Axle |
$3.64
|
| Rate for Payer: Aetna Commercial |
$4.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.64
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cofinity Commercial |
$3.92
|
| Rate for Payer: Cofinity Commercial |
$4.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.48
|
| Rate for Payer: Healthscope Commercial |
$5.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.76
|
| Rate for Payer: PHP Commercial |
$4.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.92
|
| Rate for Payer: Priority Health SBD |
$3.53
|
| Rate for Payer: UMR Bronson Commercial |
$2.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.20
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$317.25
|
|
|
Service Code
|
NDC 43353-659-60
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.59 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna American Axle |
$206.21
|
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.21
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$222.08
|
| Rate for Payer: Cofinity Commercial |
$272.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$222.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$269.66
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.08
|
| Rate for Payer: Priority Health SBD |
$199.87
|
| Rate for Payer: UMR Bronson Commercial |
$139.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.94
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$126.90
|
|
|
Service Code
|
NDC 0093-9433-01
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.84 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna American Axle |
$82.48
|
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.48
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Cofinity Commercial |
$88.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.86
|
| Rate for Payer: PHP Commercial |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.83
|
| Rate for Payer: Priority Health SBD |
$79.95
|
| Rate for Payer: UMR Bronson Commercial |
$55.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.18
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 65862-029-01
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.07 |
| Max. Negotiated Rate |
$315.14 |
| Rate for Payer: Aetna American Axle |
$227.60
|
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.60
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$315.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$245.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$297.63
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.10
|
| Rate for Payer: Priority Health SBD |
$220.59
|
| Rate for Payer: UMR Bronson Commercial |
$154.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.61
|
|
|
GLYBURIDE 5 MG TABLET
|
Facility
|
IP
|
$217.55
|
|
|
Service Code
|
NDC 65862-030-01
|
| Hospital Charge Code |
3489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.72 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna American Axle |
$141.41
|
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.28
|
| Rate for Payer: Priority Health SBD |
$137.06
|
| Rate for Payer: UMR Bronson Commercial |
$95.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.16
|
|
|
GLYBURIDE MICRONIZED 3 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 0093-8035-01
|
| Hospital Charge Code |
14778
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$226.30 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.02
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.02
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
GLYBURIDE MICRONIZED 6 MG TABLET
|
Facility
|
IP
|
$331.35
|
|
|
Service Code
|
NDC 0093-8036-01
|
| Hospital Charge Code |
22146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.79 |
| Max. Negotiated Rate |
$298.22 |
| Rate for Payer: Aetna American Axle |
$215.38
|
| Rate for Payer: Aetna Commercial |
$281.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.38
|
| Rate for Payer: Cash Price |
$265.08
|
| Rate for Payer: Cofinity Commercial |
$231.94
|
| Rate for Payer: Cofinity Commercial |
$284.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.08
|
| Rate for Payer: Healthscope Commercial |
$298.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.65
|
| Rate for Payer: PHP Commercial |
$281.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.94
|
| Rate for Payer: Priority Health SBD |
$208.75
|
| Rate for Payer: UMR Bronson Commercial |
$145.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.51
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION
|
Facility
|
IP
|
$221.37
|
|
|
Service Code
|
NDC 0395-1031-16
|
| Hospital Charge Code |
116359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.40 |
| Max. Negotiated Rate |
$199.23 |
| Rate for Payer: Aetna American Axle |
$143.89
|
| Rate for Payer: Aetna Commercial |
$188.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.89
|
| Rate for Payer: Cash Price |
$177.10
|
| Rate for Payer: Cofinity Commercial |
$154.96
|
| Rate for Payer: Cofinity Commercial |
$190.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.10
|
| Rate for Payer: Healthscope Commercial |
$199.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$154.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$188.16
|
| Rate for Payer: PHP Commercial |
$188.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.96
|
| Rate for Payer: Priority Health SBD |
$139.46
|
| Rate for Payer: UMR Bronson Commercial |
$97.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.03
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION
|
Facility
|
IP
|
$44.61
|
|
|
Service Code
|
NDC 8770140072
|
| Hospital Charge Code |
116359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.63 |
| Max. Negotiated Rate |
$40.15 |
| Rate for Payer: Aetna American Axle |
$29.00
|
| Rate for Payer: Aetna Commercial |
$37.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.00
|
| Rate for Payer: Cash Price |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$31.23
|
| Rate for Payer: Cofinity Commercial |
$38.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.69
|
| Rate for Payer: Healthscope Commercial |
$40.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.92
|
| Rate for Payer: PHP Commercial |
$37.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.23
|
| Rate for Payer: Priority Health SBD |
$28.10
|
| Rate for Payer: UMR Bronson Commercial |
$19.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.46
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$56.40
|
|
|
Service Code
|
NDC 132007924
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.66
|
| Rate for Payer: Cash Price |
$45.12
|
| Rate for Payer: Cofinity Commercial |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.12
|
| Rate for Payer: Healthscope Commercial |
$50.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.94
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.48
|
| Rate for Payer: Priority Health SBD |
$35.53
|
| Rate for Payer: UMR Bronson Commercial |
$24.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$42.30
|
|
|
Service Code
|
NDC 58980-410-12
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.61 |
| Max. Negotiated Rate |
$38.07 |
| Rate for Payer: Aetna American Axle |
$27.50
|
| Rate for Payer: Aetna Commercial |
$35.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.50
|
| Rate for Payer: Cash Price |
$33.84
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Cofinity Commercial |
$36.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.84
|
| Rate for Payer: Healthscope Commercial |
$38.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.96
|
| Rate for Payer: PHP Commercial |
$35.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.61
|
| Rate for Payer: Priority Health SBD |
$26.65
|
| Rate for Payer: UMR Bronson Commercial |
$18.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
