|
DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 00006430900
|
| Hospital Charge Code |
173258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 00006430900
|
| Hospital Charge Code |
173258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 00006430901
|
| Hospital Charge Code |
173258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINE (STERILE WATER) SYRINGE
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 00006417589
|
| Hospital Charge Code |
206168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINE (STERILE WATER) SYRINGE
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 00006417588
|
| Hospital Charge Code |
206168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINE (STERILE WATER) SYRINGE
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 00006417589
|
| Hospital Charge Code |
206168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINE (STERILE WATER) SYRINGE
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 00006417588
|
| Hospital Charge Code |
206168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna American Axle |
$0.01
|
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.02
|
| Rate for Payer: Healthscope Commercial |
$0.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.02
|
| Rate for Payer: PHP Commercial |
$0.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health SBD |
$0.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.02
|
|
|
DIMENHYDRINATE 25 MG TABLET (CUSTOM)
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 09900001999
|
| Hospital Charge Code |
301909
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna American Axle |
$0.29
|
| Rate for Payer: Aetna Commercial |
$0.38
|
| Rate for Payer: Aetna Medicare |
$0.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.29
|
| Rate for Payer: BCBS Complete |
$0.18
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cofinity Commercial |
$0.32
|
| Rate for Payer: Cofinity Commercial |
$0.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.36
|
| Rate for Payer: Healthscope Commercial |
$0.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.38
|
| Rate for Payer: PHP Commercial |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.29
|
| Rate for Payer: Priority Health SBD |
$0.28
|
| Rate for Payer: UMR Bronson Commercial |
$0.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.34
|
|
|
DIMENHYDRINATE 25 MG TABLET (CUSTOM)
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 09900001999
|
| Hospital Charge Code |
301909
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna American Axle |
$0.29
|
| Rate for Payer: Aetna Commercial |
$0.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.29
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cofinity Commercial |
$0.32
|
| Rate for Payer: Cofinity Commercial |
$0.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.36
|
| Rate for Payer: Healthscope Commercial |
$0.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.38
|
| Rate for Payer: PHP Commercial |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.29
|
| Rate for Payer: Priority Health SBD |
$0.28
|
| Rate for Payer: UMR Bronson Commercial |
$0.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.34
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.01
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Aetna American Axle |
$15.61
|
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: Aetna Medicare |
$12.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.61
|
| Rate for Payer: BCBS Complete |
$9.60
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cofinity Commercial |
$16.81
|
| Rate for Payer: Cofinity Commercial |
$20.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.21
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.41
|
| Rate for Payer: PHP Commercial |
$20.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.61
|
| Rate for Payer: Priority Health SBD |
$15.13
|
| Rate for Payer: UMR Bronson Commercial |
$8.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.01
|
|
|
DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.01
|
|
|
Service Code
|
HCPCS J1240
|
| Hospital Charge Code |
2483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Aetna American Axle |
$15.61
|
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.61
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cofinity Commercial |
$16.81
|
| Rate for Payer: Cofinity Commercial |
$20.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.21
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.41
|
| Rate for Payer: PHP Commercial |
$20.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.61
|
| Rate for Payer: Priority Health SBD |
$15.13
|
| Rate for Payer: UMR Bronson Commercial |
$10.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.01
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
OP
|
$24.96
|
|
|
Service Code
|
NDC 00904677212
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Aetna American Axle |
$16.22
|
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna Medicare |
$12.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.22
|
| Rate for Payer: BCBS Complete |
$9.98
|
| Rate for Payer: Cash Price |
$19.97
|
| Rate for Payer: Cofinity Commercial |
$17.47
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.97
|
| Rate for Payer: Healthscope Commercial |
$22.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.22
|
| Rate for Payer: Priority Health SBD |
$15.72
|
| Rate for Payer: UMR Bronson Commercial |
$9.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.72
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
OP
|
$88.20
|
|
|
Service Code
|
NDC 00904205159
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.63 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna American Axle |
$57.33
|
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna Medicare |
$44.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.33
|
| Rate for Payer: BCBS Complete |
$35.28
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$61.74
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health SBD |
$55.57
|
| Rate for Payer: UMR Bronson Commercial |
$32.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$24.96
|
|
|
Service Code
|
NDC 00904677212
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Aetna American Axle |
$16.22
|
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.22
|
| Rate for Payer: Cash Price |
$19.97
|
| Rate for Payer: Cofinity Commercial |
$17.47
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.97
|
| Rate for Payer: Healthscope Commercial |
$22.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.22
|
| Rate for Payer: Priority Health SBD |
$15.72
|
| Rate for Payer: UMR Bronson Commercial |
$10.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.72
|
|
|
DIMENHYDRINATE 50 MG TABLET
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 00904205159
|
| Hospital Charge Code |
2485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.81 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna American Axle |
$57.33
|
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.33
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$61.74
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health SBD |
$55.57
|
| Rate for Payer: UMR Bronson Commercial |
$38.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION
|
Facility
|
IP
|
$2,391.50
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
118456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,052.26 |
| Max. Negotiated Rate |
$2,152.35 |
| Rate for Payer: Aetna American Axle |
$1,554.47
|
| Rate for Payer: Aetna Commercial |
$2,032.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,554.47
|
| Rate for Payer: Cash Price |
$1,913.20
|
| Rate for Payer: Cofinity Commercial |
$1,674.05
|
| Rate for Payer: Cofinity Commercial |
$2,056.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,674.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,913.20
|
| Rate for Payer: Healthscope Commercial |
$2,152.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,674.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,793.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,032.78
|
| Rate for Payer: PHP Commercial |
$2,032.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,554.47
|
| Rate for Payer: Priority Health SBD |
$1,506.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,052.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,793.62
|
|
|
DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION
|
Facility
|
OP
|
$2,391.50
|
|
|
Service Code
|
HCPCS J1212
|
| Hospital Charge Code |
118456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$401.38 |
| Max. Negotiated Rate |
$2,152.35 |
| Rate for Payer: Aetna American Axle |
$1,554.47
|
| Rate for Payer: Aetna Commercial |
$2,032.78
|
| Rate for Payer: Aetna Medicare |
$778.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,554.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$936.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$936.06
|
| Rate for Payer: BCBS Complete |
$421.45
|
| Rate for Payer: BCBS MAPPO |
$748.85
|
| Rate for Payer: BCN Medicare Advantage |
$748.85
|
| Rate for Payer: Cash Price |
$1,913.20
|
| Rate for Payer: Cash Price |
$1,913.20
|
| Rate for Payer: Cofinity Commercial |
$2,056.69
|
| Rate for Payer: Cofinity Commercial |
$1,674.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,674.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,913.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$748.85
|
| Rate for Payer: Healthscope Commercial |
$2,152.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,674.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,793.62
|
| Rate for Payer: Mclaren Medicaid |
$401.38
|
| Rate for Payer: Mclaren Medicare |
$748.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$786.29
|
| Rate for Payer: Meridian Medicaid |
$421.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$861.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,032.78
|
| Rate for Payer: PACE Medicare |
$711.41
|
| Rate for Payer: PACE SWMI |
$748.85
|
| Rate for Payer: PHP Commercial |
$2,032.78
|
| Rate for Payer: PHP Medicare Advantage |
$748.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$401.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,554.47
|
| Rate for Payer: Priority Health Medicare |
$748.85
|
| Rate for Payer: Priority Health SBD |
$1,506.64
|
| Rate for Payer: Railroad Medicare Medicare |
$748.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,107.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$748.85
|
| Rate for Payer: UHC Exchange |
$1,431.13
|
| Rate for Payer: UHC Medicare Advantage |
$748.85
|
| Rate for Payer: UHCCP Medicaid |
$401.38
|
| Rate for Payer: UMR Bronson Commercial |
$884.86
|
| Rate for Payer: VA VA |
$748.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,793.62
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,803.01
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$793.32 |
| Max. Negotiated Rate |
$1,622.71 |
| Rate for Payer: Aetna American Axle |
$1,171.96
|
| Rate for Payer: Aetna Commercial |
$1,532.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,171.96
|
| Rate for Payer: Cash Price |
$1,442.41
|
| Rate for Payer: Cofinity Commercial |
$1,262.11
|
| Rate for Payer: Cofinity Commercial |
$1,550.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,262.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,442.41
|
| Rate for Payer: Healthscope Commercial |
$1,622.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,262.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,352.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,532.56
|
| Rate for Payer: PHP Commercial |
$1,532.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,171.96
|
| Rate for Payer: Priority Health SBD |
$1,135.90
|
| Rate for Payer: UMR Bronson Commercial |
$793.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,352.26
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
OP
|
$1,803.01
|
|
|
Service Code
|
NDC 55566280001
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$667.11 |
| Max. Negotiated Rate |
$1,622.71 |
| Rate for Payer: Aetna American Axle |
$1,171.96
|
| Rate for Payer: Aetna Commercial |
$1,532.56
|
| Rate for Payer: Aetna Medicare |
$901.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,171.96
|
| Rate for Payer: BCBS Complete |
$721.20
|
| Rate for Payer: Cash Price |
$1,442.41
|
| Rate for Payer: Cofinity Commercial |
$1,262.11
|
| Rate for Payer: Cofinity Commercial |
$1,550.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,262.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,442.41
|
| Rate for Payer: Healthscope Commercial |
$1,622.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,262.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,352.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,532.56
|
| Rate for Payer: PHP Commercial |
$1,532.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,171.96
|
| Rate for Payer: Priority Health SBD |
$1,135.90
|
| Rate for Payer: UMR Bronson Commercial |
$667.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,352.26
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
OP
|
$1,803.01
|
|
|
Service Code
|
NDC 55566280000
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$667.11 |
| Max. Negotiated Rate |
$1,622.71 |
| Rate for Payer: Aetna American Axle |
$1,171.96
|
| Rate for Payer: Aetna Commercial |
$1,532.56
|
| Rate for Payer: Aetna Medicare |
$901.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,171.96
|
| Rate for Payer: BCBS Complete |
$721.20
|
| Rate for Payer: Cash Price |
$1,442.41
|
| Rate for Payer: Cofinity Commercial |
$1,262.11
|
| Rate for Payer: Cofinity Commercial |
$1,550.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,262.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,442.41
|
| Rate for Payer: Healthscope Commercial |
$1,622.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,262.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,352.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,532.56
|
| Rate for Payer: PHP Commercial |
$1,532.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,171.96
|
| Rate for Payer: Priority Health SBD |
$1,135.90
|
| Rate for Payer: UMR Bronson Commercial |
$667.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,352.26
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE
|
Facility
|
IP
|
$1,803.01
|
|
|
Service Code
|
NDC 55566280000
|
| Hospital Charge Code |
27467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$793.32 |
| Max. Negotiated Rate |
$1,622.71 |
| Rate for Payer: Aetna American Axle |
$1,171.96
|
| Rate for Payer: Aetna Commercial |
$1,532.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,171.96
|
| Rate for Payer: Cash Price |
$1,442.41
|
| Rate for Payer: Cofinity Commercial |
$1,262.11
|
| Rate for Payer: Cofinity Commercial |
$1,550.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,262.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,442.41
|
| Rate for Payer: Healthscope Commercial |
$1,622.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,262.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,352.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,532.56
|
| Rate for Payer: PHP Commercial |
$1,532.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,171.96
|
| Rate for Payer: Priority Health SBD |
$1,135.90
|
| Rate for Payer: UMR Bronson Commercial |
$793.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,352.26
|
|
|
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 Commercial |
$13,650.00
|
| Rate for Payer: Cofinity Commercial |
$16,770.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,650.00
|
| 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: PHP Commercial |
$16,575.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,675.00
|
| 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 Commercial |
$13,650.00
|
| Rate for Payer: Cofinity Commercial |
$16,770.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,650.00
|
| 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: PHP Commercial |
$16,575.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,675.00
|
| 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
|
$6.54
|
|
|
Service Code
|
NDC 09900000847
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: Aetna American Axle |
$4.25
|
| Rate for Payer: Aetna Commercial |
$5.56
|
| Rate for Payer: Aetna Medicare |
$3.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.25
|
| Rate for Payer: BCBS Complete |
$2.62
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Cofinity Commercial |
$4.58
|
| Rate for Payer: Cofinity Commercial |
$5.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.23
|
| Rate for Payer: Healthscope Commercial |
$5.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.56
|
| Rate for Payer: PHP Commercial |
$5.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.25
|
| Rate for Payer: Priority Health SBD |
$4.12
|
| Rate for Payer: UMR Bronson Commercial |
$2.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.91
|
|
|
DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH
|
Facility
|
IP
|
$426.37
|
|
|
Service Code
|
NDC 65628005001
|
| Hospital Charge Code |
39984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.60 |
| Max. Negotiated Rate |
$383.73 |
| Rate for Payer: Aetna American Axle |
$277.14
|
| Rate for Payer: Aetna Commercial |
$362.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.14
|
| Rate for Payer: Cash Price |
$341.10
|
| Rate for Payer: Cofinity Commercial |
$298.46
|
| Rate for Payer: Cofinity Commercial |
$366.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.10
|
| Rate for Payer: Healthscope Commercial |
$383.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.41
|
| Rate for Payer: PHP Commercial |
$362.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.14
|
| Rate for Payer: Priority Health SBD |
$268.61
|
| Rate for Payer: UMR Bronson Commercial |
$187.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.78
|
|
