|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 73320-002-02
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$254.40
|
|
|
Service Code
|
NDC 68084-855-01
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.94 |
| Max. Negotiated Rate |
$228.96 |
| Rate for Payer: Aetna American Axle |
$165.36
|
| Rate for Payer: Aetna Commercial |
$216.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.36
|
| Rate for Payer: Cash Price |
$203.52
|
| Rate for Payer: Cofinity Commercial |
$178.08
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.52
|
| Rate for Payer: Healthscope Commercial |
$228.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.24
|
| Rate for Payer: PHP Commercial |
$216.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.08
|
| Rate for Payer: Priority Health SBD |
$160.27
|
| Rate for Payer: UMR Bronson Commercial |
$111.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.80
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 68084-855-11
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
IP
|
$3,497.02
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,538.69 |
| Max. Negotiated Rate |
$3,147.32 |
| Rate for Payer: Aetna American Axle |
$2,273.06
|
| Rate for Payer: Aetna Commercial |
$2,972.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,273.06
|
| Rate for Payer: Cash Price |
$2,797.62
|
| Rate for Payer: Cofinity Commercial |
$2,447.91
|
| Rate for Payer: Cofinity Commercial |
$3,007.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,797.62
|
| Rate for Payer: Healthscope Commercial |
$3,147.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,447.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,622.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,972.47
|
| Rate for Payer: PHP Commercial |
$2,972.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,447.91
|
| Rate for Payer: Priority Health SBD |
$2,203.12
|
| Rate for Payer: UMR Bronson Commercial |
$1,538.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,622.76
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 68084-868-11
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna American Axle |
$2.73
|
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.73
|
| Rate for Payer: Cash Price |
$3.36
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Cofinity Commercial |
$3.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.36
|
| Rate for Payer: Healthscope Commercial |
$3.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.57
|
| Rate for Payer: PHP Commercial |
$3.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.94
|
| Rate for Payer: Priority Health SBD |
$2.65
|
| Rate for Payer: UMR Bronson Commercial |
$1.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.15
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 0172-4097-60
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna American Axle |
$116.09
|
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
| Rate for Payer: Priority Health SBD |
$112.52
|
| Rate for Payer: UMR Bronson Commercial |
$78.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$243.84
|
|
|
Service Code
|
NDC 0904-6476-61
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.29 |
| Max. Negotiated Rate |
$219.46 |
| Rate for Payer: Aetna American Axle |
$158.50
|
| Rate for Payer: Aetna Commercial |
$207.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.50
|
| Rate for Payer: Cash Price |
$195.07
|
| Rate for Payer: Cofinity Commercial |
$170.69
|
| Rate for Payer: Cofinity Commercial |
$209.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.07
|
| Rate for Payer: Healthscope Commercial |
$219.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.26
|
| Rate for Payer: PHP Commercial |
$207.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.69
|
| Rate for Payer: Priority Health SBD |
$153.62
|
| Rate for Payer: UMR Bronson Commercial |
$107.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.88
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
NDC 68084-868-01
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.80 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: Aetna American Axle |
$273.00
|
| Rate for Payer: Aetna Commercial |
$357.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cofinity Commercial |
$294.00
|
| Rate for Payer: Cofinity Commercial |
$361.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.00
|
| Rate for Payer: Healthscope Commercial |
$378.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$357.00
|
| Rate for Payer: PHP Commercial |
$357.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$294.00
|
| Rate for Payer: Priority Health SBD |
$264.60
|
| Rate for Payer: UMR Bronson Commercial |
$184.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.00
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
|
IP
|
$256.32
|
|
|
Service Code
|
NDC 63739-480-10
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.78 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna American Axle |
$166.61
|
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.87
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.42
|
| Rate for Payer: Priority Health SBD |
$161.48
|
| Rate for Payer: UMR Bronson Commercial |
$112.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION
|
Facility
|
IP
|
$2,053.06
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
107800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$903.35 |
| Max. Negotiated Rate |
$1,847.75 |
| Rate for Payer: Aetna American Axle |
$1,334.49
|
| Rate for Payer: Aetna American Axle |
$1,094.58
|
| Rate for Payer: Aetna American Axle |
$613.75
|
| Rate for Payer: Aetna Commercial |
$1,431.37
|
| Rate for Payer: Aetna Commercial |
$802.60
|
| Rate for Payer: Aetna Commercial |
$1,745.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,334.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,094.58
|
| Rate for Payer: Cash Price |
$1,347.18
|
| Rate for Payer: Cash Price |
$755.38
|
| Rate for Payer: Cash Price |
$1,642.45
|
| Rate for Payer: Cofinity Commercial |
$660.96
|
| Rate for Payer: Cofinity Commercial |
$1,178.78
|
| Rate for Payer: Cofinity Commercial |
$1,448.21
|
| Rate for Payer: Cofinity Commercial |
$812.04
|
| Rate for Payer: Cofinity Commercial |
$1,437.14
|
| Rate for Payer: Cofinity Commercial |
$1,765.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,347.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,642.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.38
|
| Rate for Payer: Healthscope Commercial |
$1,515.57
|
| Rate for Payer: Healthscope Commercial |
$1,847.75
|
| Rate for Payer: Healthscope Commercial |
$849.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,437.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,178.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$660.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,539.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,262.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$802.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,431.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,745.10
|
| Rate for Payer: PHP Commercial |
$1,745.10
|
| Rate for Payer: PHP Commercial |
$1,431.37
|
| Rate for Payer: PHP Commercial |
$802.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,437.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,178.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$660.96
|
| Rate for Payer: Priority Health SBD |
$594.86
|
| Rate for Payer: Priority Health SBD |
$1,293.43
|
| Rate for Payer: Priority Health SBD |
$1,060.90
|
| Rate for Payer: UMR Bronson Commercial |
$415.46
|
| Rate for Payer: UMR Bronson Commercial |
$903.35
|
| Rate for Payer: UMR Bronson Commercial |
$740.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,262.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,539.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.17
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION
|
Facility
|
IP
|
$838.87
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
9209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$369.10 |
| Max. Negotiated Rate |
$754.98 |
| Rate for Payer: Aetna American Axle |
$545.27
|
| Rate for Payer: Aetna American Axle |
$545.22
|
| Rate for Payer: Aetna Commercial |
$713.04
|
| Rate for Payer: Aetna Commercial |
$712.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$545.27
|
| Rate for Payer: Cash Price |
$671.04
|
| Rate for Payer: Cash Price |
$671.10
|
| Rate for Payer: Cofinity Commercial |
$721.43
|
| Rate for Payer: Cofinity Commercial |
$721.37
|
| Rate for Payer: Cofinity Commercial |
$587.16
|
| Rate for Payer: Cofinity Commercial |
$587.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$671.04
|
| Rate for Payer: Healthscope Commercial |
$754.92
|
| Rate for Payer: Healthscope Commercial |
$754.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$587.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$629.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$713.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$712.98
|
| Rate for Payer: PHP Commercial |
$713.04
|
| Rate for Payer: PHP Commercial |
$712.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$587.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$587.21
|
| Rate for Payer: Priority Health SBD |
$528.44
|
| Rate for Payer: Priority Health SBD |
$528.49
|
| Rate for Payer: UMR Bronson Commercial |
$369.07
|
| Rate for Payer: UMR Bronson Commercial |
$369.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$629.10
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 50268-105-11
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna American Axle |
$3.33
|
| Rate for Payer: Aetna Commercial |
$4.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.33
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Cofinity Commercial |
$4.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.10
|
| Rate for Payer: Healthscope Commercial |
$4.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.36
|
| Rate for Payer: PHP Commercial |
$4.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.59
|
| Rate for Payer: Priority Health SBD |
$3.23
|
| Rate for Payer: UMR Bronson Commercial |
$2.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.85
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 72888-009-01
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.58 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna American Axle |
$250.51
|
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.78
|
| Rate for Payer: Priority Health SBD |
$242.80
|
| Rate for Payer: UMR Bronson Commercial |
$169.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$256.08
|
|
|
Service Code
|
NDC 50268-105-15
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.68 |
| Max. Negotiated Rate |
$230.47 |
| Rate for Payer: Aetna American Axle |
$166.45
|
| Rate for Payer: Aetna Commercial |
$217.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.45
|
| Rate for Payer: Cash Price |
$204.86
|
| Rate for Payer: Cofinity Commercial |
$179.26
|
| Rate for Payer: Cofinity Commercial |
$220.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.86
|
| Rate for Payer: Healthscope Commercial |
$230.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.67
|
| Rate for Payer: PHP Commercial |
$217.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.26
|
| Rate for Payer: Priority Health SBD |
$161.33
|
| Rate for Payer: UMR Bronson Commercial |
$112.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.06
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
|
IP
|
$284.16
|
|
|
Service Code
|
NDC 71930-066-12
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.03 |
| Max. Negotiated Rate |
$255.74 |
| Rate for Payer: Aetna American Axle |
$184.70
|
| Rate for Payer: Aetna Commercial |
$241.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.70
|
| Rate for Payer: Cash Price |
$227.33
|
| Rate for Payer: Cofinity Commercial |
$198.91
|
| Rate for Payer: Cofinity Commercial |
$244.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.33
|
| Rate for Payer: Healthscope Commercial |
$255.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.54
|
| Rate for Payer: PHP Commercial |
$241.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.91
|
| Rate for Payer: Priority Health SBD |
$179.02
|
| Rate for Payer: UMR Bronson Commercial |
$125.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.12
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC
|
Facility
|
IP
|
$62,257.10
|
|
|
Service Code
|
MS-DRG 095
|
| Min. Negotiated Rate |
$17,940.82 |
| Max. Negotiated Rate |
$62,257.10 |
| Rate for Payer: Aetna Medicare |
$19,640.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,606.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,606.34
|
| Rate for Payer: BCBS MAPPO |
$18,885.07
|
| Rate for Payer: BCBS Trust/PPO |
$62,257.10
|
| Rate for Payer: BCN Medicare Advantage |
$18,885.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,885.07
|
| Rate for Payer: Mclaren Medicare |
$18,885.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,829.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,717.83
|
| Rate for Payer: PACE Medicare |
$17,940.82
|
| Rate for Payer: PACE SWMI |
$18,885.07
|
| Rate for Payer: PHP Medicare Advantage |
$18,885.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,213.08
|
| Rate for Payer: Priority Health Medicare |
$18,885.07
|
| Rate for Payer: Priority Health Narrow Network |
$27,370.46
|
| Rate for Payer: Railroad Medicare Medicare |
$18,885.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36,368.59
|
| Rate for Payer: UHC Core |
$29,821.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$18,885.07
|
| Rate for Payer: UHC Exchange |
$23,708.48
|
| Rate for Payer: UHC Medicare Advantage |
$19,451.62
|
| Rate for Payer: VA VA |
$18,885.07
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC
|
Facility
|
IP
|
$73,472.17
|
|
|
Service Code
|
MS-DRG 094
|
| Min. Negotiated Rate |
$27,007.56 |
| Max. Negotiated Rate |
$73,472.17 |
| Rate for Payer: Aetna Medicare |
$29,566.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$35,536.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$35,536.26
|
| Rate for Payer: BCBS MAPPO |
$28,429.01
|
| Rate for Payer: BCBS Trust/PPO |
$73,472.17
|
| Rate for Payer: BCN Medicare Advantage |
$28,429.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28,429.01
|
| Rate for Payer: Mclaren Medicare |
$28,429.01
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$29,850.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32,693.36
|
| Rate for Payer: PACE Medicare |
$27,007.56
|
| Rate for Payer: PACE SWMI |
$28,429.01
|
| Rate for Payer: PHP Medicare Advantage |
$28,429.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51,985.46
|
| Rate for Payer: Priority Health Medicare |
$28,429.01
|
| Rate for Payer: Priority Health Narrow Network |
$41,588.37
|
| Rate for Payer: Railroad Medicare Medicare |
$28,429.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55,260.67
|
| Rate for Payer: UHC Core |
$45,312.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$28,429.01
|
| Rate for Payer: UHC Exchange |
$36,024.13
|
| Rate for Payer: UHC Medicare Advantage |
$29,281.88
|
| Rate for Payer: VA VA |
$28,429.01
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$43,719.43
|
|
|
Service Code
|
MS-DRG 096
|
| Min. Negotiated Rate |
$16,443.74 |
| Max. Negotiated Rate |
$43,719.43 |
| Rate for Payer: Aetna Medicare |
$18,001.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,636.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,636.50
|
| Rate for Payer: BCBS MAPPO |
$17,309.20
|
| Rate for Payer: BCBS Trust/PPO |
$43,719.43
|
| Rate for Payer: BCN Medicare Advantage |
$17,309.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,309.20
|
| Rate for Payer: Mclaren Medicare |
$17,309.20
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18,174.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,905.58
|
| Rate for Payer: PACE Medicare |
$16,443.74
|
| Rate for Payer: PACE SWMI |
$17,309.20
|
| Rate for Payer: PHP Medicare Advantage |
$17,309.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31,278.52
|
| Rate for Payer: Priority Health Medicare |
$17,309.20
|
| Rate for Payer: Priority Health Narrow Network |
$25,022.82
|
| Rate for Payer: Railroad Medicare Medicare |
$17,309.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33,249.14
|
| Rate for Payer: UHC Core |
$27,263.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$17,309.20
|
| Rate for Payer: UHC Exchange |
$21,674.94
|
| Rate for Payer: UHC Medicare Advantage |
$17,828.48
|
| Rate for Payer: VA VA |
$17,309.20
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION
|
Facility
|
IP
|
$201.25
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
14123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.55 |
| Max. Negotiated Rate |
$181.12 |
| Rate for Payer: Aetna American Axle |
$130.81
|
| Rate for Payer: Aetna Commercial |
$171.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.81
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cofinity Commercial |
$173.08
|
| Rate for Payer: Cofinity Commercial |
$140.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.00
|
| Rate for Payer: Healthscope Commercial |
$181.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.06
|
| Rate for Payer: PHP Commercial |
$171.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.88
|
| Rate for Payer: Priority Health SBD |
$126.79
|
| Rate for Payer: UMR Bronson Commercial |
$88.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.94
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION
|
Facility
|
IP
|
$24.75
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$22.28 |
| Rate for Payer: Aetna American Axle |
$16.09
|
| Rate for Payer: Aetna Commercial |
$21.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.09
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cofinity Commercial |
$17.32
|
| Rate for Payer: Cofinity Commercial |
$21.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.80
|
| Rate for Payer: Healthscope Commercial |
$22.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.04
|
| Rate for Payer: PHP Commercial |
$21.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.32
|
| Rate for Payer: Priority Health SBD |
$15.59
|
| Rate for Payer: UMR Bronson Commercial |
$10.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.56
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION
|
Facility
|
IP
|
$10.53
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
10781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Aetna American Axle |
$6.84
|
| Rate for Payer: Aetna Commercial |
$8.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.84
|
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Cofinity Commercial |
$7.37
|
| Rate for Payer: Cofinity Commercial |
$9.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.42
|
| Rate for Payer: Healthscope Commercial |
$9.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.95
|
| Rate for Payer: PHP Commercial |
$8.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.37
|
| Rate for Payer: Priority Health SBD |
$6.63
|
| Rate for Payer: UMR Bronson Commercial |
$4.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.90
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH
|
Facility
|
IP
|
$88.62
|
|
|
Service Code
|
NDC 0065-0530-01
|
| Hospital Charge Code |
10780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.99 |
| Max. Negotiated Rate |
$79.76 |
| Rate for Payer: Aetna American Axle |
$57.60
|
| Rate for Payer: Aetna Commercial |
$75.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.60
|
| Rate for Payer: Cash Price |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$62.03
|
| Rate for Payer: Cofinity Commercial |
$76.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.90
|
| Rate for Payer: Healthscope Commercial |
$79.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.33
|
| Rate for Payer: PHP Commercial |
$75.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.03
|
| Rate for Payer: Priority Health SBD |
$55.83
|
| Rate for Payer: UMR Bronson Commercial |
$38.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.46
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
IP
|
$731.14
|
|
|
Service Code
|
NDC 0378-6750-82
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.70 |
| Max. Negotiated Rate |
$658.03 |
| Rate for Payer: Aetna American Axle |
$475.24
|
| Rate for Payer: Aetna Commercial |
$621.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.24
|
| Rate for Payer: Cash Price |
$584.91
|
| Rate for Payer: Cofinity Commercial |
$511.80
|
| Rate for Payer: Cofinity Commercial |
$628.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$584.91
|
| Rate for Payer: Healthscope Commercial |
$658.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$511.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$548.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$621.47
|
| Rate for Payer: PHP Commercial |
$621.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$511.80
|
| Rate for Payer: Priority Health SBD |
$460.62
|
| Rate for Payer: UMR Bronson Commercial |
$321.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$548.36
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
IP
|
$962.31
|
|
|
Service Code
|
NDC 0054-0079-28
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$423.42 |
| Max. Negotiated Rate |
$866.08 |
| Rate for Payer: Aetna American Axle |
$625.50
|
| Rate for Payer: Aetna Commercial |
$817.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$625.50
|
| Rate for Payer: Cash Price |
$769.85
|
| Rate for Payer: Cofinity Commercial |
$673.62
|
| Rate for Payer: Cofinity Commercial |
$827.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$769.85
|
| Rate for Payer: Healthscope Commercial |
$866.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$673.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$721.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$817.96
|
| Rate for Payer: PHP Commercial |
$817.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$673.62
|
| Rate for Payer: Priority Health SBD |
$606.26
|
| Rate for Payer: UMR Bronson Commercial |
$423.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$721.73
|
|
|
BALSALAZIDE 750 MG CAPSULE
|
Facility
|
IP
|
$1,018.78
|
|
|
Service Code
|
NDC 60505-2575-7
|
| Hospital Charge Code |
29299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$448.26 |
| Max. Negotiated Rate |
$916.90 |
| Rate for Payer: Aetna American Axle |
$662.21
|
| Rate for Payer: Aetna Commercial |
$865.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$662.21
|
| Rate for Payer: Cash Price |
$815.02
|
| Rate for Payer: Cofinity Commercial |
$713.15
|
| Rate for Payer: Cofinity Commercial |
$876.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$815.02
|
| Rate for Payer: Healthscope Commercial |
$916.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$713.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$764.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$865.96
|
| Rate for Payer: PHP Commercial |
$865.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$713.15
|
| Rate for Payer: Priority Health SBD |
$641.83
|
| Rate for Payer: UMR Bronson Commercial |
$448.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$764.08
|
|
