|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$721.44
|
|
|
Service Code
|
NDC 60687022801
|
| Hospital Charge Code |
29276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.93 |
| Max. Negotiated Rate |
$649.30 |
| Rate for Payer: Aetna American Axle |
$468.94
|
| Rate for Payer: Aetna Commercial |
$613.22
|
| Rate for Payer: Aetna Medicare |
$360.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.94
|
| Rate for Payer: BCBS Complete |
$288.58
|
| Rate for Payer: Cash Price |
$577.15
|
| Rate for Payer: Cofinity Commercial |
$505.01
|
| Rate for Payer: Cofinity Commercial |
$620.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$505.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$577.15
|
| Rate for Payer: Healthscope Commercial |
$649.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$505.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$541.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$613.22
|
| Rate for Payer: PHP Commercial |
$613.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.94
|
| Rate for Payer: Priority Health SBD |
$454.51
|
| Rate for Payer: UMR Bronson Commercial |
$266.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$541.08
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$650.88
|
|
|
Service Code
|
NDC 00904722061
|
| Hospital Charge Code |
29276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.39 |
| Max. Negotiated Rate |
$585.79 |
| Rate for Payer: Aetna American Axle |
$423.07
|
| Rate for Payer: Aetna Commercial |
$553.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$423.07
|
| Rate for Payer: Cash Price |
$520.70
|
| Rate for Payer: Cofinity Commercial |
$455.62
|
| Rate for Payer: Cofinity Commercial |
$559.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$455.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$520.70
|
| Rate for Payer: Healthscope Commercial |
$585.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$455.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$488.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$553.25
|
| Rate for Payer: PHP Commercial |
$553.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$423.07
|
| Rate for Payer: Priority Health SBD |
$410.05
|
| Rate for Payer: UMR Bronson Commercial |
$286.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$488.16
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$721.44
|
|
|
Service Code
|
NDC 60687022801
|
| Hospital Charge Code |
29276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$317.43 |
| Max. Negotiated Rate |
$649.30 |
| Rate for Payer: Aetna American Axle |
$468.94
|
| Rate for Payer: Aetna Commercial |
$613.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.94
|
| Rate for Payer: Cash Price |
$577.15
|
| Rate for Payer: Cofinity Commercial |
$505.01
|
| Rate for Payer: Cofinity Commercial |
$620.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$505.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$577.15
|
| Rate for Payer: Healthscope Commercial |
$649.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$505.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$541.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$613.22
|
| Rate for Payer: PHP Commercial |
$613.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.94
|
| Rate for Payer: Priority Health SBD |
$454.51
|
| Rate for Payer: UMR Bronson Commercial |
$317.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$541.08
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$7.22
|
|
|
Service Code
|
NDC 60687022811
|
| Hospital Charge Code |
29276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Aetna American Axle |
$4.69
|
| Rate for Payer: Aetna Commercial |
$6.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.69
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Cofinity Commercial |
$5.05
|
| Rate for Payer: Cofinity Commercial |
$6.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.78
|
| Rate for Payer: Healthscope Commercial |
$6.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.14
|
| Rate for Payer: PHP Commercial |
$6.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.69
|
| Rate for Payer: Priority Health SBD |
$4.55
|
| Rate for Payer: UMR Bronson Commercial |
$3.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.42
|
|
|
DILTIAZEM ER 240 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$464.98
|
|
|
Service Code
|
NDC 00187204730
|
| Hospital Charge Code |
35179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.04 |
| Max. Negotiated Rate |
$418.48 |
| Rate for Payer: Aetna American Axle |
$302.24
|
| Rate for Payer: Aetna Commercial |
$395.23
|
| Rate for Payer: Aetna Medicare |
$232.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.24
|
| Rate for Payer: BCBS Complete |
$185.99
|
| Rate for Payer: Cash Price |
$371.98
|
| Rate for Payer: Cofinity Commercial |
$325.49
|
| Rate for Payer: Cofinity Commercial |
$399.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$325.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.98
|
| Rate for Payer: Healthscope Commercial |
$418.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$325.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.23
|
| Rate for Payer: PHP Commercial |
$395.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.24
|
| Rate for Payer: Priority Health SBD |
$292.94
|
| Rate for Payer: UMR Bronson Commercial |
$172.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.74
|
|
|
DILTIAZEM ER 240 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$464.98
|
|
|
Service Code
|
NDC 00187204730
|
| Hospital Charge Code |
35179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.59 |
| Max. Negotiated Rate |
$418.48 |
| Rate for Payer: Aetna American Axle |
$302.24
|
| Rate for Payer: Aetna Commercial |
$395.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.24
|
| Rate for Payer: Cash Price |
$371.98
|
| Rate for Payer: Cofinity Commercial |
$325.49
|
| Rate for Payer: Cofinity Commercial |
$399.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$325.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.98
|
| Rate for Payer: Healthscope Commercial |
$418.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$325.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.23
|
| Rate for Payer: PHP Commercial |
$395.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.24
|
| Rate for Payer: Priority Health SBD |
$292.94
|
| Rate for Payer: UMR Bronson Commercial |
$204.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.74
|
|
|
DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL
|
Facility
|
OP
|
$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 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 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 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
|
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 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 Medicare |
$0.01
|
| 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: 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
|
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 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
|
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
|
|
|
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
|
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: PHP Commercial |
$20.41
|
| 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: 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/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 |
$23.37 |
| Rate for Payer: Aetna American Axle |
$15.61
|
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: Aetna Medicare |
$12.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.61
|
| Rate for Payer: BCBS Complete |
$9.60
|
| Rate for Payer: BCBS Trust/PPO |
$23.37
|
| Rate for Payer: BCN Commercial |
$23.37
|
| Rate for Payer: Cash Price |
$19.21
|
| 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 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
|
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
|
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: 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: 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: 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
|
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 |
$1,554.48
|
| Rate for Payer: Aetna Commercial |
$2,032.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,554.48
|
| 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 |
$1,554.48
|
| 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 |
$383.45 |
| Max. Negotiated Rate |
$2,152.35 |
| Rate for Payer: Aetna American Axle |
$1,554.48
|
| Rate for Payer: Aetna Commercial |
$2,032.78
|
| Rate for Payer: Aetna Medicare |
$744.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,554.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$894.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$894.24
|
| Rate for Payer: BCBS Complete |
$402.62
|
| Rate for Payer: BCBS MAPPO |
$715.39
|
| Rate for Payer: BCBS Trust/PPO |
$1,930.28
|
| Rate for Payer: BCN Commercial |
$1,930.28
|
| Rate for Payer: BCN Medicare Advantage |
$715.39
|
| 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 |
$715.39
|
| 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 |
$383.45
|
| Rate for Payer: Mclaren Medicare |
$715.39
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$751.16
|
| Rate for Payer: Meridian Medicaid |
$402.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$822.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,032.78
|
| Rate for Payer: Nomi Health Commercial |
$2,146.17
|
| Rate for Payer: PACE Medicare |
$679.62
|
| Rate for Payer: PACE SWMI |
$715.39
|
| Rate for Payer: PHP Commercial |
$2,032.78
|
| Rate for Payer: PHP Medicare Advantage |
$715.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$383.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,554.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,060.38
|
| Rate for Payer: Priority Health Medicare |
$715.39
|
| Rate for Payer: Priority Health Narrow Network |
$1,648.30
|
| Rate for Payer: Priority Health SBD |
$1,506.64
|
| Rate for Payer: Railroad Medicare Medicare |
$715.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,013.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$715.39
|
| Rate for Payer: UHC Exchange |
$1,367.18
|
| Rate for Payer: UHC Medicare Advantage |
$715.39
|
| Rate for Payer: UHCCP Medicaid |
$383.45
|
| Rate for Payer: UMR Bronson Commercial |
$884.86
|
| Rate for Payer: VA VA |
$715.39
|
| 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
|
|
