|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
OP
|
$1,893.18
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$700.48 |
| Max. Negotiated Rate |
$1,703.86 |
| Rate for Payer: Aetna American Axle |
$1,230.57
|
| Rate for Payer: Aetna Commercial |
$1,609.20
|
| Rate for Payer: Aetna Medicare |
$946.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,230.57
|
| Rate for Payer: BCBS Complete |
$757.27
|
| Rate for Payer: Cash Price |
$1,514.54
|
| Rate for Payer: Cofinity Advantage |
$1,325.23
|
| Rate for Payer: Cofinity Commercial |
$1,628.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,514.54
|
| Rate for Payer: Healthscope Commercial |
$1,703.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,325.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,419.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,514.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,609.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,419.88
|
| Rate for Payer: PHP Commercial |
$1,609.20
|
| Rate for Payer: Priority Health SBD |
$1,192.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,230.57
|
| Rate for Payer: UHC Core |
$986.35
|
| Rate for Payer: UHC Exchange |
$744.02
|
| Rate for Payer: UMR Bronson Commercial |
$700.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,419.88
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,893.18
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$833.00 |
| Max. Negotiated Rate |
$1,703.86 |
| Rate for Payer: Aetna American Axle |
$1,230.57
|
| Rate for Payer: Aetna Commercial |
$1,609.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,230.57
|
| Rate for Payer: Cash Price |
$1,514.54
|
| Rate for Payer: Cofinity Advantage |
$1,325.23
|
| Rate for Payer: Cofinity Commercial |
$1,628.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,514.54
|
| Rate for Payer: Healthscope Commercial |
$1,703.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,325.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,419.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,609.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,419.88
|
| Rate for Payer: PHP Commercial |
$1,609.20
|
| Rate for Payer: Priority Health SBD |
$1,192.70
|
| Rate for Payer: UMR Bronson Commercial |
$833.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,419.88
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19,500.00
|
|
|
Service Code
|
HCPCS J9999
|
| Hospital Charge Code |
171873
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,215.00 |
| Max. Negotiated Rate |
$17,550.00 |
| Rate for Payer: Aetna American Axle |
$12,675.00
|
| Rate for Payer: Aetna Commercial |
$16,575.00
|
| Rate for Payer: Aetna Medicare |
$9,750.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,675.00
|
| Rate for Payer: BCBS Complete |
$7,800.00
|
| Rate for Payer: Cash Price |
$15,600.00
|
| Rate for Payer: Cofinity Advantage |
$13,650.00
|
| Rate for Payer: Cofinity Commercial |
$16,770.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,600.00
|
| Rate for Payer: Healthscope Commercial |
$17,550.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,650.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,625.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,600.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,575.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,625.00
|
| Rate for Payer: PHP Commercial |
$16,575.00
|
| Rate for Payer: Priority Health SBD |
$12,285.00
|
| Rate for Payer: UMR Bronson Commercial |
$7,215.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,625.00
|
|
|
DINUTUXIMAB 3.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19,500.00
|
|
|
Service Code
|
HCPCS J9999
|
| Hospital Charge Code |
171873
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,580.00 |
| Max. Negotiated Rate |
$17,550.00 |
| Rate for Payer: Aetna American Axle |
$12,675.00
|
| Rate for Payer: Aetna Commercial |
$16,575.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,675.00
|
| Rate for Payer: Cash Price |
$15,600.00
|
| Rate for Payer: Cofinity Advantage |
$13,650.00
|
| Rate for Payer: Cofinity Commercial |
$16,770.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,600.00
|
| Rate for Payer: Healthscope Commercial |
$17,550.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,650.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,625.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,575.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,625.00
|
| Rate for Payer: PHP Commercial |
$16,575.00
|
| Rate for Payer: Priority Health SBD |
$12,285.00
|
| Rate for Payer: UMR Bronson Commercial |
$8,580.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,625.00
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
OP
|
$306.97
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.58 |
| Max. Negotiated Rate |
$276.27 |
| Rate for Payer: Aetna American Axle |
$199.53
|
| Rate for Payer: Aetna Commercial |
$260.92
|
| Rate for Payer: Aetna Medicare |
$153.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.53
|
| Rate for Payer: BCBS Complete |
$122.79
|
| Rate for Payer: Cash Price |
$245.58
|
| Rate for Payer: Cofinity Advantage |
$214.88
|
| Rate for Payer: Cofinity Commercial |
$263.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.58
|
| Rate for Payer: Healthscope Commercial |
$276.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$245.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.23
|
| Rate for Payer: PHP Commercial |
$260.92
|
| Rate for Payer: Priority Health SBD |
$193.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$199.53
|
| Rate for Payer: UHC Core |
$159.93
|
| Rate for Payer: UHC Exchange |
$120.64
|
| Rate for Payer: UMR Bronson Commercial |
$113.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.23
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$306.97
|
|
|
Service Code
|
NDC 65628005004
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.07 |
| Max. Negotiated Rate |
$276.27 |
| Rate for Payer: Aetna American Axle |
$199.53
|
| Rate for Payer: Aetna Commercial |
$260.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.53
|
| Rate for Payer: Cash Price |
$245.58
|
| Rate for Payer: Cofinity Advantage |
$214.88
|
| Rate for Payer: Cofinity Commercial |
$263.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.58
|
| Rate for Payer: Healthscope Commercial |
$276.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.23
|
| Rate for Payer: PHP Commercial |
$260.92
|
| Rate for Payer: Priority Health SBD |
$193.39
|
| Rate for Payer: UMR Bronson Commercial |
$135.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.23
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
OP
|
$15.51
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$13.96 |
| Rate for Payer: Aetna American Axle |
$10.08
|
| Rate for Payer: Aetna American Axle |
$10.45
|
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Commercial |
$13.67
|
| Rate for Payer: Aetna Medicare |
$7.75
|
| Rate for Payer: Aetna Medicare |
$8.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.45
|
| Rate for Payer: BCBS Complete |
$6.43
|
| Rate for Payer: BCBS Complete |
$6.20
|
| Rate for Payer: BCBS Trust/PPO |
$0.25
|
| Rate for Payer: BCBS Trust/PPO |
$0.25
|
| Rate for Payer: BCN Commercial |
$0.25
|
| Rate for Payer: BCN Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cofinity Advantage |
$10.86
|
| Rate for Payer: Cofinity Advantage |
$11.26
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Cofinity Commercial |
$13.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.86
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: Healthscope Commercial |
$14.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.63
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$13.67
|
| Rate for Payer: Priority Health SBD |
$9.77
|
| Rate for Payer: Priority Health SBD |
$10.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.34
|
| Rate for Payer: UHC Core |
$2.34
|
| Rate for Payer: UHC Core |
$2.34
|
| Rate for Payer: UHC Exchange |
$2.34
|
| Rate for Payer: UHC Exchange |
$2.34
|
| Rate for Payer: UMR Bronson Commercial |
$5.74
|
| Rate for Payer: UMR Bronson Commercial |
$5.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.06
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR
|
Facility
|
IP
|
$15.51
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2511
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$13.96 |
| Rate for Payer: Aetna American Axle |
$10.08
|
| Rate for Payer: Aetna American Axle |
$10.45
|
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Commercial |
$13.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.45
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cofinity Advantage |
$11.26
|
| Rate for Payer: Cofinity Advantage |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$13.83
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.86
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: Healthscope Commercial |
$14.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.06
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$13.67
|
| Rate for Payer: Priority Health SBD |
$10.13
|
| Rate for Payer: Priority Health SBD |
$9.77
|
| Rate for Payer: UMR Bronson Commercial |
$6.82
|
| Rate for Payer: UMR Bronson Commercial |
$7.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.06
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$14.06
|
|
|
Service Code
|
NDC 68094002262
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna American Axle |
$9.14
|
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: Aetna Medicare |
$7.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
| Rate for Payer: BCBS Complete |
$5.62
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cofinity Advantage |
$9.84
|
| Rate for Payer: Cofinity Commercial |
$12.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
| Rate for Payer: Healthscope Commercial |
$12.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.54
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health SBD |
$8.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.14
|
| Rate for Payer: UHC Core |
$7.33
|
| Rate for Payer: UHC Exchange |
$5.53
|
| Rate for Payer: UMR Bronson Commercial |
$5.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$14.06
|
|
|
Service Code
|
NDC 68094002259
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna American Axle |
$9.14
|
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: Aetna Medicare |
$7.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
| Rate for Payer: BCBS Complete |
$5.62
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cofinity Advantage |
$9.84
|
| Rate for Payer: Cofinity Commercial |
$12.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
| Rate for Payer: Healthscope Commercial |
$12.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.54
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health SBD |
$8.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.14
|
| Rate for Payer: UHC Core |
$7.33
|
| Rate for Payer: UHC Exchange |
$5.53
|
| Rate for Payer: UMR Bronson Commercial |
$5.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$19.62
|
|
|
Service Code
|
NDC 69339015117
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$17.66 |
| Rate for Payer: Aetna American Axle |
$12.75
|
| Rate for Payer: Aetna Commercial |
$16.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Advantage |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.71
|
| Rate for Payer: PHP Commercial |
$16.68
|
| Rate for Payer: Priority Health SBD |
$12.36
|
| Rate for Payer: UMR Bronson Commercial |
$8.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.71
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$19.62
|
|
|
Service Code
|
NDC 69339015105
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$17.66 |
| Rate for Payer: Aetna American Axle |
$12.75
|
| Rate for Payer: Aetna Commercial |
$16.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Advantage |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.71
|
| Rate for Payer: PHP Commercial |
$16.68
|
| Rate for Payer: Priority Health SBD |
$12.36
|
| Rate for Payer: UMR Bronson Commercial |
$8.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.71
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$144.51
|
|
|
Service Code
|
NDC 00904698516
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.58 |
| Max. Negotiated Rate |
$130.06 |
| Rate for Payer: Aetna American Axle |
$93.93
|
| Rate for Payer: Aetna Commercial |
$122.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.93
|
| Rate for Payer: Cash Price |
$115.61
|
| Rate for Payer: Cofinity Advantage |
$101.16
|
| Rate for Payer: Cofinity Commercial |
$124.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.61
|
| Rate for Payer: Healthscope Commercial |
$130.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$108.38
|
| Rate for Payer: PHP Commercial |
$122.83
|
| Rate for Payer: Priority Health SBD |
$91.04
|
| Rate for Payer: UMR Bronson Commercial |
$63.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.38
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$144.51
|
|
|
Service Code
|
NDC 00904698516
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.47 |
| Max. Negotiated Rate |
$130.06 |
| Rate for Payer: Aetna American Axle |
$93.93
|
| Rate for Payer: Aetna Commercial |
$122.83
|
| Rate for Payer: Aetna Medicare |
$72.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.93
|
| Rate for Payer: BCBS Complete |
$57.80
|
| Rate for Payer: Cash Price |
$115.61
|
| Rate for Payer: Cofinity Advantage |
$101.16
|
| Rate for Payer: Cofinity Commercial |
$124.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.61
|
| Rate for Payer: Healthscope Commercial |
$130.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$115.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$108.38
|
| Rate for Payer: PHP Commercial |
$122.83
|
| Rate for Payer: Priority Health SBD |
$91.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.93
|
| Rate for Payer: UHC Core |
$75.29
|
| Rate for Payer: UHC Exchange |
$56.79
|
| Rate for Payer: UMR Bronson Commercial |
$53.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.38
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$19.62
|
|
|
Service Code
|
NDC 69339015117
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$17.66 |
| Rate for Payer: Aetna American Axle |
$12.75
|
| Rate for Payer: Aetna Commercial |
$16.68
|
| Rate for Payer: Aetna Medicare |
$9.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: BCBS Complete |
$7.85
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Advantage |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.71
|
| Rate for Payer: PHP Commercial |
$16.68
|
| Rate for Payer: Priority Health SBD |
$12.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.75
|
| Rate for Payer: UHC Core |
$10.22
|
| Rate for Payer: UHC Exchange |
$7.71
|
| Rate for Payer: UMR Bronson Commercial |
$7.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.71
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$41.83
|
|
|
Service Code
|
NDC 68094002462
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna American Axle |
$27.19
|
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Advantage |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.37
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.19
|
| Rate for Payer: UHC Core |
$21.79
|
| Rate for Payer: UHC Exchange |
$16.44
|
| Rate for Payer: UMR Bronson Commercial |
$15.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.37
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$14.06
|
|
|
Service Code
|
NDC 68094002262
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna American Axle |
$9.14
|
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.14
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cofinity Advantage |
$9.84
|
| Rate for Payer: Cofinity Commercial |
$12.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.25
|
| Rate for Payer: Healthscope Commercial |
$12.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.54
|
| Rate for Payer: PHP Commercial |
$11.95
|
| Rate for Payer: Priority Health SBD |
$8.86
|
| Rate for Payer: UMR Bronson Commercial |
$6.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.54
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$255.66
|
|
|
Service Code
|
NDC 58657052816
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.59 |
| Max. Negotiated Rate |
$230.09 |
| Rate for Payer: Aetna American Axle |
$166.18
|
| Rate for Payer: Aetna Commercial |
$217.31
|
| Rate for Payer: Aetna Medicare |
$127.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.18
|
| Rate for Payer: BCBS Complete |
$102.26
|
| Rate for Payer: Cash Price |
$204.53
|
| Rate for Payer: Cofinity Advantage |
$178.96
|
| Rate for Payer: Cofinity Commercial |
$219.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.53
|
| Rate for Payer: Healthscope Commercial |
$230.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$191.75
|
| Rate for Payer: PHP Commercial |
$217.31
|
| Rate for Payer: Priority Health SBD |
$161.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$166.18
|
| Rate for Payer: UHC Core |
$133.20
|
| Rate for Payer: UHC Exchange |
$100.47
|
| Rate for Payer: UMR Bronson Commercial |
$94.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.75
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$61.01
|
|
|
Service Code
|
NDC 70000049201
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$54.91 |
| Rate for Payer: Aetna American Axle |
$39.66
|
| Rate for Payer: Aetna Commercial |
$51.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.66
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cofinity Advantage |
$42.71
|
| Rate for Payer: Cofinity Commercial |
$52.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.81
|
| Rate for Payer: Healthscope Commercial |
$54.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.76
|
| Rate for Payer: PHP Commercial |
$51.86
|
| Rate for Payer: Priority Health SBD |
$38.44
|
| Rate for Payer: UMR Bronson Commercial |
$26.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.76
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$144.51
|
|
|
Service Code
|
NDC 57237030516
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.58 |
| Max. Negotiated Rate |
$130.06 |
| Rate for Payer: Aetna American Axle |
$93.93
|
| Rate for Payer: Aetna Commercial |
$122.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.93
|
| Rate for Payer: Cash Price |
$115.61
|
| Rate for Payer: Cofinity Advantage |
$101.16
|
| Rate for Payer: Cofinity Commercial |
$124.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.61
|
| Rate for Payer: Healthscope Commercial |
$130.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$108.38
|
| Rate for Payer: PHP Commercial |
$122.83
|
| Rate for Payer: Priority Health SBD |
$91.04
|
| Rate for Payer: UMR Bronson Commercial |
$63.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.38
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 69339015201
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna American Axle |
$13.21
|
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: BCBS Complete |
$8.13
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.21
|
| Rate for Payer: UHC Core |
$10.59
|
| Rate for Payer: UHC Exchange |
$7.99
|
| Rate for Payer: UMR Bronson Commercial |
$7.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.25
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 69339015217
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$18.30 |
| Rate for Payer: Aetna American Axle |
$13.21
|
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Aetna Medicare |
$10.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.21
|
| Rate for Payer: BCBS Complete |
$8.13
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cofinity Advantage |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$18.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.25
|
| Rate for Payer: PHP Commercial |
$17.28
|
| Rate for Payer: Priority Health SBD |
$12.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.21
|
| Rate for Payer: UHC Core |
$10.59
|
| Rate for Payer: UHC Exchange |
$7.99
|
| Rate for Payer: UMR Bronson Commercial |
$7.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.25
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$144.51
|
|
|
Service Code
|
NDC 57237030516
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.47 |
| Max. Negotiated Rate |
$130.06 |
| Rate for Payer: Aetna American Axle |
$93.93
|
| Rate for Payer: Aetna Commercial |
$122.83
|
| Rate for Payer: Aetna Medicare |
$72.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.93
|
| Rate for Payer: BCBS Complete |
$57.80
|
| Rate for Payer: Cash Price |
$115.61
|
| Rate for Payer: Cofinity Advantage |
$101.16
|
| Rate for Payer: Cofinity Commercial |
$124.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.61
|
| Rate for Payer: Healthscope Commercial |
$130.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$115.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$108.38
|
| Rate for Payer: PHP Commercial |
$122.83
|
| Rate for Payer: Priority Health SBD |
$91.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.93
|
| Rate for Payer: UHC Core |
$75.29
|
| Rate for Payer: UHC Exchange |
$56.79
|
| Rate for Payer: UMR Bronson Commercial |
$53.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.38
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$41.83
|
|
|
Service Code
|
NDC 68094002459
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$37.65 |
| Rate for Payer: Aetna American Axle |
$27.19
|
| Rate for Payer: Aetna Commercial |
$35.56
|
| Rate for Payer: Aetna Medicare |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.19
|
| Rate for Payer: BCBS Complete |
$16.73
|
| Rate for Payer: Cash Price |
$33.46
|
| Rate for Payer: Cofinity Advantage |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$35.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.46
|
| Rate for Payer: Healthscope Commercial |
$37.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.37
|
| Rate for Payer: PHP Commercial |
$35.56
|
| Rate for Payer: Priority Health SBD |
$26.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.19
|
| Rate for Payer: UHC Core |
$21.79
|
| Rate for Payer: UHC Exchange |
$16.44
|
| Rate for Payer: UMR Bronson Commercial |
$15.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.37
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$255.66
|
|
|
Service Code
|
NDC 58657052816
|
| Hospital Charge Code |
12556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.49 |
| Max. Negotiated Rate |
$230.09 |
| Rate for Payer: Aetna American Axle |
$166.18
|
| Rate for Payer: Aetna Commercial |
$217.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.18
|
| Rate for Payer: Cash Price |
$204.53
|
| Rate for Payer: Cofinity Advantage |
$178.96
|
| Rate for Payer: Cofinity Commercial |
$219.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.53
|
| Rate for Payer: Healthscope Commercial |
$230.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$191.75
|
| Rate for Payer: PHP Commercial |
$217.31
|
| Rate for Payer: Priority Health SBD |
$161.07
|
| Rate for Payer: UMR Bronson Commercial |
$112.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.75
|
|
