|
HYPROMELLOSE 2.5 % EYE DROPS
|
Facility
|
IP
|
$88.05
|
|
|
Service Code
|
NDC 17478-064-12
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$79.24 |
| Rate for Payer: Aetna American Axle |
$57.23
|
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cofinity Commercial |
$61.64
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Healthscope Commercial |
$79.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.84
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.64
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: UMR Bronson Commercial |
$38.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.04
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,748.29
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.33 |
| Max. Negotiated Rate |
$8,748.29 |
| Rate for Payer: Aetna Medicare |
$2,890.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,473.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,473.69
|
| Rate for Payer: BCBS Complete |
$1,596.23
|
| Rate for Payer: BCBS MAPPO |
$2,778.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,606.67
|
| Rate for Payer: BCN Medicare Advantage |
$2,778.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,778.95
|
| Rate for Payer: Mclaren Medicaid |
$1,520.09
|
| Rate for Payer: Mclaren Medicare |
$2,778.95
|
| Rate for Payer: Meridian Medicaid |
$1,596.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,917.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,195.79
|
| Rate for Payer: PACE Medicare |
$2,640.00
|
| Rate for Payer: PACE SWMI |
$2,778.95
|
| Rate for Payer: PHP Medicare Advantage |
$2,778.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,520.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,748.29
|
| Rate for Payer: Priority Health Medicare |
$2,778.95
|
| Rate for Payer: Priority Health Narrow Network |
$6,998.63
|
| Rate for Payer: Railroad Medicare Medicare |
$2,778.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.16
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,778.95
|
| Rate for Payer: UHC Exchange |
$148.33
|
| Rate for Payer: UHC Medicare Advantage |
$2,862.32
|
| Rate for Payer: VA VA |
$2,778.95
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$13,918.15
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$240.67 |
| Max. Negotiated Rate |
$13,918.15 |
| Rate for Payer: Aetna Medicare |
$4,598.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,526.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,526.50
|
| Rate for Payer: BCBS Complete |
$2,539.54
|
| Rate for Payer: BCBS MAPPO |
$4,421.20
|
| Rate for Payer: BCBS Trust/PPO |
$3,393.91
|
| Rate for Payer: BCN Medicare Advantage |
$4,421.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,421.20
|
| Rate for Payer: Mclaren Medicaid |
$2,418.40
|
| Rate for Payer: Mclaren Medicare |
$4,421.20
|
| Rate for Payer: Meridian Medicaid |
$2,539.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$4,642.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,084.38
|
| Rate for Payer: PACE Medicare |
$4,200.14
|
| Rate for Payer: PACE SWMI |
$4,421.20
|
| Rate for Payer: PHP Medicare Advantage |
$4,421.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,418.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,918.15
|
| Rate for Payer: Priority Health Medicare |
$4,421.20
|
| Rate for Payer: Priority Health Narrow Network |
$11,134.52
|
| Rate for Payer: Railroad Medicare Medicare |
$4,421.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.74
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,421.20
|
| Rate for Payer: UHC Exchange |
$240.67
|
| Rate for Payer: UHC Medicare Advantage |
$4,553.84
|
| Rate for Payer: VA VA |
$4,421.20
|
|
|
HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)
|
Facility
|
OP
|
$13,918.15
|
|
|
Service Code
|
CPT 58559
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$278.00 |
| Max. Negotiated Rate |
$13,918.15 |
| Rate for Payer: Aetna Medicare |
$4,598.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,526.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,526.50
|
| Rate for Payer: BCBS Complete |
$2,539.54
|
| Rate for Payer: BCBS MAPPO |
$4,421.20
|
| Rate for Payer: BCBS Trust/PPO |
$2,667.99
|
| Rate for Payer: BCN Medicare Advantage |
$4,421.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,421.20
|
| Rate for Payer: Mclaren Medicaid |
$2,418.40
|
| Rate for Payer: Mclaren Medicare |
$4,421.20
|
| Rate for Payer: Meridian Medicaid |
$2,539.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$4,642.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,084.38
|
| Rate for Payer: PACE Medicare |
$4,200.14
|
| Rate for Payer: PACE SWMI |
$4,421.20
|
| Rate for Payer: PHP Medicare Advantage |
$4,421.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,418.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,918.15
|
| Rate for Payer: Priority Health Medicare |
$4,421.20
|
| Rate for Payer: Priority Health Narrow Network |
$11,134.52
|
| Rate for Payer: Railroad Medicare Medicare |
$4,421.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$305.80
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,421.20
|
| Rate for Payer: UHC Exchange |
$278.00
|
| Rate for Payer: UHC Medicare Advantage |
$4,553.84
|
| Rate for Payer: VA VA |
$4,421.20
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY
|
Facility
|
OP
|
$8,748.29
|
|
|
Service Code
|
CPT 58562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$217.09 |
| Max. Negotiated Rate |
$8,748.29 |
| Rate for Payer: Aetna Medicare |
$2,890.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,473.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,473.69
|
| Rate for Payer: BCBS Complete |
$1,596.23
|
| Rate for Payer: BCBS MAPPO |
$2,778.95
|
| Rate for Payer: BCBS Trust/PPO |
$2,575.71
|
| Rate for Payer: BCN Medicare Advantage |
$2,778.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,778.95
|
| Rate for Payer: Mclaren Medicaid |
$1,520.09
|
| Rate for Payer: Mclaren Medicare |
$2,778.95
|
| Rate for Payer: Meridian Medicaid |
$1,596.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,917.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,195.79
|
| Rate for Payer: PACE Medicare |
$2,640.00
|
| Rate for Payer: PACE SWMI |
$2,778.95
|
| Rate for Payer: PHP Medicare Advantage |
$2,778.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,520.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,748.29
|
| Rate for Payer: Priority Health Medicare |
$2,778.95
|
| Rate for Payer: Priority Health Narrow Network |
$6,998.63
|
| Rate for Payer: Railroad Medicare Medicare |
$2,778.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.80
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,778.95
|
| Rate for Payer: UHC Exchange |
$217.09
|
| Rate for Payer: UHC Medicare Advantage |
$2,862.32
|
| Rate for Payer: VA VA |
$2,778.95
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA
|
Facility
|
OP
|
$13,918.15
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$350.36 |
| Max. Negotiated Rate |
$13,918.15 |
| Rate for Payer: Aetna Medicare |
$4,598.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,526.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,526.50
|
| Rate for Payer: BCBS Complete |
$2,539.54
|
| Rate for Payer: BCBS MAPPO |
$4,421.20
|
| Rate for Payer: BCBS Trust/PPO |
$4,098.13
|
| Rate for Payer: BCN Medicare Advantage |
$4,421.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,421.20
|
| Rate for Payer: Mclaren Medicaid |
$2,418.40
|
| Rate for Payer: Mclaren Medicare |
$4,421.20
|
| Rate for Payer: Meridian Medicaid |
$2,539.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$4,642.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,084.38
|
| Rate for Payer: PACE Medicare |
$4,200.14
|
| Rate for Payer: PACE SWMI |
$4,421.20
|
| Rate for Payer: PHP Medicare Advantage |
$4,421.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,418.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,918.15
|
| Rate for Payer: Priority Health Medicare |
$4,421.20
|
| Rate for Payer: Priority Health Narrow Network |
$11,134.52
|
| Rate for Payer: Railroad Medicare Medicare |
$4,421.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$385.40
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,421.20
|
| Rate for Payer: UHC Exchange |
$350.36
|
| Rate for Payer: UHC Medicare Advantage |
$4,553.84
|
| Rate for Payer: VA VA |
$4,421.20
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C
|
Facility
|
OP
|
$8,748.29
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$226.59 |
| Max. Negotiated Rate |
$8,748.29 |
| Rate for Payer: Aetna Medicare |
$2,890.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,473.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,473.69
|
| Rate for Payer: BCBS Complete |
$1,596.23
|
| Rate for Payer: BCBS MAPPO |
$2,778.95
|
| Rate for Payer: BCBS Trust/PPO |
$3,078.05
|
| Rate for Payer: BCN Medicare Advantage |
$2,778.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,778.95
|
| Rate for Payer: Mclaren Medicaid |
$1,520.09
|
| Rate for Payer: Mclaren Medicare |
$2,778.95
|
| Rate for Payer: Meridian Medicaid |
$1,596.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,917.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,195.79
|
| Rate for Payer: PACE Medicare |
$2,640.00
|
| Rate for Payer: PACE SWMI |
$2,778.95
|
| Rate for Payer: PHP Medicare Advantage |
$2,778.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,520.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,748.29
|
| Rate for Payer: Priority Health Medicare |
$2,778.95
|
| Rate for Payer: Priority Health Narrow Network |
$6,998.63
|
| Rate for Payer: Railroad Medicare Medicare |
$2,778.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$249.25
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,778.95
|
| Rate for Payer: UHC Exchange |
$226.59
|
| Rate for Payer: UHC Medicare Advantage |
$2,862.32
|
| Rate for Payer: VA VA |
$2,778.95
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$429.20
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
70544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.85 |
| Max. Negotiated Rate |
$386.28 |
| Rate for Payer: Aetna American Axle |
$278.98
|
| Rate for Payer: Aetna Commercial |
$364.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.98
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cofinity Commercial |
$300.44
|
| Rate for Payer: Cofinity Commercial |
$369.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.36
|
| Rate for Payer: Healthscope Commercial |
$386.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$300.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.82
|
| Rate for Payer: PHP Commercial |
$364.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$300.44
|
| Rate for Payer: Priority Health SBD |
$270.40
|
| Rate for Payer: UMR Bronson Commercial |
$188.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.90
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$256.21
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
70544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.69 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna American Axle |
$166.54
|
| Rate for Payer: Aetna American Axle |
$278.98
|
| Rate for Payer: Aetna Commercial |
$364.82
|
| Rate for Payer: Aetna Commercial |
$217.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.98
|
| Rate for Payer: BCBS Complete |
$102.48
|
| Rate for Payer: BCBS Complete |
$171.68
|
| Rate for Payer: BCBS Trust/PPO |
$82.69
|
| Rate for Payer: BCBS Trust/PPO |
$82.69
|
| Rate for Payer: Cash Price |
$204.97
|
| Rate for Payer: Cash Price |
$204.97
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cofinity Commercial |
$369.11
|
| Rate for Payer: Cofinity Commercial |
$220.34
|
| Rate for Payer: Cofinity Commercial |
$300.44
|
| Rate for Payer: Cofinity Commercial |
$179.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.97
|
| Rate for Payer: Healthscope Commercial |
$230.59
|
| Rate for Payer: Healthscope Commercial |
$386.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$300.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.78
|
| Rate for Payer: PHP Commercial |
$217.78
|
| Rate for Payer: PHP Commercial |
$364.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$300.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.35
|
| Rate for Payer: Priority Health SBD |
$270.40
|
| Rate for Payer: Priority Health SBD |
$161.41
|
| Rate for Payer: UMR Bronson Commercial |
$94.80
|
| Rate for Payer: UMR Bronson Commercial |
$158.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.90
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 9900-0019-42
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna American Axle |
$3.06
|
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.06
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Commercial |
$4.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.76
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.00
|
| Rate for Payer: PHP Commercial |
$4.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.29
|
| Rate for Payer: Priority Health SBD |
$2.96
|
| Rate for Payer: UMR Bronson Commercial |
$2.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.52
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$20.43
|
|
|
Service Code
|
NDC 0904-5309-09
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$18.39 |
| Rate for Payer: Aetna American Axle |
$13.28
|
| Rate for Payer: Aetna Commercial |
$17.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.28
|
| Rate for Payer: Cash Price |
$16.34
|
| Rate for Payer: Cofinity Commercial |
$14.30
|
| Rate for Payer: Cofinity Commercial |
$17.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.34
|
| Rate for Payer: Healthscope Commercial |
$18.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.37
|
| Rate for Payer: PHP Commercial |
$17.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.30
|
| Rate for Payer: Priority Health SBD |
$12.87
|
| Rate for Payer: UMR Bronson Commercial |
$8.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.32
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 0121-1828-10
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna American Axle |
$2.34
|
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.34
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.88
|
| Rate for Payer: Healthscope Commercial |
$3.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.06
|
| Rate for Payer: PHP Commercial |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health SBD |
$2.27
|
| Rate for Payer: UMR Bronson Commercial |
$1.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.70
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 68094-494-59
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna American Axle |
$1.67
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.80
|
| Rate for Payer: Priority Health SBD |
$1.62
|
| Rate for Payer: UMR Bronson Commercial |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.91
|
|
|
Service Code
|
NDC 0121-0918-40
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna American Axle |
$1.89
|
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.89
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cofinity Commercial |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.33
|
| Rate for Payer: Healthscope Commercial |
$2.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.47
|
| Rate for Payer: PHP Commercial |
$2.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.04
|
| Rate for Payer: Priority Health SBD |
$1.83
|
| Rate for Payer: UMR Bronson Commercial |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.18
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.81
|
|
|
Service Code
|
NDC 68094-503-59
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$5.23 |
| Rate for Payer: Aetna American Axle |
$3.78
|
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.78
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cofinity Commercial |
$4.07
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.65
|
| Rate for Payer: Healthscope Commercial |
$5.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.94
|
| Rate for Payer: PHP Commercial |
$4.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.07
|
| Rate for Payer: Priority Health SBD |
$3.66
|
| Rate for Payer: UMR Bronson Commercial |
$2.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.36
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$89.26
|
|
|
Service Code
|
NDC 51672-1385-9
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.27 |
| Max. Negotiated Rate |
$80.33 |
| Rate for Payer: Aetna American Axle |
$58.02
|
| Rate for Payer: Aetna Commercial |
$75.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.02
|
| Rate for Payer: Cash Price |
$71.41
|
| Rate for Payer: Cofinity Commercial |
$62.48
|
| Rate for Payer: Cofinity Commercial |
$76.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.41
|
| Rate for Payer: Healthscope Commercial |
$80.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.87
|
| Rate for Payer: PHP Commercial |
$75.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.48
|
| Rate for Payer: Priority Health SBD |
$56.23
|
| Rate for Payer: UMR Bronson Commercial |
$39.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.94
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.91
|
|
|
Service Code
|
NDC 0121-0918-05
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna American Axle |
$1.89
|
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.89
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cofinity Commercial |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.33
|
| Rate for Payer: Healthscope Commercial |
$2.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.47
|
| Rate for Payer: PHP Commercial |
$2.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.04
|
| Rate for Payer: Priority Health SBD |
$1.83
|
| Rate for Payer: UMR Bronson Commercial |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.18
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 66689-339-01
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna American Axle |
$3.00
|
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.00
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cofinity Commercial |
$3.23
|
| Rate for Payer: Cofinity Commercial |
$3.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.69
|
| Rate for Payer: Healthscope Commercial |
$4.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.92
|
| Rate for Payer: PHP Commercial |
$3.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.23
|
| Rate for Payer: Priority Health SBD |
$2.90
|
| Rate for Payer: UMR Bronson Commercial |
$2.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.46
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.81
|
|
|
Service Code
|
NDC 68094-503-61
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$5.23 |
| Rate for Payer: Aetna American Axle |
$3.78
|
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.78
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cofinity Commercial |
$4.07
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.65
|
| Rate for Payer: Healthscope Commercial |
$5.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.94
|
| Rate for Payer: PHP Commercial |
$4.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.07
|
| Rate for Payer: Priority Health SBD |
$3.66
|
| Rate for Payer: UMR Bronson Commercial |
$2.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.36
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 0121-0917-05
|
| Hospital Charge Code |
10246
|
|
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
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.51
|
|
|
Service Code
|
NDC 59651-032-47
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$47.26 |
| Rate for Payer: Aetna American Axle |
$34.13
|
| Rate for Payer: Aetna Commercial |
$44.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.13
|
| Rate for Payer: Cash Price |
$42.01
|
| Rate for Payer: Cofinity Commercial |
$36.76
|
| Rate for Payer: Cofinity Commercial |
$45.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.01
|
| Rate for Payer: Healthscope Commercial |
$47.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.63
|
| Rate for Payer: PHP Commercial |
$44.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.76
|
| Rate for Payer: Priority Health SBD |
$33.08
|
| Rate for Payer: UMR Bronson Commercial |
$23.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.38
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 0121-1828-00
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna American Axle |
$2.34
|
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.34
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.88
|
| Rate for Payer: Healthscope Commercial |
$3.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.06
|
| Rate for Payer: PHP Commercial |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health SBD |
$2.27
|
| Rate for Payer: UMR Bronson Commercial |
$1.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.70
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 0121-1836-05
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna American Axle |
$3.09
|
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.09
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health SBD |
$2.99
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.63
|
|
|
Service Code
|
NDC 68094-600-59
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna American Axle |
$2.36
|
| Rate for Payer: Aetna Commercial |
$3.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.36
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$3.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.54
|
| Rate for Payer: Priority Health SBD |
$2.29
|
| Rate for Payer: UMR Bronson Commercial |
$1.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.72
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 0121-0917-00
|
| Hospital Charge Code |
10246
|
|
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
|
|
