|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE
|
Facility
|
OP
|
$10,039.01
|
|
|
Service Code
|
CPT 15771
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$505.57 |
| Max. Negotiated Rate |
$10,039.01 |
| Rate for Payer: Aetna Medicare |
$3,316.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,986.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,986.20
|
| Rate for Payer: BCBS Complete |
$1,831.74
|
| Rate for Payer: BCBS MAPPO |
$3,188.96
|
| Rate for Payer: BCBS Trust/PPO |
$4,338.83
|
| Rate for Payer: BCN Medicare Advantage |
$3,188.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,188.96
|
| Rate for Payer: Mclaren Medicaid |
$1,744.36
|
| Rate for Payer: Mclaren Medicare |
$3,188.96
|
| Rate for Payer: Meridian Medicaid |
$1,831.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,348.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,667.30
|
| Rate for Payer: PACE Medicare |
$3,029.51
|
| Rate for Payer: PACE SWMI |
$3,188.96
|
| Rate for Payer: PHP Medicare Advantage |
$3,188.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,744.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,039.01
|
| Rate for Payer: Priority Health Medicare |
$3,188.96
|
| Rate for Payer: Priority Health Narrow Network |
$8,031.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3,188.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$556.13
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,188.96
|
| Rate for Payer: UHC Exchange |
$505.57
|
| Rate for Payer: UHC Medicare Advantage |
$3,284.63
|
| Rate for Payer: VA VA |
$3,188.96
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$144.40 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$611.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$158.84
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$144.40
|
|
|
GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)
|
Facility
|
OP
|
$10,039.01
|
|
|
Service Code
|
CPT 15769
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$474.14 |
| Max. Negotiated Rate |
$10,039.01 |
| Rate for Payer: Aetna Medicare |
$3,316.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,986.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,986.20
|
| Rate for Payer: BCBS Complete |
$1,831.74
|
| Rate for Payer: BCBS MAPPO |
$3,188.96
|
| Rate for Payer: BCBS Trust/PPO |
$2,481.85
|
| Rate for Payer: BCN Medicare Advantage |
$3,188.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,188.96
|
| Rate for Payer: Mclaren Medicaid |
$1,744.36
|
| Rate for Payer: Mclaren Medicare |
$3,188.96
|
| Rate for Payer: Meridian Medicaid |
$1,831.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,348.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,667.30
|
| Rate for Payer: PACE Medicare |
$3,029.51
|
| Rate for Payer: PACE SWMI |
$3,188.96
|
| Rate for Payer: PHP Medicare Advantage |
$3,188.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,744.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,039.01
|
| Rate for Payer: Priority Health Medicare |
$3,188.96
|
| Rate for Payer: Priority Health Narrow Network |
$8,031.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3,188.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$521.55
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,188.96
|
| Rate for Payer: UHC Exchange |
$474.14
|
| Rate for Payer: UHC Medicare Advantage |
$3,284.63
|
| Rate for Payer: VA VA |
$3,188.96
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$17.93
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
117977
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$16.14 |
| Rate for Payer: Aetna American Axle |
$11.65
|
| Rate for Payer: Aetna Commercial |
$15.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.65
|
| Rate for Payer: BCBS Complete |
$7.17
|
| Rate for Payer: BCBS Trust/PPO |
$1.21
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cofinity Commercial |
$12.55
|
| Rate for Payer: Cofinity Commercial |
$15.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.34
|
| Rate for Payer: Healthscope Commercial |
$16.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.24
|
| Rate for Payer: PHP Commercial |
$15.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health SBD |
$11.30
|
| Rate for Payer: UMR Bronson Commercial |
$6.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.45
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$27.09
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
117977
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.92 |
| Max. Negotiated Rate |
$24.38 |
| Rate for Payer: Aetna American Axle |
$17.61
|
| Rate for Payer: Aetna Commercial |
$23.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.61
|
| Rate for Payer: Cash Price |
$21.67
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$23.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.67
|
| Rate for Payer: Healthscope Commercial |
$24.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.03
|
| Rate for Payer: PHP Commercial |
$23.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.96
|
| Rate for Payer: Priority Health SBD |
$17.07
|
| Rate for Payer: UMR Bronson Commercial |
$11.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.32
|
|
|
GRANISETRON HCL 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$291.57
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
12552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.29 |
| Max. Negotiated Rate |
$262.41 |
| Rate for Payer: Aetna American Axle |
$189.52
|
| Rate for Payer: Aetna American Axle |
$48.83
|
| Rate for Payer: Aetna Commercial |
$247.83
|
| Rate for Payer: Aetna Commercial |
$63.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.52
|
| Rate for Payer: Cash Price |
$233.26
|
| Rate for Payer: Cash Price |
$60.10
|
| Rate for Payer: Cofinity Commercial |
$64.61
|
| Rate for Payer: Cofinity Commercial |
$204.10
|
| Rate for Payer: Cofinity Commercial |
$250.75
|
| Rate for Payer: Cofinity Commercial |
$52.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.26
|
| Rate for Payer: Healthscope Commercial |
$262.41
|
| Rate for Payer: Healthscope Commercial |
$67.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$247.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.86
|
| Rate for Payer: PHP Commercial |
$247.83
|
| Rate for Payer: PHP Commercial |
$63.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.59
|
| Rate for Payer: Priority Health SBD |
$183.69
|
| Rate for Payer: Priority Health SBD |
$47.33
|
| Rate for Payer: UMR Bronson Commercial |
$128.29
|
| Rate for Payer: UMR Bronson Commercial |
$33.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.35
|
|
|
GRANISETRON HCL 1 MG TABLET
|
Facility
|
OP
|
$126.53
|
|
|
Service Code
|
HCPCS Q0166
|
| Hospital Charge Code |
14720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$113.88 |
| Rate for Payer: Aetna American Axle |
$82.24
|
| Rate for Payer: Aetna Commercial |
$107.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.24
|
| Rate for Payer: BCBS Complete |
$50.61
|
| Rate for Payer: BCBS Trust/PPO |
$6.34
|
| Rate for Payer: Cash Price |
$101.22
|
| Rate for Payer: Cash Price |
$101.22
|
| Rate for Payer: Cofinity Commercial |
$108.82
|
| Rate for Payer: Cofinity Commercial |
$88.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.22
|
| Rate for Payer: Healthscope Commercial |
$113.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.55
|
| Rate for Payer: PHP Commercial |
$107.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.57
|
| Rate for Payer: Priority Health SBD |
$79.71
|
| Rate for Payer: UMR Bronson Commercial |
$46.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.90
|
|
|
GRANISETRON HCL 1 MG TABLET
|
Facility
|
IP
|
$126.53
|
|
|
Service Code
|
HCPCS Q0166
|
| Hospital Charge Code |
14720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.67 |
| Max. Negotiated Rate |
$113.88 |
| Rate for Payer: Aetna American Axle |
$82.24
|
| Rate for Payer: Aetna American Axle |
$4.11
|
| Rate for Payer: Aetna Commercial |
$107.55
|
| Rate for Payer: Aetna Commercial |
$5.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.11
|
| Rate for Payer: Cash Price |
$101.22
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Cofinity Commercial |
$5.44
|
| Rate for Payer: Cofinity Commercial |
$4.43
|
| Rate for Payer: Cofinity Commercial |
$108.82
|
| Rate for Payer: Cofinity Commercial |
$88.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.06
|
| Rate for Payer: Healthscope Commercial |
$113.88
|
| Rate for Payer: Healthscope Commercial |
$5.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.38
|
| Rate for Payer: PHP Commercial |
$107.55
|
| Rate for Payer: PHP Commercial |
$5.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.43
|
| Rate for Payer: Priority Health SBD |
$3.99
|
| Rate for Payer: Priority Health SBD |
$79.71
|
| Rate for Payer: UMR Bronson Commercial |
$55.67
|
| Rate for Payer: UMR Bronson Commercial |
$2.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.75
|
|
|
GRANISETRON (PF) 1 MG/ML (1 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$27.55
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
117975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.12 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Aetna American Axle |
$17.91
|
| Rate for Payer: Aetna American Axle |
$57.82
|
| Rate for Payer: Aetna Commercial |
$75.62
|
| Rate for Payer: Aetna Commercial |
$23.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.82
|
| Rate for Payer: Cash Price |
$22.04
|
| Rate for Payer: Cash Price |
$71.17
|
| Rate for Payer: Cofinity Commercial |
$76.51
|
| Rate for Payer: Cofinity Commercial |
$19.28
|
| Rate for Payer: Cofinity Commercial |
$23.69
|
| Rate for Payer: Cofinity Commercial |
$62.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$24.80
|
| Rate for Payer: Healthscope Commercial |
$80.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.62
|
| Rate for Payer: PHP Commercial |
$23.42
|
| Rate for Payer: PHP Commercial |
$75.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.28
|
| Rate for Payer: Priority Health SBD |
$17.36
|
| Rate for Payer: Priority Health SBD |
$56.04
|
| Rate for Payer: UMR Bronson Commercial |
$12.12
|
| Rate for Payer: UMR Bronson Commercial |
$39.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.66
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$7.01
|
|
|
Service Code
|
NDC 0121-1488-10
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna American Axle |
$4.56
|
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.56
|
| Rate for Payer: Cash Price |
$5.61
|
| Rate for Payer: Cofinity Commercial |
$4.91
|
| Rate for Payer: Cofinity Commercial |
$6.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.61
|
| Rate for Payer: Healthscope Commercial |
$6.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.96
|
| Rate for Payer: PHP Commercial |
$5.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.91
|
| Rate for Payer: Priority Health SBD |
$4.42
|
| Rate for Payer: UMR Bronson Commercial |
$3.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.26
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$3.80
|
|
|
Service Code
|
NDC 0121-1744-10
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna American Axle |
$2.47
|
| Rate for Payer: Aetna Commercial |
$3.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.47
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cofinity Commercial |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$3.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.04
|
| Rate for Payer: Healthscope Commercial |
$3.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.23
|
| Rate for Payer: PHP Commercial |
$3.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.66
|
| Rate for Payer: Priority Health SBD |
$2.39
|
| Rate for Payer: UMR Bronson Commercial |
$1.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.85
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$7.01
|
|
|
Service Code
|
NDC 0121-1488-00
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna American Axle |
$4.56
|
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.56
|
| Rate for Payer: Cash Price |
$5.61
|
| Rate for Payer: Cofinity Commercial |
$4.91
|
| Rate for Payer: Cofinity Commercial |
$6.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.61
|
| Rate for Payer: Healthscope Commercial |
$6.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.96
|
| Rate for Payer: PHP Commercial |
$5.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.91
|
| Rate for Payer: Priority Health SBD |
$4.42
|
| Rate for Payer: UMR Bronson Commercial |
$3.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.26
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$269.80
|
|
|
Service Code
|
NDC 63824-008-15
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.71 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.33
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.86
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$118.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$320.64
|
|
|
Service Code
|
NDC 0904-6718-39
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.08 |
| Max. Negotiated Rate |
$288.58 |
| Rate for Payer: Aetna American Axle |
$208.42
|
| Rate for Payer: Aetna Commercial |
$272.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.42
|
| Rate for Payer: Cash Price |
$256.51
|
| Rate for Payer: Cofinity Commercial |
$224.45
|
| Rate for Payer: Cofinity Commercial |
$275.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.51
|
| Rate for Payer: Healthscope Commercial |
$288.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$224.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$240.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$272.54
|
| Rate for Payer: PHP Commercial |
$272.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.45
|
| Rate for Payer: Priority Health SBD |
$202.00
|
| Rate for Payer: UMR Bronson Commercial |
$141.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$240.48
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$1,268.25
|
|
|
Service Code
|
NDC 63824-008-50
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$558.03 |
| Max. Negotiated Rate |
$1,141.42 |
| Rate for Payer: Aetna American Axle |
$824.36
|
| Rate for Payer: Aetna Commercial |
$1,078.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$824.36
|
| Rate for Payer: Cash Price |
$1,014.60
|
| Rate for Payer: Cofinity Commercial |
$1,090.70
|
| Rate for Payer: Cofinity Commercial |
$887.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,014.60
|
| Rate for Payer: Healthscope Commercial |
$1,141.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$887.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$951.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,078.01
|
| Rate for Payer: PHP Commercial |
$1,078.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$887.78
|
| Rate for Payer: Priority Health SBD |
$799.00
|
| Rate for Payer: UMR Bronson Commercial |
$558.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$951.19
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$126.20
|
|
|
Service Code
|
NDC 96295-12390
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.53 |
| Max. Negotiated Rate |
$113.58 |
| Rate for Payer: Aetna American Axle |
$82.03
|
| Rate for Payer: Aetna Commercial |
$107.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.03
|
| Rate for Payer: Cash Price |
$100.96
|
| Rate for Payer: Cofinity Commercial |
$88.34
|
| Rate for Payer: Cofinity Commercial |
$108.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.96
|
| Rate for Payer: Healthscope Commercial |
$113.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.27
|
| Rate for Payer: PHP Commercial |
$107.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.34
|
| Rate for Payer: Priority Health SBD |
$79.51
|
| Rate for Payer: UMR Bronson Commercial |
$55.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.65
|
|
|
GUANFACINE 1 MG TABLET
|
Facility
|
IP
|
$452.20
|
|
|
Service Code
|
NDC 53746-711-01
|
| Hospital Charge Code |
10149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.97 |
| Max. Negotiated Rate |
$406.98 |
| Rate for Payer: Aetna American Axle |
$293.93
|
| Rate for Payer: Aetna Commercial |
$384.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.93
|
| Rate for Payer: Cash Price |
$361.76
|
| Rate for Payer: Cofinity Commercial |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.76
|
| Rate for Payer: Healthscope Commercial |
$406.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$316.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$384.37
|
| Rate for Payer: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.54
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| Rate for Payer: UMR Bronson Commercial |
$198.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.15
|
|
|
GUANFACINE 1 MG TABLET
|
Facility
|
IP
|
$446.50
|
|
|
Service Code
|
NDC 0591-0444-01
|
| Hospital Charge Code |
10149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.46 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna American Axle |
$290.22
|
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.22
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Cofinity Commercial |
$312.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$312.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$379.52
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.55
|
| Rate for Payer: Priority Health SBD |
$281.30
|
| Rate for Payer: UMR Bronson Commercial |
$196.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.88
|
|
|
GUANFACINE 1 MG TABLET
|
Facility
|
IP
|
$319.20
|
|
|
Service Code
|
NDC 42806-048-01
|
| Hospital Charge Code |
10149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.45 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna American Axle |
$207.48
|
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.48
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$274.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$271.32
|
| Rate for Payer: PHP Commercial |
$271.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.44
|
| Rate for Payer: Priority Health SBD |
$201.10
|
| Rate for Payer: UMR Bronson Commercial |
$140.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
GUANFACINE 1 MG TABLET
|
Facility
|
IP
|
$317.25
|
|
|
Service Code
|
NDC 0378-1160-01
|
| Hospital Charge Code |
10149
|
|
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 |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$222.08
|
| 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
|
|
|
GUANFACINE 1 MG TABLET
|
Facility
|
IP
|
$210.96
|
|
|
Service Code
|
NDC 0904-7140-04
|
| Hospital Charge Code |
10149
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.82 |
| Max. Negotiated Rate |
$189.86 |
| Rate for Payer: Aetna American Axle |
$137.12
|
| Rate for Payer: Aetna Commercial |
$179.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.12
|
| Rate for Payer: Cash Price |
$168.77
|
| Rate for Payer: Cofinity Commercial |
$147.67
|
| Rate for Payer: Cofinity Commercial |
$181.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.77
|
| Rate for Payer: Healthscope Commercial |
$189.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.32
|
| Rate for Payer: PHP Commercial |
$179.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.67
|
| Rate for Payer: Priority Health SBD |
$132.90
|
| Rate for Payer: UMR Bronson Commercial |
$92.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.22
|
|
|
GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$370.50
|
|
|
Service Code
|
NDC 24979-533-01
|
| Hospital Charge Code |
99835
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.02 |
| Max. Negotiated Rate |
$333.45 |
| Rate for Payer: Aetna American Axle |
$240.82
|
| Rate for Payer: Aetna Commercial |
$314.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.82
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cofinity Commercial |
$259.35
|
| Rate for Payer: Cofinity Commercial |
$318.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$296.40
|
| Rate for Payer: Healthscope Commercial |
$333.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$277.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.92
|
| Rate for Payer: PHP Commercial |
$314.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$259.35
|
| Rate for Payer: Priority Health SBD |
$233.42
|
| Rate for Payer: UMR Bronson Commercial |
$163.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$277.88
|
|
|
GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3,342.58
|
|
|
Service Code
|
NDC 54092-513-02
|
| Hospital Charge Code |
99835
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,470.74 |
| Max. Negotiated Rate |
$3,008.32 |
| Rate for Payer: Aetna American Axle |
$2,172.68
|
| Rate for Payer: Aetna Commercial |
$2,841.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,172.68
|
| Rate for Payer: Cash Price |
$2,674.06
|
| Rate for Payer: Cofinity Commercial |
$2,339.81
|
| Rate for Payer: Cofinity Commercial |
$2,874.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,674.06
|
| Rate for Payer: Healthscope Commercial |
$3,008.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,339.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,506.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,841.19
|
| Rate for Payer: PHP Commercial |
$2,841.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,339.81
|
| Rate for Payer: Priority Health SBD |
$2,105.83
|
| Rate for Payer: UMR Bronson Commercial |
$1,470.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,506.94
|
|
|
GUANFACINE ER 2 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3,342.58
|
|
|
Service Code
|
NDC 54092-515-02
|
| Hospital Charge Code |
99836
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,470.74 |
| Max. Negotiated Rate |
$3,008.32 |
| Rate for Payer: Aetna American Axle |
$2,172.68
|
| Rate for Payer: Aetna Commercial |
$2,841.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,172.68
|
| Rate for Payer: Cash Price |
$2,674.06
|
| Rate for Payer: Cofinity Commercial |
$2,339.81
|
| Rate for Payer: Cofinity Commercial |
$2,874.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,674.06
|
| Rate for Payer: Healthscope Commercial |
$3,008.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,339.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,506.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,841.19
|
| Rate for Payer: PHP Commercial |
$2,841.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,339.81
|
| Rate for Payer: Priority Health SBD |
$2,105.83
|
| Rate for Payer: UMR Bronson Commercial |
$1,470.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,506.94
|
|
|
GUANFACINE ER 2 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$370.50
|
|
|
Service Code
|
NDC 24979-534-01
|
| Hospital Charge Code |
99836
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.02 |
| Max. Negotiated Rate |
$333.45 |
| Rate for Payer: Aetna American Axle |
$240.82
|
| Rate for Payer: Aetna Commercial |
$314.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.82
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cofinity Commercial |
$259.35
|
| Rate for Payer: Cofinity Commercial |
$318.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$296.40
|
| Rate for Payer: Healthscope Commercial |
$333.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$277.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.92
|
| Rate for Payer: PHP Commercial |
$314.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$259.35
|
| Rate for Payer: Priority Health SBD |
$233.42
|
| Rate for Payer: UMR Bronson Commercial |
$163.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$277.88
|
|
