|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$341.28
|
|
|
Service Code
|
NDC 0904-6939-61
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.16 |
| Max. Negotiated Rate |
$307.15 |
| Rate for Payer: Aetna American Axle |
$221.83
|
| Rate for Payer: Aetna Commercial |
$290.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.83
|
| Rate for Payer: Cash Price |
$273.02
|
| Rate for Payer: Cofinity Commercial |
$238.90
|
| Rate for Payer: Cofinity Commercial |
$293.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$273.02
|
| Rate for Payer: Healthscope Commercial |
$307.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$290.09
|
| Rate for Payer: PHP Commercial |
$290.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.90
|
| Rate for Payer: Priority Health SBD |
$215.01
|
| Rate for Payer: UMR Bronson Commercial |
$150.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.96
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
NDC 51552-0851-9
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.20 |
| Max. Negotiated Rate |
$297.00 |
| Rate for Payer: Aetna American Axle |
$214.50
|
| Rate for Payer: Aetna Commercial |
$280.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.50
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cofinity Commercial |
$231.00
|
| Rate for Payer: Cofinity Commercial |
$283.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.00
|
| Rate for Payer: Healthscope Commercial |
$297.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$280.50
|
| Rate for Payer: PHP Commercial |
$280.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.00
|
| Rate for Payer: Priority Health SBD |
$207.90
|
| Rate for Payer: UMR Bronson Commercial |
$145.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.50
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
IP
|
$1,272.00
|
|
|
Service Code
|
NDC 51552-0851-4
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$559.68 |
| Max. Negotiated Rate |
$1,144.80 |
| Rate for Payer: Aetna American Axle |
$826.80
|
| Rate for Payer: Aetna Commercial |
$1,081.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$826.80
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cofinity Commercial |
$1,093.92
|
| Rate for Payer: Cofinity Commercial |
$890.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,017.60
|
| Rate for Payer: Healthscope Commercial |
$1,144.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$890.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$954.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,081.20
|
| Rate for Payer: PHP Commercial |
$1,081.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$890.40
|
| Rate for Payer: Priority Health SBD |
$801.36
|
| Rate for Payer: UMR Bronson Commercial |
$559.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$954.00
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$236.88
|
|
|
Service Code
|
NDC 60432-150-04
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.23 |
| Max. Negotiated Rate |
$213.19 |
| Rate for Payer: Aetna American Axle |
$153.97
|
| Rate for Payer: Aetna Commercial |
$201.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.97
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Commercial |
$203.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.50
|
| Rate for Payer: Healthscope Commercial |
$213.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.35
|
| Rate for Payer: PHP Commercial |
$201.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.82
|
| Rate for Payer: Priority Health SBD |
$149.23
|
| Rate for Payer: UMR Bronson Commercial |
$104.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.66
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$277.89
|
|
|
Service Code
|
NDC 60432-150-16
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.27 |
| Max. Negotiated Rate |
$250.10 |
| Rate for Payer: Aetna American Axle |
$180.63
|
| Rate for Payer: Aetna Commercial |
$236.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.63
|
| Rate for Payer: Cash Price |
$222.31
|
| Rate for Payer: Cofinity Commercial |
$194.52
|
| Rate for Payer: Cofinity Commercial |
$238.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.31
|
| Rate for Payer: Healthscope Commercial |
$250.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$236.21
|
| Rate for Payer: PHP Commercial |
$236.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.52
|
| Rate for Payer: Priority Health SBD |
$175.07
|
| Rate for Payer: UMR Bronson Commercial |
$122.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.42
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$236.88
|
|
|
Service Code
|
NDC 60432-150-04
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$213.19 |
| Rate for Payer: Aetna American Axle |
$153.97
|
| Rate for Payer: Aetna Commercial |
$201.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.97
|
| Rate for Payer: BCBS Complete |
$94.75
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Commercial |
$203.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.50
|
| Rate for Payer: Healthscope Commercial |
$213.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.35
|
| Rate for Payer: PHP Commercial |
$201.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.82
|
| Rate for Payer: Priority Health SBD |
$149.23
|
| Rate for Payer: UMR Bronson Commercial |
$87.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.66
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,067.09
|
|
|
Service Code
|
NDC 54838-502-80
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$469.52 |
| Max. Negotiated Rate |
$960.38 |
| Rate for Payer: Aetna American Axle |
$693.61
|
| Rate for Payer: Aetna Commercial |
$907.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$693.61
|
| Rate for Payer: Cash Price |
$853.67
|
| Rate for Payer: Cofinity Commercial |
$746.96
|
| Rate for Payer: Cofinity Commercial |
$917.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$853.67
|
| Rate for Payer: Healthscope Commercial |
$960.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$746.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$800.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$907.03
|
| Rate for Payer: PHP Commercial |
$907.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$746.96
|
| Rate for Payer: Priority Health SBD |
$672.27
|
| Rate for Payer: UMR Bronson Commercial |
$469.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$800.32
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$427.70
|
|
|
Service Code
|
NDC 68084-253-11
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.19 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna American Axle |
$278.00
|
| Rate for Payer: Aetna Commercial |
$363.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.00
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$299.39
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$363.54
|
| Rate for Payer: PHP Commercial |
$363.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.39
|
| Rate for Payer: Priority Health SBD |
$269.45
|
| Rate for Payer: UMR Bronson Commercial |
$188.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.78
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 23155-500-01
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.90
|
| Rate for Payer: PHP Commercial |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.09
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$427.70
|
|
|
Service Code
|
NDC 68084-253-01
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.19 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna American Axle |
$278.00
|
| Rate for Payer: Aetna Commercial |
$363.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.00
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$299.39
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$363.54
|
| Rate for Payer: PHP Commercial |
$363.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.39
|
| Rate for Payer: Priority Health SBD |
$269.45
|
| Rate for Payer: UMR Bronson Commercial |
$188.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.78
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 63739-486-10
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.12 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna American Axle |
$274.95
|
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.95
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$296.10
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.55
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.10
|
| Rate for Payer: Priority Health SBD |
$266.49
|
| Rate for Payer: UMR Bronson Commercial |
$186.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$281.20
|
|
|
Service Code
|
NDC 68084-254-01
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.73 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna American Axle |
$182.78
|
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.78
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$196.84
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.02
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.84
|
| Rate for Payer: Priority Health SBD |
$177.16
|
| Rate for Payer: UMR Bronson Commercial |
$123.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 68084-254-11
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 0904-6617-61
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.00 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna American Axle |
$224.54
|
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.54
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$241.82
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.82
|
| Rate for Payer: Priority Health SBD |
$217.63
|
| Rate for Payer: UMR Bronson Commercial |
$152.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.09
|
|
|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS
|
Facility
|
IP
|
$52.49
|
|
|
Service Code
|
NDC 54838-506-15
|
| Hospital Charge Code |
3782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$47.24 |
| Rate for Payer: Aetna American Axle |
$34.12
|
| Rate for Payer: Aetna Commercial |
$44.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.12
|
| Rate for Payer: Cash Price |
$41.99
|
| Rate for Payer: Cofinity Commercial |
$36.74
|
| Rate for Payer: Cofinity Commercial |
$45.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.99
|
| Rate for Payer: Healthscope Commercial |
$47.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.62
|
| Rate for Payer: PHP Commercial |
$44.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.74
|
| Rate for Payer: Priority Health SBD |
$33.07
|
| Rate for Payer: UMR Bronson Commercial |
$23.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.37
|
|
|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS
|
Facility
|
IP
|
$88.92
|
|
|
Service Code
|
NDC 39328-047-15
|
| Hospital Charge Code |
3782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.12 |
| Max. Negotiated Rate |
$80.03 |
| Rate for Payer: Aetna American Axle |
$57.80
|
| Rate for Payer: Aetna Commercial |
$75.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.80
|
| Rate for Payer: Cash Price |
$71.14
|
| Rate for Payer: Cofinity Commercial |
$62.24
|
| Rate for Payer: Cofinity Commercial |
$76.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.14
|
| Rate for Payer: Healthscope Commercial |
$80.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.58
|
| Rate for Payer: PHP Commercial |
$75.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.24
|
| Rate for Payer: Priority Health SBD |
$56.02
|
| Rate for Payer: UMR Bronson Commercial |
$39.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.69
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 43199-011-01
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.28 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Commercial |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$317.60
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.56
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UMR Bronson Commercial |
$164.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$406.60
|
|
|
Service Code
|
NDC 42192-339-01
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.90 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna American Axle |
$264.29
|
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$345.61
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.62
|
| Rate for Payer: Priority Health SBD |
$256.16
|
| Rate for Payer: UMR Bronson Commercial |
$178.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.95
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 47781-011-01
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$226.30 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.02
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.02
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
HYPERTENSION WITH MCC
|
Facility
|
IP
|
$27,976.12
|
|
|
Service Code
|
MS-DRG 304
|
| Min. Negotiated Rate |
$8,898.25 |
| Max. Negotiated Rate |
$27,976.12 |
| Rate for Payer: Aetna Medicare |
$9,741.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,708.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,708.22
|
| Rate for Payer: BCBS MAPPO |
$9,366.58
|
| Rate for Payer: BCBS Trust/PPO |
$27,976.12
|
| Rate for Payer: BCN Medicare Advantage |
$9,366.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,366.58
|
| Rate for Payer: Mclaren Medicare |
$9,366.58
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,834.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,771.57
|
| Rate for Payer: PACE Medicare |
$8,898.25
|
| Rate for Payer: PACE SWMI |
$9,366.58
|
| Rate for Payer: PHP Medicare Advantage |
$9,366.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,488.06
|
| Rate for Payer: Priority Health Medicare |
$9,366.58
|
| Rate for Payer: Priority Health Narrow Network |
$13,190.45
|
| Rate for Payer: Railroad Medicare Medicare |
$9,366.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,526.85
|
| Rate for Payer: UHC Core |
$14,371.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,366.58
|
| Rate for Payer: UHC Exchange |
$11,425.66
|
| Rate for Payer: UHC Medicare Advantage |
$9,647.58
|
| Rate for Payer: VA VA |
$9,366.58
|
|
|
HYPERTENSION WITHOUT MCC
|
Facility
|
IP
|
$14,554.72
|
|
|
Service Code
|
MS-DRG 305
|
| Min. Negotiated Rate |
$6,002.91 |
| Max. Negotiated Rate |
$14,554.72 |
| Rate for Payer: Aetna Medicare |
$6,571.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,898.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,898.56
|
| Rate for Payer: BCBS MAPPO |
$6,318.85
|
| Rate for Payer: BCBS Trust/PPO |
$14,554.72
|
| Rate for Payer: BCN Medicare Advantage |
$6,318.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,318.85
|
| Rate for Payer: Mclaren Medicare |
$6,318.85
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,634.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,266.68
|
| Rate for Payer: PACE Medicare |
$6,002.91
|
| Rate for Payer: PACE SWMI |
$6,318.85
|
| Rate for Payer: PHP Medicare Advantage |
$6,318.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,812.66
|
| Rate for Payer: Priority Health Medicare |
$6,318.85
|
| Rate for Payer: Priority Health Narrow Network |
$8,650.13
|
| Rate for Payer: Railroad Medicare Medicare |
$6,318.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,493.89
|
| Rate for Payer: UHC Core |
$9,424.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,318.85
|
| Rate for Payer: UHC Exchange |
$7,492.80
|
| Rate for Payer: UHC Medicare Advantage |
$6,508.42
|
| Rate for Payer: VA VA |
$6,318.85
|
|
|
HYPERTENSIVE ENCEPHALOPATHY WITH CC
|
Facility
|
IP
|
$19,555.39
|
|
|
Service Code
|
MS-DRG 078
|
| Min. Negotiated Rate |
$7,931.19 |
| Max. Negotiated Rate |
$19,555.39 |
| Rate for Payer: Aetna Medicare |
$8,682.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,435.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,435.78
|
| Rate for Payer: BCBS MAPPO |
$8,348.62
|
| Rate for Payer: BCBS Trust/PPO |
$19,555.39
|
| Rate for Payer: BCN Medicare Advantage |
$8,348.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,348.62
|
| Rate for Payer: Mclaren Medicare |
$8,348.62
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,766.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,600.91
|
| Rate for Payer: PACE Medicare |
$7,931.19
|
| Rate for Payer: PACE SWMI |
$8,348.62
|
| Rate for Payer: PHP Medicare Advantage |
$8,348.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14,592.43
|
| Rate for Payer: Priority Health Medicare |
$8,348.62
|
| Rate for Payer: Priority Health Narrow Network |
$11,673.94
|
| Rate for Payer: Railroad Medicare Medicare |
$8,348.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,511.79
|
| Rate for Payer: UHC Core |
$12,719.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,348.62
|
| Rate for Payer: UHC Exchange |
$10,112.05
|
| Rate for Payer: UHC Medicare Advantage |
$8,599.08
|
| Rate for Payer: VA VA |
$8,348.62
|
|
|
HYPERTENSIVE ENCEPHALOPATHY WITH MCC
|
Facility
|
IP
|
$36,763.73
|
|
|
Service Code
|
MS-DRG 077
|
| Min. Negotiated Rate |
$11,547.62 |
| Max. Negotiated Rate |
$36,763.73 |
| Rate for Payer: Aetna Medicare |
$12,641.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,194.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,194.24
|
| Rate for Payer: BCBS MAPPO |
$12,155.39
|
| Rate for Payer: BCBS Trust/PPO |
$36,763.73
|
| Rate for Payer: BCN Medicare Advantage |
$12,155.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,155.39
|
| Rate for Payer: Mclaren Medicare |
$12,155.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,763.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,978.70
|
| Rate for Payer: PACE Medicare |
$11,547.62
|
| Rate for Payer: PACE SWMI |
$12,155.39
|
| Rate for Payer: PHP Medicare Advantage |
$12,155.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,681.29
|
| Rate for Payer: Priority Health Medicare |
$12,155.39
|
| Rate for Payer: Priority Health Narrow Network |
$17,345.03
|
| Rate for Payer: Railroad Medicare Medicare |
$12,155.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23,047.27
|
| Rate for Payer: UHC Core |
$18,898.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,155.39
|
| Rate for Payer: UHC Exchange |
$15,024.39
|
| Rate for Payer: UHC Medicare Advantage |
$12,520.05
|
| Rate for Payer: VA VA |
$12,155.39
|
|
|
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC
|
Facility
|
IP
|
$15,399.05
|
|
|
Service Code
|
MS-DRG 079
|
| Min. Negotiated Rate |
$5,909.94 |
| Max. Negotiated Rate |
$15,399.05 |
| Rate for Payer: Aetna Medicare |
$6,469.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,776.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,776.24
|
| Rate for Payer: BCBS MAPPO |
$6,220.99
|
| Rate for Payer: BCBS Trust/PPO |
$15,399.05
|
| Rate for Payer: BCN Medicare Advantage |
$6,220.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,220.99
|
| Rate for Payer: Mclaren Medicare |
$6,220.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,532.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,154.14
|
| Rate for Payer: PACE Medicare |
$5,909.94
|
| Rate for Payer: PACE SWMI |
$6,220.99
|
| Rate for Payer: PHP Medicare Advantage |
$6,220.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,630.42
|
| Rate for Payer: Priority Health Medicare |
$6,220.99
|
| Rate for Payer: Priority Health Narrow Network |
$8,504.34
|
| Rate for Payer: Railroad Medicare Medicare |
$6,220.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,300.16
|
| Rate for Payer: UHC Core |
$9,265.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,220.99
|
| Rate for Payer: UHC Exchange |
$7,366.52
|
| Rate for Payer: UHC Medicare Advantage |
$6,407.62
|
| Rate for Payer: VA VA |
$6,220.99
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS
|
Facility
|
IP
|
$22.89
|
|
|
Service Code
|
NDC 59390-182-13
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$10.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
