|
CHG X-RAY HIP UNILAT 1 VW
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 73500
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: UMR Bronson Commercial |
$46.00
|
| Rate for Payer: UMR Bronson Commercial |
$14.26
|
|
|
CHG X-RAY PELVIS/HIPS CHILD/INFANT
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 73540
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Medicare |
$17.50
|
| Rate for Payer: Aetna Medicare |
$48.50
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: BCBS Complete |
$38.80
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cash Price |
$77.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: UMR Bronson Commercial |
$16.10
|
| Rate for Payer: UMR Bronson Commercial |
$44.62
|
|
|
CHG X-RAY SPINE SURVEY
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 72010
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna Medicare |
$36.50
|
| Rate for Payer: BCBS Complete |
$29.20
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.45
|
| Rate for Payer: UMR Bronson Commercial |
$33.58
|
|
|
CHG X-RAY THOR-LUMB SP SCOLIOSIS
|
Professional
|
Both
|
$133.00
|
|
|
Service Code
|
HCPCS 72090
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$86.45 |
| Rate for Payer: Aetna Medicare |
$66.50
|
| Rate for Payer: Aetna Medicare |
$35.50
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Complete |
$28.40
|
| Rate for Payer: BCBS Complete |
$53.20
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: UMR Bronson Commercial |
$32.66
|
| Rate for Payer: UMR Bronson Commercial |
$46.00
|
| Rate for Payer: UMR Bronson Commercial |
$61.18
|
|
|
CHG X-RAY TRUNK SPINE SCOLIOSIS
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS 72069
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$29.25 |
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: Aetna Medicare |
$30.00
|
| Rate for Payer: BCBS Complete |
$18.00
|
| Rate for Payer: BCBS Complete |
$24.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.25
|
| Rate for Payer: UMR Bronson Commercial |
$27.60
|
| Rate for Payer: UMR Bronson Commercial |
$20.70
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna American Axle |
$2.83
|
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.83
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.05
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health SBD |
$2.75
|
| Rate for Payer: UMR Bronson Commercial |
$1.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.27
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$435.10
|
|
|
Service Code
|
NDC 51079037520
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.99 |
| Max. Negotiated Rate |
$391.59 |
| Rate for Payer: Aetna American Axle |
$282.81
|
| Rate for Payer: Aetna Commercial |
$369.83
|
| Rate for Payer: Aetna Medicare |
$217.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.81
|
| Rate for Payer: BCBS Complete |
$174.04
|
| Rate for Payer: Cash Price |
$348.08
|
| Rate for Payer: Cofinity Commercial |
$304.57
|
| Rate for Payer: Cofinity Commercial |
$374.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.08
|
| Rate for Payer: Healthscope Commercial |
$391.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.83
|
| Rate for Payer: PHP Commercial |
$369.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.81
|
| Rate for Payer: Priority Health SBD |
$274.11
|
| Rate for Payer: UMR Bronson Commercial |
$160.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.32
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$286.70
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.08 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna American Axle |
$186.35
|
| Rate for Payer: Aetna Commercial |
$243.69
|
| Rate for Payer: Aetna Medicare |
$143.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.35
|
| Rate for Payer: BCBS Complete |
$114.68
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.69
|
| Rate for Payer: PHP Commercial |
$243.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.35
|
| Rate for Payer: Priority Health SBD |
$180.62
|
| Rate for Payer: UMR Bronson Commercial |
$106.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.03
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$435.10
|
|
|
Service Code
|
NDC 51079037520
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.44 |
| Max. Negotiated Rate |
$391.59 |
| Rate for Payer: Aetna American Axle |
$282.81
|
| Rate for Payer: Aetna Commercial |
$369.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.81
|
| Rate for Payer: Cash Price |
$348.08
|
| Rate for Payer: Cofinity Commercial |
$304.57
|
| Rate for Payer: Cofinity Commercial |
$374.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.08
|
| Rate for Payer: Healthscope Commercial |
$391.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.83
|
| Rate for Payer: PHP Commercial |
$369.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.81
|
| Rate for Payer: Priority Health SBD |
$274.11
|
| Rate for Payer: UMR Bronson Commercial |
$191.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.32
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna American Axle |
$2.83
|
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Aetna Medicare |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.83
|
| Rate for Payer: BCBS Complete |
$1.74
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.05
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health SBD |
$2.75
|
| Rate for Payer: UMR Bronson Commercial |
$1.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.27
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$286.70
|
|
|
Service Code
|
NDC 00555003302
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.15 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna American Axle |
$186.35
|
| Rate for Payer: Aetna Commercial |
$243.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.35
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.69
|
| Rate for Payer: PHP Commercial |
$243.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.35
|
| Rate for Payer: Priority Health SBD |
$180.62
|
| Rate for Payer: UMR Bronson Commercial |
$126.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.03
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$176.25
|
|
|
Service Code
|
NDC 43547025310
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.21 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna American Axle |
$114.56
|
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna Medicare |
$88.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: BCBS Complete |
$70.50
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$151.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$158.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: PHP Commercial |
$149.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.56
|
| Rate for Payer: Priority Health SBD |
$111.04
|
| Rate for Payer: UMR Bronson Commercial |
$65.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.19
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$1,527.50
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$565.17 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna American Axle |
$992.88
|
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: Aetna Medicare |
$763.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$992.88
|
| Rate for Payer: BCBS Complete |
$611.00
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,069.25
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,069.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,069.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,145.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,298.38
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$992.88
|
| Rate for Payer: Priority Health SBD |
$962.33
|
| Rate for Payer: UMR Bronson Commercial |
$565.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,145.62
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$1,527.50
|
|
|
Service Code
|
NDC 00555015904
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$672.10 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna American Axle |
$992.88
|
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$992.88
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,069.25
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,069.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,069.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,145.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,298.38
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$992.88
|
| Rate for Payer: Priority Health SBD |
$962.33
|
| Rate for Payer: UMR Bronson Commercial |
$672.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,145.62
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$354.85
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.29 |
| Max. Negotiated Rate |
$319.37 |
| Rate for Payer: Aetna American Axle |
$230.65
|
| Rate for Payer: Aetna Commercial |
$301.62
|
| Rate for Payer: Aetna Medicare |
$177.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.65
|
| Rate for Payer: BCBS Complete |
$141.94
|
| Rate for Payer: Cash Price |
$283.88
|
| Rate for Payer: Cofinity Commercial |
$248.40
|
| Rate for Payer: Cofinity Commercial |
$305.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.88
|
| Rate for Payer: Healthscope Commercial |
$319.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.62
|
| Rate for Payer: PHP Commercial |
$301.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.65
|
| Rate for Payer: Priority Health SBD |
$223.56
|
| Rate for Payer: UMR Bronson Commercial |
$131.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.14
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$176.25
|
|
|
Service Code
|
NDC 43547025310
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.55 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna American Axle |
$114.56
|
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$151.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$158.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: PHP Commercial |
$149.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.56
|
| Rate for Payer: Priority Health SBD |
$111.04
|
| Rate for Payer: UMR Bronson Commercial |
$77.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.19
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$354.85
|
|
|
Service Code
|
NDC 00555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.13 |
| Max. Negotiated Rate |
$319.37 |
| Rate for Payer: Aetna American Axle |
$230.65
|
| Rate for Payer: Aetna Commercial |
$301.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.65
|
| Rate for Payer: Cash Price |
$283.88
|
| Rate for Payer: Cofinity Commercial |
$248.40
|
| Rate for Payer: Cofinity Commercial |
$305.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.88
|
| Rate for Payer: Healthscope Commercial |
$319.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.62
|
| Rate for Payer: PHP Commercial |
$301.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.65
|
| Rate for Payer: Priority Health SBD |
$223.56
|
| Rate for Payer: UMR Bronson Commercial |
$156.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.14
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
IP
|
$406.55
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.88 |
| Max. Negotiated Rate |
$365.89 |
| Rate for Payer: Aetna American Axle |
$264.26
|
| Rate for Payer: Aetna Commercial |
$345.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.26
|
| Rate for Payer: Cash Price |
$325.24
|
| Rate for Payer: Cofinity Commercial |
$284.58
|
| Rate for Payer: Cofinity Commercial |
$349.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.24
|
| Rate for Payer: Healthscope Commercial |
$365.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.57
|
| Rate for Payer: PHP Commercial |
$345.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.26
|
| Rate for Payer: Priority Health SBD |
$256.13
|
| Rate for Payer: UMR Bronson Commercial |
$178.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.91
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
OP
|
$406.55
|
|
|
Service Code
|
NDC 00555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.42 |
| Max. Negotiated Rate |
$365.89 |
| Rate for Payer: Aetna American Axle |
$264.26
|
| Rate for Payer: Aetna Commercial |
$345.57
|
| Rate for Payer: Aetna Medicare |
$203.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.26
|
| Rate for Payer: BCBS Complete |
$162.62
|
| Rate for Payer: Cash Price |
$325.24
|
| Rate for Payer: Cofinity Commercial |
$284.58
|
| Rate for Payer: Cofinity Commercial |
$349.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.24
|
| Rate for Payer: Healthscope Commercial |
$365.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.57
|
| Rate for Payer: PHP Commercial |
$345.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.26
|
| Rate for Payer: Priority Health SBD |
$256.13
|
| Rate for Payer: UMR Bronson Commercial |
$150.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.91
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$25.38
|
|
|
Service Code
|
NDC 48878062004
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$22.84 |
| Rate for Payer: Aetna American Axle |
$16.50
|
| Rate for Payer: Aetna Commercial |
$21.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.50
|
| Rate for Payer: Cash Price |
$20.30
|
| Rate for Payer: Cofinity Commercial |
$17.77
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.30
|
| Rate for Payer: Healthscope Commercial |
$22.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.57
|
| Rate for Payer: PHP Commercial |
$21.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.50
|
| Rate for Payer: Priority Health SBD |
$15.99
|
| Rate for Payer: UMR Bronson Commercial |
$11.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.04
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 00116200115
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna American Axle |
$1.38
|
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Medicare |
$1.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.38
|
| Rate for Payer: BCBS Complete |
$0.85
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cofinity Commercial |
$1.48
|
| Rate for Payer: Cofinity Commercial |
$1.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.70
|
| Rate for Payer: Healthscope Commercial |
$1.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.80
|
| Rate for Payer: PHP Commercial |
$1.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.38
|
| Rate for Payer: Priority Health SBD |
$1.34
|
| Rate for Payer: UMR Bronson Commercial |
$0.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.59
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$44.77
|
|
|
Service Code
|
NDC 60687061644
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$40.29 |
| Rate for Payer: Aetna American Axle |
$29.10
|
| Rate for Payer: Aetna Commercial |
$38.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.10
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$31.34
|
| Rate for Payer: Cofinity Commercial |
$38.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.05
|
| Rate for Payer: PHP Commercial |
$38.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.10
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UMR Bronson Commercial |
$19.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$3.88
|
|
|
Service Code
|
NDC 09900000023
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna Medicare |
$1.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: BCBS Complete |
$1.55
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$25.38
|
|
|
Service Code
|
NDC 48878062004
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$22.84 |
| Rate for Payer: Aetna American Axle |
$16.50
|
| Rate for Payer: Aetna Commercial |
$21.57
|
| Rate for Payer: Aetna Medicare |
$12.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.50
|
| Rate for Payer: BCBS Complete |
$10.15
|
| Rate for Payer: Cash Price |
$20.30
|
| Rate for Payer: Cofinity Commercial |
$17.77
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.30
|
| Rate for Payer: Healthscope Commercial |
$22.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.57
|
| Rate for Payer: PHP Commercial |
$21.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.50
|
| Rate for Payer: Priority Health SBD |
$15.99
|
| Rate for Payer: UMR Bronson Commercial |
$9.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.04
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$100.04
|
|
|
Service Code
|
NDC 52376002102
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.02 |
| Max. Negotiated Rate |
$90.04 |
| Rate for Payer: Aetna American Axle |
$65.03
|
| Rate for Payer: Aetna Commercial |
$85.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.03
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cofinity Commercial |
$70.03
|
| Rate for Payer: Cofinity Commercial |
$86.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.03
|
| Rate for Payer: Healthscope Commercial |
$90.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.03
|
| Rate for Payer: PHP Commercial |
$85.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.03
|
| Rate for Payer: Priority Health SBD |
$63.03
|
| Rate for Payer: UMR Bronson Commercial |
$44.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.03
|
|
