|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
IP
|
$423.50
|
|
|
Service Code
|
NDC 31722022901
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.34 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: Aetna American Axle |
$275.28
|
| Rate for Payer: Aetna Commercial |
$359.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.28
|
| Rate for Payer: Cash Price |
$338.80
|
| Rate for Payer: Cofinity Commercial |
$296.45
|
| Rate for Payer: Cofinity Commercial |
$364.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$296.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.80
|
| Rate for Payer: Healthscope Commercial |
$381.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.98
|
| Rate for Payer: PHP Commercial |
$359.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$275.28
|
| Rate for Payer: Priority Health SBD |
$266.80
|
| Rate for Payer: UMR Bronson Commercial |
$186.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.62
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
IP
|
$817.83
|
|
|
Service Code
|
NDC 00115991801
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$359.85 |
| Max. Negotiated Rate |
$736.05 |
| Rate for Payer: Aetna American Axle |
$531.59
|
| Rate for Payer: Aetna Commercial |
$695.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$531.59
|
| Rate for Payer: Cash Price |
$654.26
|
| Rate for Payer: Cofinity Commercial |
$572.48
|
| Rate for Payer: Cofinity Commercial |
$703.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$572.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$654.26
|
| Rate for Payer: Healthscope Commercial |
$736.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$572.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$613.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$695.16
|
| Rate for Payer: PHP Commercial |
$695.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$531.59
|
| Rate for Payer: Priority Health SBD |
$515.23
|
| Rate for Payer: UMR Bronson Commercial |
$359.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$613.37
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
OP
|
$423.50
|
|
|
Service Code
|
NDC 31722022901
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.70 |
| Max. Negotiated Rate |
$381.15 |
| Rate for Payer: Aetna American Axle |
$275.28
|
| Rate for Payer: Aetna Commercial |
$359.98
|
| Rate for Payer: Aetna Medicare |
$211.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.28
|
| Rate for Payer: BCBS Complete |
$169.40
|
| Rate for Payer: Cash Price |
$338.80
|
| Rate for Payer: Cofinity Commercial |
$296.45
|
| Rate for Payer: Cofinity Commercial |
$364.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$296.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.80
|
| Rate for Payer: Healthscope Commercial |
$381.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.98
|
| Rate for Payer: PHP Commercial |
$359.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$275.28
|
| Rate for Payer: Priority Health SBD |
$266.80
|
| Rate for Payer: UMR Bronson Commercial |
$156.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.62
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
OP
|
$1,783.86
|
|
|
Service Code
|
NDC 00078043005
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$660.03 |
| Max. Negotiated Rate |
$1,605.47 |
| Rate for Payer: Aetna American Axle |
$1,159.51
|
| Rate for Payer: Aetna Commercial |
$1,516.28
|
| Rate for Payer: Aetna Medicare |
$891.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,159.51
|
| Rate for Payer: BCBS Complete |
$713.54
|
| Rate for Payer: Cash Price |
$1,427.09
|
| Rate for Payer: Cofinity Commercial |
$1,248.70
|
| Rate for Payer: Cofinity Commercial |
$1,534.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,248.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,427.09
|
| Rate for Payer: Healthscope Commercial |
$1,605.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,248.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,337.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,516.28
|
| Rate for Payer: PHP Commercial |
$1,516.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,159.51
|
| Rate for Payer: Priority Health SBD |
$1,123.83
|
| Rate for Payer: UMR Bronson Commercial |
$660.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,337.90
|
|
|
DEXMETHYLPHENIDATE ER 5 MG CAPSULE,EXTENDED RELEASE BIPHASIC50-50
|
Facility
|
OP
|
$817.83
|
|
|
Service Code
|
NDC 00115991801
|
| Hospital Charge Code |
41545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$302.60 |
| Max. Negotiated Rate |
$736.05 |
| Rate for Payer: Aetna American Axle |
$531.59
|
| Rate for Payer: Aetna Commercial |
$695.16
|
| Rate for Payer: Aetna Medicare |
$408.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$531.59
|
| Rate for Payer: BCBS Complete |
$327.13
|
| Rate for Payer: Cash Price |
$654.26
|
| Rate for Payer: Cofinity Commercial |
$572.48
|
| Rate for Payer: Cofinity Commercial |
$703.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$572.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$654.26
|
| Rate for Payer: Healthscope Commercial |
$736.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$572.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$613.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$695.16
|
| Rate for Payer: PHP Commercial |
$695.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$531.59
|
| Rate for Payer: Priority Health SBD |
$515.23
|
| Rate for Payer: UMR Bronson Commercial |
$302.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$613.37
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$257.66
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.37 |
| Max. Negotiated Rate |
$231.89 |
| Rate for Payer: Aetna American Axle |
$167.48
|
| Rate for Payer: Aetna Commercial |
$219.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.48
|
| Rate for Payer: Cash Price |
$206.13
|
| Rate for Payer: Cofinity Commercial |
$180.36
|
| Rate for Payer: Cofinity Commercial |
$221.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.13
|
| Rate for Payer: Healthscope Commercial |
$231.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.01
|
| Rate for Payer: PHP Commercial |
$219.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.48
|
| Rate for Payer: Priority Health SBD |
$162.33
|
| Rate for Payer: UMR Bronson Commercial |
$113.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.24
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$257.66
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$251.81 |
| Rate for Payer: Aetna American Axle |
$167.48
|
| Rate for Payer: Aetna Commercial |
$219.01
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: Cash Price |
$206.13
|
| Rate for Payer: Cash Price |
$206.13
|
| Rate for Payer: Cofinity Commercial |
$221.59
|
| Rate for Payer: Cofinity Commercial |
$180.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Healthscope Commercial |
$231.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.24
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.01
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PHP Commercial |
$219.01
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health SBD |
$162.33
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UMR Bronson Commercial |
$95.33
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.24
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$317.06
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$139.51 |
| Max. Negotiated Rate |
$285.35 |
| Rate for Payer: Aetna American Axle |
$206.09
|
| Rate for Payer: Aetna American Axle |
$306.76
|
| Rate for Payer: Aetna American Axle |
$306.00
|
| Rate for Payer: Aetna American Axle |
$272.15
|
| Rate for Payer: Aetna American Axle |
$282.58
|
| Rate for Payer: Aetna American Axle |
$639.32
|
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Aetna Commercial |
$355.89
|
| Rate for Payer: Aetna Commercial |
$400.15
|
| Rate for Payer: Aetna Commercial |
$836.03
|
| Rate for Payer: Aetna Commercial |
$401.15
|
| Rate for Payer: Aetna Commercial |
$369.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$272.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.76
|
| Rate for Payer: Cash Price |
$377.55
|
| Rate for Payer: Cash Price |
$376.62
|
| Rate for Payer: Cash Price |
$253.65
|
| Rate for Payer: Cash Price |
$347.79
|
| Rate for Payer: Cash Price |
$334.95
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cofinity Commercial |
$405.87
|
| Rate for Payer: Cofinity Commercial |
$221.94
|
| Rate for Payer: Cofinity Commercial |
$404.86
|
| Rate for Payer: Cofinity Commercial |
$329.54
|
| Rate for Payer: Cofinity Commercial |
$304.32
|
| Rate for Payer: Cofinity Commercial |
$293.08
|
| Rate for Payer: Cofinity Commercial |
$360.07
|
| Rate for Payer: Cofinity Commercial |
$373.88
|
| Rate for Payer: Cofinity Commercial |
$272.67
|
| Rate for Payer: Cofinity Commercial |
$845.87
|
| Rate for Payer: Cofinity Commercial |
$688.50
|
| Rate for Payer: Cofinity Commercial |
$330.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$293.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$688.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$330.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$221.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$347.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.86
|
| Rate for Payer: Healthscope Commercial |
$423.69
|
| Rate for Payer: Healthscope Commercial |
$885.21
|
| Rate for Payer: Healthscope Commercial |
$424.75
|
| Rate for Payer: Healthscope Commercial |
$376.82
|
| Rate for Payer: Healthscope Commercial |
$391.27
|
| Rate for Payer: Healthscope Commercial |
$285.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$221.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$688.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$737.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$314.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$836.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$400.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.53
|
| Rate for Payer: PHP Commercial |
$269.50
|
| Rate for Payer: PHP Commercial |
$355.89
|
| Rate for Payer: PHP Commercial |
$400.15
|
| Rate for Payer: PHP Commercial |
$401.15
|
| Rate for Payer: PHP Commercial |
$369.53
|
| Rate for Payer: PHP Commercial |
$836.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$272.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$639.32
|
| Rate for Payer: Priority Health SBD |
$297.32
|
| Rate for Payer: Priority Health SBD |
$296.59
|
| Rate for Payer: Priority Health SBD |
$199.75
|
| Rate for Payer: Priority Health SBD |
$263.77
|
| Rate for Payer: Priority Health SBD |
$273.89
|
| Rate for Payer: Priority Health SBD |
$619.65
|
| Rate for Payer: UMR Bronson Commercial |
$432.77
|
| Rate for Payer: UMR Bronson Commercial |
$184.22
|
| Rate for Payer: UMR Bronson Commercial |
$191.29
|
| Rate for Payer: UMR Bronson Commercial |
$207.65
|
| Rate for Payer: UMR Bronson Commercial |
$207.14
|
| Rate for Payer: UMR Bronson Commercial |
$139.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$314.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$737.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.80
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$434.74
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$391.27 |
| Rate for Payer: Aetna American Axle |
$282.58
|
| Rate for Payer: Aetna American Axle |
$306.00
|
| Rate for Payer: Aetna American Axle |
$272.15
|
| Rate for Payer: Aetna American Axle |
$639.32
|
| Rate for Payer: Aetna American Axle |
$306.76
|
| Rate for Payer: Aetna American Axle |
$206.09
|
| Rate for Payer: Aetna Commercial |
$369.53
|
| Rate for Payer: Aetna Commercial |
$836.03
|
| Rate for Payer: Aetna Commercial |
$400.15
|
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Aetna Commercial |
$355.89
|
| Rate for Payer: Aetna Commercial |
$401.15
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna Medicare |
$84.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$272.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$639.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.10
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS Complete |
$45.52
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS MAPPO |
$80.88
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Commercial |
$235.90
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: BCN Medicare Advantage |
$80.88
|
| Rate for Payer: Cash Price |
$334.95
|
| Rate for Payer: Cash Price |
$377.55
|
| Rate for Payer: Cash Price |
$347.79
|
| Rate for Payer: Cash Price |
$334.95
|
| Rate for Payer: Cash Price |
$376.62
|
| Rate for Payer: Cash Price |
$376.62
|
| Rate for Payer: Cash Price |
$347.79
|
| Rate for Payer: Cash Price |
$253.65
|
| Rate for Payer: Cash Price |
$377.55
|
| Rate for Payer: Cash Price |
$253.65
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cash Price |
$786.86
|
| Rate for Payer: Cofinity Commercial |
$330.36
|
| Rate for Payer: Cofinity Commercial |
$293.08
|
| Rate for Payer: Cofinity Commercial |
$360.07
|
| Rate for Payer: Cofinity Commercial |
$688.50
|
| Rate for Payer: Cofinity Commercial |
$845.87
|
| Rate for Payer: Cofinity Commercial |
$404.86
|
| Rate for Payer: Cofinity Commercial |
$329.54
|
| Rate for Payer: Cofinity Commercial |
$221.94
|
| Rate for Payer: Cofinity Commercial |
$272.67
|
| Rate for Payer: Cofinity Commercial |
$304.32
|
| Rate for Payer: Cofinity Commercial |
$373.88
|
| Rate for Payer: Cofinity Commercial |
$405.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$330.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$293.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$688.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$221.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$347.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.88
|
| Rate for Payer: Healthscope Commercial |
$391.27
|
| Rate for Payer: Healthscope Commercial |
$285.35
|
| Rate for Payer: Healthscope Commercial |
$885.21
|
| Rate for Payer: Healthscope Commercial |
$376.82
|
| Rate for Payer: Healthscope Commercial |
$424.75
|
| Rate for Payer: Healthscope Commercial |
$423.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$688.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$221.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$293.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$314.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$737.68
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicaid |
$43.35
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Mclaren Medicare |
$80.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$84.92
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: Meridian Medicaid |
$45.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$400.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$836.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.53
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: Nomi Health Commercial |
$242.64
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE Medicare |
$76.84
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PACE SWMI |
$80.88
|
| Rate for Payer: PHP Commercial |
$401.15
|
| Rate for Payer: PHP Commercial |
$355.89
|
| Rate for Payer: PHP Commercial |
$836.03
|
| Rate for Payer: PHP Commercial |
$269.50
|
| Rate for Payer: PHP Commercial |
$369.53
|
| Rate for Payer: PHP Commercial |
$400.15
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: PHP Medicare Advantage |
$80.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$272.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$639.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.81
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Medicare |
$80.88
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health Narrow Network |
$201.45
|
| Rate for Payer: Priority Health SBD |
$273.89
|
| Rate for Payer: Priority Health SBD |
$297.32
|
| Rate for Payer: Priority Health SBD |
$296.59
|
| Rate for Payer: Priority Health SBD |
$619.65
|
| Rate for Payer: Priority Health SBD |
$199.75
|
| Rate for Payer: Priority Health SBD |
$263.77
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: Railroad Medicare Medicare |
$80.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$80.88
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Exchange |
$154.57
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHC Medicare Advantage |
$80.88
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UHCCP Medicaid |
$43.35
|
| Rate for Payer: UMR Bronson Commercial |
$160.85
|
| Rate for Payer: UMR Bronson Commercial |
$117.31
|
| Rate for Payer: UMR Bronson Commercial |
$154.92
|
| Rate for Payer: UMR Bronson Commercial |
$174.18
|
| Rate for Payer: UMR Bronson Commercial |
$174.62
|
| Rate for Payer: UMR Bronson Commercial |
$363.92
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: VA VA |
$80.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$314.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$737.68
|
|
|
DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS
|
Facility
|
IP
|
$148.48
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
9759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.33 |
| Max. Negotiated Rate |
$133.63 |
| Rate for Payer: Aetna American Axle |
$96.51
|
| Rate for Payer: Aetna Commercial |
$126.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.51
|
| Rate for Payer: Cash Price |
$118.78
|
| Rate for Payer: Cofinity Commercial |
$103.94
|
| Rate for Payer: Cofinity Commercial |
$127.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.78
|
| Rate for Payer: Healthscope Commercial |
$133.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.21
|
| Rate for Payer: PHP Commercial |
$126.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.51
|
| Rate for Payer: Priority Health SBD |
$93.54
|
| Rate for Payer: UMR Bronson Commercial |
$65.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.36
|
|
|
DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS
|
Facility
|
OP
|
$148.48
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
9759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.94 |
| Max. Negotiated Rate |
$133.63 |
| Rate for Payer: Aetna American Axle |
$96.51
|
| Rate for Payer: Aetna Commercial |
$126.21
|
| Rate for Payer: Aetna Medicare |
$74.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.51
|
| Rate for Payer: BCBS Complete |
$59.39
|
| Rate for Payer: BCBS Trust/PPO |
$105.96
|
| Rate for Payer: BCN Commercial |
$105.96
|
| Rate for Payer: Cash Price |
$118.78
|
| Rate for Payer: Cash Price |
$118.78
|
| Rate for Payer: Cofinity Commercial |
$103.94
|
| Rate for Payer: Cofinity Commercial |
$127.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.78
|
| Rate for Payer: Healthscope Commercial |
$133.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.21
|
| Rate for Payer: PHP Commercial |
$126.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.51
|
| Rate for Payer: Priority Health SBD |
$93.54
|
| Rate for Payer: UMR Bronson Commercial |
$54.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.36
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$610.75
|
|
|
Service Code
|
NDC 13107007001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.73 |
| Max. Negotiated Rate |
$549.68 |
| Rate for Payer: Aetna American Axle |
$396.99
|
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Commercial |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$427.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$458.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.14
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$396.99
|
| Rate for Payer: Priority Health SBD |
$384.77
|
| Rate for Payer: UMR Bronson Commercial |
$268.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$458.06
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$822.50
|
|
|
Service Code
|
NDC 00527150237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$304.32 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna Medicare |
$411.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: BCBS Complete |
$329.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Commercial |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$575.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$534.62
|
| Rate for Payer: Priority Health SBD |
$518.18
|
| Rate for Payer: UMR Bronson Commercial |
$304.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$605.50
|
|
|
Service Code
|
NDC 68382095201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.04 |
| Max. Negotiated Rate |
$544.95 |
| Rate for Payer: Aetna American Axle |
$393.58
|
| Rate for Payer: Aetna Commercial |
$514.68
|
| Rate for Payer: Aetna Medicare |
$302.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.58
|
| Rate for Payer: BCBS Complete |
$242.20
|
| Rate for Payer: Cash Price |
$484.40
|
| Rate for Payer: Cofinity Commercial |
$423.85
|
| Rate for Payer: Cofinity Commercial |
$520.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$423.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.40
|
| Rate for Payer: Healthscope Commercial |
$544.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$454.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.68
|
| Rate for Payer: PHP Commercial |
$514.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$393.58
|
| Rate for Payer: Priority Health SBD |
$381.46
|
| Rate for Payer: UMR Bronson Commercial |
$224.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$454.12
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 00555097202
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.28
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.28
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Commercial |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$394.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$366.28
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$247.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$607.25
|
|
|
Service Code
|
NDC 47781017601
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.19 |
| Max. Negotiated Rate |
$546.52 |
| Rate for Payer: Aetna American Axle |
$394.71
|
| Rate for Payer: Aetna Commercial |
$516.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$394.71
|
| Rate for Payer: Cash Price |
$485.80
|
| Rate for Payer: Cofinity Commercial |
$425.08
|
| Rate for Payer: Cofinity Commercial |
$522.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$425.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$485.80
|
| Rate for Payer: Healthscope Commercial |
$546.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$425.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$455.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$516.16
|
| Rate for Payer: PHP Commercial |
$516.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$394.71
|
| Rate for Payer: Priority Health SBD |
$382.57
|
| Rate for Payer: UMR Bronson Commercial |
$267.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$455.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
|
Service Code
|
NDC 00527150237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$361.90 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Commercial |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$575.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$534.62
|
| Rate for Payer: Priority Health SBD |
$518.18
|
| Rate for Payer: UMR Bronson Commercial |
$361.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$563.50
|
|
|
Service Code
|
NDC 00555097202
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.28
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna Medicare |
$281.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.28
|
| Rate for Payer: BCBS Complete |
$225.40
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Commercial |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$394.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$366.28
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$208.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$607.25
|
|
|
Service Code
|
NDC 47781017601
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.68 |
| Max. Negotiated Rate |
$546.52 |
| Rate for Payer: Aetna American Axle |
$394.71
|
| Rate for Payer: Aetna Commercial |
$516.16
|
| Rate for Payer: Aetna Medicare |
$303.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$394.71
|
| Rate for Payer: BCBS Complete |
$242.90
|
| Rate for Payer: Cash Price |
$485.80
|
| Rate for Payer: Cofinity Commercial |
$425.08
|
| Rate for Payer: Cofinity Commercial |
$522.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$425.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$485.80
|
| Rate for Payer: Healthscope Commercial |
$546.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$425.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$455.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$516.16
|
| Rate for Payer: PHP Commercial |
$516.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$394.71
|
| Rate for Payer: Priority Health SBD |
$382.57
|
| Rate for Payer: UMR Bronson Commercial |
$224.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$455.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$605.50
|
|
|
Service Code
|
NDC 68382095201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.42 |
| Max. Negotiated Rate |
$544.95 |
| Rate for Payer: Aetna American Axle |
$393.58
|
| Rate for Payer: Aetna Commercial |
$514.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.58
|
| Rate for Payer: Cash Price |
$484.40
|
| Rate for Payer: Cofinity Commercial |
$423.85
|
| Rate for Payer: Cofinity Commercial |
$520.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$423.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.40
|
| Rate for Payer: Healthscope Commercial |
$544.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$454.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.68
|
| Rate for Payer: PHP Commercial |
$514.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$393.58
|
| Rate for Payer: Priority Health SBD |
$381.46
|
| Rate for Payer: UMR Bronson Commercial |
$266.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$454.12
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$610.75
|
|
|
Service Code
|
NDC 13107007001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.98 |
| Max. Negotiated Rate |
$549.68 |
| Rate for Payer: Aetna American Axle |
$396.99
|
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna Medicare |
$305.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: BCBS Complete |
$244.30
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Commercial |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$427.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$458.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.14
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$396.99
|
| Rate for Payer: Priority Health SBD |
$384.77
|
| Rate for Payer: UMR Bronson Commercial |
$225.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$458.06
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 00555097102
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.28
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.28
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Commercial |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$394.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$366.28
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$247.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
OP
|
$3,600.30
|
|
|
Service Code
|
NDC 57844010501
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,332.11 |
| Max. Negotiated Rate |
$3,240.27 |
| Rate for Payer: Aetna American Axle |
$2,340.20
|
| Rate for Payer: Aetna Commercial |
$3,060.26
|
| Rate for Payer: Aetna Medicare |
$1,800.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,340.20
|
| Rate for Payer: BCBS Complete |
$1,440.12
|
| Rate for Payer: Cash Price |
$2,880.24
|
| Rate for Payer: Cofinity Commercial |
$2,520.21
|
| Rate for Payer: Cofinity Commercial |
$3,096.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,520.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,880.24
|
| Rate for Payer: Healthscope Commercial |
$3,240.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,520.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,700.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,060.26
|
| Rate for Payer: PHP Commercial |
$3,060.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,340.20
|
| Rate for Payer: Priority Health SBD |
$2,268.19
|
| Rate for Payer: UMR Bronson Commercial |
$1,332.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,700.22
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
OP
|
$563.50
|
|
|
Service Code
|
NDC 00555097102
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.28
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna Medicare |
$281.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.28
|
| Rate for Payer: BCBS Complete |
$225.40
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Commercial |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$394.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$366.28
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$208.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
IP
|
$3,600.30
|
|
|
Service Code
|
NDC 57844010501
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,584.13 |
| Max. Negotiated Rate |
$3,240.27 |
| Rate for Payer: Aetna American Axle |
$2,340.20
|
| Rate for Payer: Aetna Commercial |
$3,060.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,340.20
|
| Rate for Payer: Cash Price |
$2,880.24
|
| Rate for Payer: Cofinity Commercial |
$2,520.21
|
| Rate for Payer: Cofinity Commercial |
$3,096.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,520.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,880.24
|
| Rate for Payer: Healthscope Commercial |
$3,240.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,520.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,700.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,060.26
|
| Rate for Payer: PHP Commercial |
$3,060.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,340.20
|
| Rate for Payer: Priority Health SBD |
$2,268.19
|
| Rate for Payer: UMR Bronson Commercial |
$1,584.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,700.22
|
|
