|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4,521.15
|
|
|
Service Code
|
NDC 00008121101
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,989.31 |
| Max. Negotiated Rate |
$4,069.04 |
| Rate for Payer: Aetna American Axle |
$2,938.75
|
| Rate for Payer: Aetna Commercial |
$3,842.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,938.75
|
| Rate for Payer: Cash Price |
$3,616.92
|
| Rate for Payer: Cofinity Commercial |
$3,164.80
|
| Rate for Payer: Cofinity Commercial |
$3,888.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,164.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,616.92
|
| Rate for Payer: Healthscope Commercial |
$4,069.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,164.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,390.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,842.98
|
| Rate for Payer: PHP Commercial |
$3,842.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,938.75
|
| Rate for Payer: Priority Health SBD |
$2,848.32
|
| Rate for Payer: UMR Bronson Commercial |
$1,989.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,390.86
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,507.05
|
|
|
Service Code
|
NDC 00008121130
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$557.61 |
| Max. Negotiated Rate |
$1,356.34 |
| Rate for Payer: Aetna American Axle |
$979.58
|
| Rate for Payer: Aetna Commercial |
$1,280.99
|
| Rate for Payer: Aetna Medicare |
$753.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$979.58
|
| Rate for Payer: BCBS Complete |
$602.82
|
| Rate for Payer: Cash Price |
$1,205.64
|
| Rate for Payer: Cofinity Commercial |
$1,054.94
|
| Rate for Payer: Cofinity Commercial |
$1,296.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,054.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,205.64
|
| Rate for Payer: Healthscope Commercial |
$1,356.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,054.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,130.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,280.99
|
| Rate for Payer: PHP Commercial |
$1,280.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$979.58
|
| Rate for Payer: Priority Health SBD |
$949.44
|
| Rate for Payer: UMR Bronson Commercial |
$557.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,130.29
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$406.98
|
|
|
Service Code
|
NDC 51991031190
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.58 |
| Max. Negotiated Rate |
$366.28 |
| Rate for Payer: Aetna American Axle |
$264.54
|
| Rate for Payer: Aetna Commercial |
$345.93
|
| Rate for Payer: Aetna Medicare |
$203.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.54
|
| Rate for Payer: BCBS Complete |
$162.79
|
| Rate for Payer: Cash Price |
$325.58
|
| Rate for Payer: Cofinity Commercial |
$284.89
|
| Rate for Payer: Cofinity Commercial |
$350.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.58
|
| Rate for Payer: Healthscope Commercial |
$366.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.93
|
| Rate for Payer: PHP Commercial |
$345.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.54
|
| Rate for Payer: Priority Health SBD |
$256.40
|
| Rate for Payer: UMR Bronson Commercial |
$150.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.24
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$130.61
|
|
|
Service Code
|
NDC 68180059206
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.47 |
| Max. Negotiated Rate |
$117.55 |
| Rate for Payer: Aetna American Axle |
$84.90
|
| Rate for Payer: Aetna Commercial |
$111.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.90
|
| Rate for Payer: Cash Price |
$104.49
|
| Rate for Payer: Cofinity Commercial |
$112.32
|
| Rate for Payer: Cofinity Commercial |
$91.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.49
|
| Rate for Payer: Healthscope Commercial |
$117.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.02
|
| Rate for Payer: PHP Commercial |
$111.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.90
|
| Rate for Payer: Priority Health SBD |
$82.28
|
| Rate for Payer: UMR Bronson Commercial |
$57.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.96
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,507.05
|
|
|
Service Code
|
NDC 00008121130
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$663.10 |
| Max. Negotiated Rate |
$1,356.34 |
| Rate for Payer: Aetna American Axle |
$979.58
|
| Rate for Payer: Aetna Commercial |
$1,280.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$979.58
|
| Rate for Payer: Cash Price |
$1,205.64
|
| Rate for Payer: Cofinity Commercial |
$1,054.94
|
| Rate for Payer: Cofinity Commercial |
$1,296.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,054.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,205.64
|
| Rate for Payer: Healthscope Commercial |
$1,356.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,054.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,130.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,280.99
|
| Rate for Payer: PHP Commercial |
$1,280.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$979.58
|
| Rate for Payer: Priority Health SBD |
$949.44
|
| Rate for Payer: UMR Bronson Commercial |
$663.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,130.29
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$406.98
|
|
|
Service Code
|
NDC 51991031190
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.07 |
| Max. Negotiated Rate |
$366.28 |
| Rate for Payer: Aetna American Axle |
$264.54
|
| Rate for Payer: Aetna Commercial |
$345.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.54
|
| Rate for Payer: Cash Price |
$325.58
|
| Rate for Payer: Cofinity Commercial |
$284.89
|
| Rate for Payer: Cofinity Commercial |
$350.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.58
|
| Rate for Payer: Healthscope Commercial |
$366.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.93
|
| Rate for Payer: PHP Commercial |
$345.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.54
|
| Rate for Payer: Priority Health SBD |
$256.40
|
| Rate for Payer: UMR Bronson Commercial |
$179.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.24
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$4,521.15
|
|
|
Service Code
|
NDC 00008121101
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,672.83 |
| Max. Negotiated Rate |
$4,069.04 |
| Rate for Payer: Aetna American Axle |
$2,938.75
|
| Rate for Payer: Aetna Commercial |
$3,842.98
|
| Rate for Payer: Aetna Medicare |
$2,260.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,938.75
|
| Rate for Payer: BCBS Complete |
$1,808.46
|
| Rate for Payer: Cash Price |
$3,616.92
|
| Rate for Payer: Cofinity Commercial |
$3,164.80
|
| Rate for Payer: Cofinity Commercial |
$3,888.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,164.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,616.92
|
| Rate for Payer: Healthscope Commercial |
$4,069.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,164.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,390.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,842.98
|
| Rate for Payer: PHP Commercial |
$3,842.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,938.75
|
| Rate for Payer: Priority Health SBD |
$2,848.32
|
| Rate for Payer: UMR Bronson Commercial |
$1,672.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,390.86
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$130.61
|
|
|
Service Code
|
NDC 68180059206
|
| Hospital Charge Code |
91073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.33 |
| Max. Negotiated Rate |
$117.55 |
| Rate for Payer: Aetna American Axle |
$84.90
|
| Rate for Payer: Aetna Commercial |
$111.02
|
| Rate for Payer: Aetna Medicare |
$65.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.90
|
| Rate for Payer: BCBS Complete |
$52.24
|
| Rate for Payer: Cash Price |
$104.49
|
| Rate for Payer: Cofinity Commercial |
$112.32
|
| Rate for Payer: Cofinity Commercial |
$91.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.49
|
| Rate for Payer: Healthscope Commercial |
$117.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.02
|
| Rate for Payer: PHP Commercial |
$111.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.90
|
| Rate for Payer: Priority Health SBD |
$82.28
|
| Rate for Payer: UMR Bronson Commercial |
$48.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.96
|
|
|
DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
NDC 00998061505
|
| Hospital Charge Code |
19596
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$220.50 |
| Rate for Payer: Aetna American Axle |
$159.25
|
| Rate for Payer: Aetna Commercial |
$208.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.25
|
| Rate for Payer: Cash Price |
$196.00
|
| Rate for Payer: Cofinity Commercial |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$210.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.00
|
| Rate for Payer: Healthscope Commercial |
$220.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.25
|
| Rate for Payer: PHP Commercial |
$208.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.25
|
| Rate for Payer: Priority Health SBD |
$154.35
|
| Rate for Payer: UMR Bronson Commercial |
$107.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.75
|
|
|
DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
NDC 00998061505
|
| Hospital Charge Code |
19596
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.65 |
| Max. Negotiated Rate |
$220.50 |
| Rate for Payer: Aetna American Axle |
$159.25
|
| Rate for Payer: Aetna Commercial |
$208.25
|
| Rate for Payer: Aetna Medicare |
$122.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.25
|
| Rate for Payer: BCBS Complete |
$98.00
|
| Rate for Payer: Cash Price |
$196.00
|
| Rate for Payer: Cofinity Commercial |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$210.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.00
|
| Rate for Payer: Healthscope Commercial |
$220.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.25
|
| Rate for Payer: PHP Commercial |
$208.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.25
|
| Rate for Payer: Priority Health SBD |
$154.35
|
| Rate for Payer: UMR Bronson Commercial |
$90.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.75
|
|
|
DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
OP
|
$235.48
|
|
|
Service Code
|
NDC 00078092525
|
| Hospital Charge Code |
19596
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.13 |
| Max. Negotiated Rate |
$211.93 |
| Rate for Payer: Aetna American Axle |
$153.06
|
| Rate for Payer: Aetna Commercial |
$200.16
|
| Rate for Payer: Aetna Medicare |
$117.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.06
|
| Rate for Payer: BCBS Complete |
$94.19
|
| Rate for Payer: Cash Price |
$188.38
|
| Rate for Payer: Cofinity Commercial |
$164.84
|
| Rate for Payer: Cofinity Commercial |
$202.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.38
|
| Rate for Payer: Healthscope Commercial |
$211.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$176.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$200.16
|
| Rate for Payer: PHP Commercial |
$200.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.06
|
| Rate for Payer: Priority Health SBD |
$148.35
|
| Rate for Payer: UMR Bronson Commercial |
$87.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$176.61
|
|
|
DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$235.48
|
|
|
Service Code
|
NDC 00078092525
|
| Hospital Charge Code |
19596
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.61 |
| Max. Negotiated Rate |
$211.93 |
| Rate for Payer: Aetna American Axle |
$153.06
|
| Rate for Payer: Aetna Commercial |
$200.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.06
|
| Rate for Payer: Cash Price |
$188.38
|
| Rate for Payer: Cofinity Commercial |
$164.84
|
| Rate for Payer: Cofinity Commercial |
$202.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.38
|
| Rate for Payer: Healthscope Commercial |
$211.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$176.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$200.16
|
| Rate for Payer: PHP Commercial |
$200.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.06
|
| Rate for Payer: Priority Health SBD |
$148.35
|
| Rate for Payer: UMR Bronson Commercial |
$103.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$176.61
|
|
|
DEXAMETHASONE 0.4 % FOR IONTOPHORESIS
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
163636
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: BCBS Trust/PPO |
$0.29
|
| Rate for Payer: BCN Commercial |
$0.29
|
|
|
DEXAMETHASONE 0.75 MG TABLET
|
Facility
|
IP
|
$451.20
|
|
|
Service Code
|
NDC 00054418025
|
| Hospital Charge Code |
2323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.53 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna American Axle |
$293.28
|
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Commercial |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$315.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$315.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.28
|
| Rate for Payer: Priority Health SBD |
$284.26
|
| Rate for Payer: UMR Bronson Commercial |
$198.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.40
|
|
|
DEXAMETHASONE 0.75 MG TABLET
|
Facility
|
OP
|
$451.20
|
|
|
Service Code
|
NDC 00054418025
|
| Hospital Charge Code |
2323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.94 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna American Axle |
$293.28
|
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna Medicare |
$225.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: BCBS Complete |
$180.48
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Commercial |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$315.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$315.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.28
|
| Rate for Payer: Priority Health SBD |
$284.26
|
| Rate for Payer: UMR Bronson Commercial |
$166.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.40
|
|
|
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE)
|
Facility
|
OP
|
$106.42
|
|
|
Service Code
|
NDC 00054317644
|
| Hospital Charge Code |
108723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$95.78 |
| Rate for Payer: Aetna American Axle |
$69.17
|
| Rate for Payer: Aetna Commercial |
$90.46
|
| Rate for Payer: Aetna Medicare |
$53.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.17
|
| Rate for Payer: BCBS Complete |
$42.57
|
| Rate for Payer: Cash Price |
$85.14
|
| Rate for Payer: Cofinity Commercial |
$74.49
|
| Rate for Payer: Cofinity Commercial |
$91.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.14
|
| Rate for Payer: Healthscope Commercial |
$95.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.46
|
| Rate for Payer: PHP Commercial |
$90.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.17
|
| Rate for Payer: Priority Health SBD |
$67.04
|
| Rate for Payer: UMR Bronson Commercial |
$39.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.82
|
|
|
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE)
|
Facility
|
IP
|
$106.42
|
|
|
Service Code
|
NDC 00054317644
|
| Hospital Charge Code |
108723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.82 |
| Max. Negotiated Rate |
$95.78 |
| Rate for Payer: Aetna American Axle |
$69.17
|
| Rate for Payer: Aetna Commercial |
$90.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.17
|
| Rate for Payer: Cash Price |
$85.14
|
| Rate for Payer: Cofinity Commercial |
$74.49
|
| Rate for Payer: Cofinity Commercial |
$91.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.14
|
| Rate for Payer: Healthscope Commercial |
$95.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.46
|
| Rate for Payer: PHP Commercial |
$90.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.17
|
| Rate for Payer: Priority Health SBD |
$67.04
|
| Rate for Payer: UMR Bronson Commercial |
$46.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.82
|
|
|
DEXAMETHASONE 1 MG TABLET
|
Facility
|
OP
|
$273.60
|
|
|
Service Code
|
NDC 00054817425
|
| Hospital Charge Code |
2324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.23 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna American Axle |
$177.84
|
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: Aetna Medicare |
$136.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.84
|
| Rate for Payer: BCBS Complete |
$109.44
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$191.52
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$191.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health SBD |
$172.37
|
| Rate for Payer: UMR Bronson Commercial |
$101.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
DEXAMETHASONE 1 MG TABLET
|
Facility
|
IP
|
$207.10
|
|
|
Service Code
|
NDC 00054418125
|
| Hospital Charge Code |
2324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.12 |
| Max. Negotiated Rate |
$186.39 |
| Rate for Payer: Aetna American Axle |
$134.62
|
| Rate for Payer: Aetna Commercial |
$176.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.62
|
| Rate for Payer: Cash Price |
$165.68
|
| Rate for Payer: Cofinity Commercial |
$144.97
|
| Rate for Payer: Cofinity Commercial |
$178.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.68
|
| Rate for Payer: Healthscope Commercial |
$186.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.04
|
| Rate for Payer: PHP Commercial |
$176.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.62
|
| Rate for Payer: Priority Health SBD |
$130.47
|
| Rate for Payer: UMR Bronson Commercial |
$91.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.32
|
|
|
DEXAMETHASONE 1 MG TABLET
|
Facility
|
IP
|
$273.60
|
|
|
Service Code
|
NDC 00054817425
|
| Hospital Charge Code |
2324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.38 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna American Axle |
$177.84
|
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.84
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$191.52
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$191.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health SBD |
$172.37
|
| Rate for Payer: UMR Bronson Commercial |
$120.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
DEXAMETHASONE 1 MG TABLET
|
Facility
|
OP
|
$207.10
|
|
|
Service Code
|
NDC 00054418125
|
| Hospital Charge Code |
2324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.63 |
| Max. Negotiated Rate |
$186.39 |
| Rate for Payer: Aetna American Axle |
$134.62
|
| Rate for Payer: Aetna Commercial |
$176.04
|
| Rate for Payer: Aetna Medicare |
$103.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.62
|
| Rate for Payer: BCBS Complete |
$82.84
|
| Rate for Payer: Cash Price |
$165.68
|
| Rate for Payer: Cofinity Commercial |
$144.97
|
| Rate for Payer: Cofinity Commercial |
$178.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.68
|
| Rate for Payer: Healthscope Commercial |
$186.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.04
|
| Rate for Payer: PHP Commercial |
$176.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.62
|
| Rate for Payer: Priority Health SBD |
$130.47
|
| Rate for Payer: UMR Bronson Commercial |
$76.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.32
|
|
|
DEXAMETHASONE 4 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$16.72
|
|
|
Service Code
|
NDC 09900000647
|
| Hospital Charge Code |
180050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna American Axle |
$10.87
|
| Rate for Payer: Aetna Commercial |
$14.21
|
| Rate for Payer: Aetna Medicare |
$8.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.87
|
| Rate for Payer: BCBS Complete |
$6.69
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$11.70
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.38
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.21
|
| Rate for Payer: PHP Commercial |
$14.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.87
|
| Rate for Payer: Priority Health SBD |
$10.53
|
| Rate for Payer: UMR Bronson Commercial |
$6.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.54
|
|
|
DEXAMETHASONE 4 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$19.76
|
|
|
Service Code
|
NDC 63323016501
|
| Hospital Charge Code |
180050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$17.78 |
| Rate for Payer: Aetna American Axle |
$12.84
|
| Rate for Payer: Aetna Commercial |
$16.80
|
| Rate for Payer: Aetna Medicare |
$9.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.84
|
| Rate for Payer: BCBS Complete |
$7.90
|
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Cofinity Commercial |
$13.83
|
| Rate for Payer: Cofinity Commercial |
$16.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.81
|
| Rate for Payer: Healthscope Commercial |
$17.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.80
|
| Rate for Payer: PHP Commercial |
$16.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.84
|
| Rate for Payer: Priority Health SBD |
$12.45
|
| Rate for Payer: UMR Bronson Commercial |
$7.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.82
|
|
|
DEXAMETHASONE 4 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$16.72
|
|
|
Service Code
|
NDC 09900000647
|
| Hospital Charge Code |
180050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna American Axle |
$10.87
|
| Rate for Payer: Aetna Commercial |
$14.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.87
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$11.70
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.38
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.21
|
| Rate for Payer: PHP Commercial |
$14.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.87
|
| Rate for Payer: Priority Health SBD |
$10.53
|
| Rate for Payer: UMR Bronson Commercial |
$7.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.54
|
|
|
DEXAMETHASONE 4 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$19.76
|
|
|
Service Code
|
NDC 63323016501
|
| Hospital Charge Code |
180050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$17.78 |
| Rate for Payer: Aetna American Axle |
$12.84
|
| Rate for Payer: Aetna Commercial |
$16.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.84
|
| Rate for Payer: Cash Price |
$15.81
|
| Rate for Payer: Cofinity Commercial |
$13.83
|
| Rate for Payer: Cofinity Commercial |
$16.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.81
|
| Rate for Payer: Healthscope Commercial |
$17.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.80
|
| Rate for Payer: PHP Commercial |
$16.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.84
|
| Rate for Payer: Priority Health SBD |
$12.45
|
| Rate for Payer: UMR Bronson Commercial |
$8.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.82
|
|
