|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$440.88
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.13 |
| Max. Negotiated Rate |
$396.79 |
| Rate for Payer: Aetna American Axle |
$286.57
|
| Rate for Payer: Aetna Commercial |
$374.75
|
| Rate for Payer: Aetna Medicare |
$220.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.57
|
| Rate for Payer: BCBS Complete |
$176.35
|
| Rate for Payer: Cash Price |
$352.70
|
| Rate for Payer: Cofinity Commercial |
$308.62
|
| Rate for Payer: Cofinity Commercial |
$379.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.70
|
| Rate for Payer: Healthscope Commercial |
$396.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.75
|
| Rate for Payer: PHP Commercial |
$374.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.57
|
| Rate for Payer: Priority Health SBD |
$277.75
|
| Rate for Payer: UMR Bronson Commercial |
$163.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.66
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$224.20
|
|
|
Service Code
|
NDC 70954031610
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.95 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna Medicare |
$112.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: BCBS Complete |
$89.68
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$82.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$441.84
|
|
|
Service Code
|
NDC 68180015001
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.41 |
| Max. Negotiated Rate |
$397.66 |
| Rate for Payer: Aetna American Axle |
$287.20
|
| Rate for Payer: Aetna Commercial |
$375.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.20
|
| Rate for Payer: Cash Price |
$353.47
|
| Rate for Payer: Cofinity Commercial |
$309.29
|
| Rate for Payer: Cofinity Commercial |
$379.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$309.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.47
|
| Rate for Payer: Healthscope Commercial |
$397.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.56
|
| Rate for Payer: PHP Commercial |
$375.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.20
|
| Rate for Payer: Priority Health SBD |
$278.36
|
| Rate for Payer: UMR Bronson Commercial |
$194.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.38
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$224.20
|
|
|
Service Code
|
NDC 70954031610
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.65 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$98.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$441.84
|
|
|
Service Code
|
NDC 68180015001
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.48 |
| Max. Negotiated Rate |
$397.66 |
| Rate for Payer: Aetna American Axle |
$287.20
|
| Rate for Payer: Aetna Commercial |
$375.56
|
| Rate for Payer: Aetna Medicare |
$220.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.20
|
| Rate for Payer: BCBS Complete |
$176.74
|
| Rate for Payer: Cash Price |
$353.47
|
| Rate for Payer: Cofinity Commercial |
$309.29
|
| Rate for Payer: Cofinity Commercial |
$379.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$309.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.47
|
| Rate for Payer: Healthscope Commercial |
$397.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.56
|
| Rate for Payer: PHP Commercial |
$375.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.20
|
| Rate for Payer: Priority Health SBD |
$278.36
|
| Rate for Payer: UMR Bronson Commercial |
$163.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.38
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 70860075102
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna American Axle |
$9.94
|
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.94
|
| Rate for Payer: BCBS Complete |
$6.12
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$10.71
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$13.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.00
|
| Rate for Payer: PHP Commercial |
$13.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.94
|
| Rate for Payer: Priority Health SBD |
$9.64
|
| Rate for Payer: UMR Bronson Commercial |
$5.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.48
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
NDC 00641602201
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$5.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 70860075141
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna American Axle |
$9.94
|
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.94
|
| Rate for Payer: BCBS Complete |
$6.12
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$10.71
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$13.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.00
|
| Rate for Payer: PHP Commercial |
$13.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.94
|
| Rate for Payer: Priority Health SBD |
$9.64
|
| Rate for Payer: UMR Bronson Commercial |
$5.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.48
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
NDC 00641602225
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$5.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.56
|
|
|
Service Code
|
NDC 55390002910
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.13 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Aetna American Axle |
$10.76
|
| Rate for Payer: Aetna Commercial |
$14.08
|
| Rate for Payer: Aetna Medicare |
$8.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.76
|
| Rate for Payer: BCBS Complete |
$6.62
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cofinity Commercial |
$11.59
|
| Rate for Payer: Cofinity Commercial |
$14.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.25
|
| Rate for Payer: Healthscope Commercial |
$14.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.08
|
| Rate for Payer: PHP Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health SBD |
$10.43
|
| Rate for Payer: UMR Bronson Commercial |
$6.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.42
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
NDC 00641602225
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna Medicare |
$6.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: BCBS Complete |
$5.18
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$4.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 67457043300
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna American Axle |
$7.83
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$6.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$8.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.83
|
| Rate for Payer: Priority Health SBD |
$7.59
|
| Rate for Payer: UMR Bronson Commercial |
$4.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 63323073912
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$7.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 63323073911
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna Medicare |
$8.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: BCBS Complete |
$6.42
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 63323073912
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna Medicare |
$8.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: BCBS Complete |
$6.42
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
NDC 00641602201
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna Medicare |
$6.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: BCBS Complete |
$5.18
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$11.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$4.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 67457043322
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna American Axle |
$7.83
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$6.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$8.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.83
|
| Rate for Payer: Priority Health SBD |
$7.59
|
| Rate for Payer: UMR Bronson Commercial |
$4.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.56
|
|
|
Service Code
|
NDC 55390002910
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Aetna American Axle |
$10.76
|
| Rate for Payer: Aetna Commercial |
$14.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.76
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cofinity Commercial |
$11.59
|
| Rate for Payer: Cofinity Commercial |
$14.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.25
|
| Rate for Payer: Healthscope Commercial |
$14.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.08
|
| Rate for Payer: PHP Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health SBD |
$10.43
|
| Rate for Payer: UMR Bronson Commercial |
$7.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.42
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 09900000629
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Aetna American Axle |
$8.26
|
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Medicare |
$6.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.26
|
| Rate for Payer: BCBS Complete |
$5.08
|
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Cofinity Commercial |
$10.92
|
| Rate for Payer: Cofinity Commercial |
$8.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.16
|
| Rate for Payer: Healthscope Commercial |
$11.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.80
|
| Rate for Payer: PHP Commercial |
$10.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.26
|
| Rate for Payer: Priority Health SBD |
$8.00
|
| Rate for Payer: UMR Bronson Commercial |
$4.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.52
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$13,177.03
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
192405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,797.89 |
| Max. Negotiated Rate |
$11,859.33 |
| Rate for Payer: Aetna American Axle |
$8,565.07
|
| Rate for Payer: Aetna Commercial |
$11,200.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,565.07
|
| Rate for Payer: Cash Price |
$10,541.62
|
| Rate for Payer: Cofinity Commercial |
$11,332.25
|
| Rate for Payer: Cofinity Commercial |
$9,223.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$9,223.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10,541.62
|
| Rate for Payer: Healthscope Commercial |
$11,859.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,223.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,882.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11,200.48
|
| Rate for Payer: PHP Commercial |
$11,200.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,565.07
|
| Rate for Payer: Priority Health SBD |
$8,301.53
|
| Rate for Payer: UMR Bronson Commercial |
$5,797.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,882.77
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$13,177.03
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
192405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.44 |
| Max. Negotiated Rate |
$11,859.33 |
| Rate for Payer: Aetna American Axle |
$8,565.07
|
| Rate for Payer: Aetna Commercial |
$11,200.48
|
| Rate for Payer: Aetna Medicare |
$29.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,565.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36.01
|
| Rate for Payer: BCBS Complete |
$16.21
|
| Rate for Payer: BCBS MAPPO |
$28.81
|
| Rate for Payer: BCBS Trust/PPO |
$77.67
|
| Rate for Payer: BCN Commercial |
$77.67
|
| Rate for Payer: BCN Medicare Advantage |
$28.81
|
| Rate for Payer: Cash Price |
$10,541.62
|
| Rate for Payer: Cash Price |
$10,541.62
|
| Rate for Payer: Cofinity Commercial |
$9,223.92
|
| Rate for Payer: Cofinity Commercial |
$11,332.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$9,223.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10,541.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28.81
|
| Rate for Payer: Healthscope Commercial |
$11,859.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,223.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,882.77
|
| Rate for Payer: Mclaren Medicaid |
$15.44
|
| Rate for Payer: Mclaren Medicare |
$28.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$30.25
|
| Rate for Payer: Meridian Medicaid |
$16.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11,200.48
|
| Rate for Payer: Nomi Health Commercial |
$86.43
|
| Rate for Payer: PACE Medicare |
$27.37
|
| Rate for Payer: PACE SWMI |
$28.81
|
| Rate for Payer: PHP Commercial |
$11,200.48
|
| Rate for Payer: PHP Medicare Advantage |
$28.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$15.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,565.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$80.04
|
| Rate for Payer: Priority Health Medicare |
$28.81
|
| Rate for Payer: Priority Health Narrow Network |
$64.03
|
| Rate for Payer: Priority Health SBD |
$8,301.53
|
| Rate for Payer: Railroad Medicare Medicare |
$28.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$81.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$28.81
|
| Rate for Payer: UHC Exchange |
$55.06
|
| Rate for Payer: UHC Medicare Advantage |
$28.81
|
| Rate for Payer: UHCCP Medicaid |
$15.44
|
| Rate for Payer: UMR Bronson Commercial |
$4,875.50
|
| Rate for Payer: VA VA |
$28.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,882.77
|
|
|
FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 26121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$582.01 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$2,214.78
|
| Rate for Payer: BCN Commercial |
$2,214.78
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$640.21
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$582.01
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,703.94
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 26123
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$811.15 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$3,252.53
|
| Rate for Payer: BCN Commercial |
$3,252.53
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$892.26
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$811.15
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,703.94
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$1,000.68
|
|
|
Service Code
|
CPT 26125
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$259.51 |
| Max. Negotiated Rate |
$1,000.68 |
| Rate for Payer: BCBS Trust/PPO |
$1,000.68
|
| Rate for Payer: BCN Commercial |
$1,000.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$285.46
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$259.51
|
|
|
FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 28060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$346.46 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$2,417.89
|
| Rate for Payer: BCN Commercial |
$2,417.89
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$381.11
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$346.46
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,703.94
|
| Rate for Payer: VA VA |
$3,179.00
|
|
