|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$104.06
|
|
|
Service Code
|
NDC 00283067902
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.79 |
| Max. Negotiated Rate |
$93.65 |
| Rate for Payer: Aetna American Axle |
$67.64
|
| Rate for Payer: Aetna Commercial |
$88.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.64
|
| Rate for Payer: Cash Price |
$83.25
|
| Rate for Payer: Cofinity Advantage |
$72.84
|
| Rate for Payer: Cofinity Commercial |
$89.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.25
|
| Rate for Payer: Healthscope Commercial |
$93.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.05
|
| Rate for Payer: PHP Commercial |
$88.45
|
| Rate for Payer: Priority Health SBD |
$65.56
|
| Rate for Payer: UMR Bronson Commercial |
$45.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.05
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$134.36
|
|
|
Service Code
|
NDC 00283067960
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.71 |
| Max. Negotiated Rate |
$120.92 |
| Rate for Payer: Aetna American Axle |
$87.33
|
| Rate for Payer: Aetna Commercial |
$114.21
|
| Rate for Payer: Aetna Medicare |
$67.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.33
|
| Rate for Payer: BCBS Complete |
$53.74
|
| Rate for Payer: Cash Price |
$107.49
|
| Rate for Payer: Cofinity Advantage |
$94.05
|
| Rate for Payer: Cofinity Commercial |
$115.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.49
|
| Rate for Payer: Healthscope Commercial |
$120.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$107.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.77
|
| Rate for Payer: PHP Commercial |
$114.21
|
| Rate for Payer: Priority Health SBD |
$84.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.33
|
| Rate for Payer: UHC Core |
$70.00
|
| Rate for Payer: UHC Exchange |
$52.80
|
| Rate for Payer: UMR Bronson Commercial |
$49.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.77
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$104.06
|
|
|
Service Code
|
NDC 00283067902
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$93.65 |
| Rate for Payer: Aetna American Axle |
$67.64
|
| Rate for Payer: Aetna Commercial |
$88.45
|
| Rate for Payer: Aetna Medicare |
$52.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.64
|
| Rate for Payer: BCBS Complete |
$41.62
|
| Rate for Payer: Cash Price |
$83.25
|
| Rate for Payer: Cofinity Advantage |
$72.84
|
| Rate for Payer: Cofinity Commercial |
$89.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.25
|
| Rate for Payer: Healthscope Commercial |
$93.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$83.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.05
|
| Rate for Payer: PHP Commercial |
$88.45
|
| Rate for Payer: Priority Health SBD |
$65.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.64
|
| Rate for Payer: UHC Core |
$54.22
|
| Rate for Payer: UHC Exchange |
$40.90
|
| Rate for Payer: UMR Bronson Commercial |
$38.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.05
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$99.36
|
|
|
Service Code
|
NDC 00283091402
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$89.42 |
| Rate for Payer: Aetna American Axle |
$64.58
|
| Rate for Payer: Aetna Commercial |
$84.46
|
| Rate for Payer: Aetna Medicare |
$49.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.58
|
| Rate for Payer: BCBS Complete |
$39.74
|
| Rate for Payer: Cash Price |
$79.49
|
| Rate for Payer: Cofinity Advantage |
$69.55
|
| Rate for Payer: Cofinity Commercial |
$85.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.49
|
| Rate for Payer: Healthscope Commercial |
$89.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.52
|
| Rate for Payer: PHP Commercial |
$84.46
|
| Rate for Payer: Priority Health SBD |
$62.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.58
|
| Rate for Payer: UHC Core |
$51.77
|
| Rate for Payer: UHC Exchange |
$39.05
|
| Rate for Payer: UMR Bronson Commercial |
$36.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.52
|
|
|
BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$99.36
|
|
|
Service Code
|
NDC 00283091402
|
| Hospital Charge Code |
19696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.72 |
| Max. Negotiated Rate |
$89.42 |
| Rate for Payer: Aetna American Axle |
$64.58
|
| Rate for Payer: Aetna Commercial |
$84.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.58
|
| Rate for Payer: Cash Price |
$79.49
|
| Rate for Payer: Cofinity Advantage |
$69.55
|
| Rate for Payer: Cofinity Commercial |
$85.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.49
|
| Rate for Payer: Healthscope Commercial |
$89.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.52
|
| Rate for Payer: PHP Commercial |
$84.46
|
| Rate for Payer: Priority Health SBD |
$62.60
|
| Rate for Payer: UMR Bronson Commercial |
$43.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.52
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
OP
|
$38.65
|
|
|
Service Code
|
NDC 00283061043
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna American Axle |
$25.12
|
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: Aetna Medicare |
$19.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.12
|
| Rate for Payer: BCBS Complete |
$15.46
|
| Rate for Payer: Cash Price |
$30.92
|
| Rate for Payer: Cofinity Advantage |
$27.05
|
| Rate for Payer: Cofinity Commercial |
$33.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.92
|
| Rate for Payer: Healthscope Commercial |
$34.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.99
|
| Rate for Payer: PHP Commercial |
$32.85
|
| Rate for Payer: Priority Health SBD |
$24.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.12
|
| Rate for Payer: UHC Core |
$20.14
|
| Rate for Payer: UHC Exchange |
$15.19
|
| Rate for Payer: UMR Bronson Commercial |
$14.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.99
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
IP
|
$36.29
|
|
|
Service Code
|
NDC 00283061026
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.97 |
| Max. Negotiated Rate |
$32.66 |
| Rate for Payer: Aetna American Axle |
$23.59
|
| Rate for Payer: Aetna Commercial |
$30.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.59
|
| Rate for Payer: Cash Price |
$29.03
|
| Rate for Payer: Cofinity Advantage |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$31.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.03
|
| Rate for Payer: Healthscope Commercial |
$32.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$27.22
|
| Rate for Payer: PHP Commercial |
$30.85
|
| Rate for Payer: Priority Health SBD |
$22.86
|
| Rate for Payer: UMR Bronson Commercial |
$15.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.22
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
OP
|
$36.29
|
|
|
Service Code
|
NDC 00283061026
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$32.66 |
| Rate for Payer: Aetna American Axle |
$23.59
|
| Rate for Payer: Aetna Commercial |
$30.85
|
| Rate for Payer: Aetna Medicare |
$18.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.59
|
| Rate for Payer: BCBS Complete |
$14.52
|
| Rate for Payer: Cash Price |
$29.03
|
| Rate for Payer: Cofinity Advantage |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$31.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.03
|
| Rate for Payer: Healthscope Commercial |
$32.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$27.22
|
| Rate for Payer: PHP Commercial |
$30.85
|
| Rate for Payer: Priority Health SBD |
$22.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.59
|
| Rate for Payer: UHC Core |
$18.91
|
| Rate for Payer: UHC Exchange |
$14.26
|
| Rate for Payer: UMR Bronson Commercial |
$13.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.22
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
IP
|
$38.65
|
|
|
Service Code
|
NDC 00283061043
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.01 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna American Axle |
$25.12
|
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.12
|
| Rate for Payer: Cash Price |
$30.92
|
| Rate for Payer: Cofinity Advantage |
$27.05
|
| Rate for Payer: Cofinity Commercial |
$33.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.92
|
| Rate for Payer: Healthscope Commercial |
$34.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.99
|
| Rate for Payer: PHP Commercial |
$32.85
|
| Rate for Payer: Priority Health SBD |
$24.35
|
| Rate for Payer: UMR Bronson Commercial |
$17.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.99
|
|
|
BENZOIN (BULK) TOPICAL TINCTURE
|
Facility
|
IP
|
$30.87
|
|
|
Service Code
|
NDC 00395024792
|
| Hospital Charge Code |
165061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.58 |
| Max. Negotiated Rate |
$27.78 |
| Rate for Payer: Aetna American Axle |
$20.07
|
| Rate for Payer: Aetna Commercial |
$26.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.07
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cofinity Advantage |
$21.61
|
| Rate for Payer: Cofinity Commercial |
$26.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.70
|
| Rate for Payer: Healthscope Commercial |
$27.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.15
|
| Rate for Payer: PHP Commercial |
$26.24
|
| Rate for Payer: Priority Health SBD |
$19.45
|
| Rate for Payer: UMR Bronson Commercial |
$13.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.15
|
|
|
BENZOIN (BULK) TOPICAL TINCTURE
|
Facility
|
OP
|
$30.87
|
|
|
Service Code
|
NDC 00395024792
|
| Hospital Charge Code |
165061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.42 |
| Max. Negotiated Rate |
$27.78 |
| Rate for Payer: Aetna American Axle |
$20.07
|
| Rate for Payer: Aetna Commercial |
$26.24
|
| Rate for Payer: Aetna Medicare |
$15.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.07
|
| Rate for Payer: BCBS Complete |
$12.35
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cofinity Advantage |
$21.61
|
| Rate for Payer: Cofinity Commercial |
$26.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.70
|
| Rate for Payer: Healthscope Commercial |
$27.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.15
|
| Rate for Payer: PHP Commercial |
$26.24
|
| Rate for Payer: Priority Health SBD |
$19.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.07
|
| Rate for Payer: UHC Core |
$16.08
|
| Rate for Payer: UHC Exchange |
$12.13
|
| Rate for Payer: UMR Bronson Commercial |
$11.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.15
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$264.10
|
|
|
Service Code
|
NDC 62332042631
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.72 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna American Axle |
$171.66
|
| Rate for Payer: Aetna Commercial |
$224.49
|
| Rate for Payer: Aetna Medicare |
$132.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: BCBS Complete |
$105.64
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Advantage |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.07
|
| Rate for Payer: PHP Commercial |
$224.49
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.66
|
| Rate for Payer: UHC Core |
$137.60
|
| Rate for Payer: UHC Exchange |
$103.79
|
| Rate for Payer: UMR Bronson Commercial |
$97.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.07
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$371.30
|
|
|
Service Code
|
NDC 67877057301
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.38 |
| Max. Negotiated Rate |
$334.17 |
| Rate for Payer: Aetna American Axle |
$241.34
|
| Rate for Payer: Aetna Commercial |
$315.61
|
| Rate for Payer: Aetna Medicare |
$185.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.34
|
| Rate for Payer: BCBS Complete |
$148.52
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Advantage |
$259.91
|
| Rate for Payer: Cofinity Commercial |
$319.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$334.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$297.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$278.48
|
| Rate for Payer: PHP Commercial |
$315.61
|
| Rate for Payer: Priority Health SBD |
$233.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.34
|
| Rate for Payer: UHC Core |
$193.45
|
| Rate for Payer: UHC Exchange |
$145.92
|
| Rate for Payer: UMR Bronson Commercial |
$137.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.48
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$425.35
|
|
|
Service Code
|
NDC 00904656460
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.15 |
| Max. Negotiated Rate |
$382.81 |
| Rate for Payer: Aetna American Axle |
$276.48
|
| Rate for Payer: Aetna Commercial |
$361.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.48
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Advantage |
$297.75
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$382.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.01
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health SBD |
$267.97
|
| Rate for Payer: UMR Bronson Commercial |
$187.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.01
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 42806071401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.35 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Advantage |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$121.61
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UMR Bronson Commercial |
$71.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$335.35
|
|
|
Service Code
|
NDC 00904715361
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.55 |
| Max. Negotiated Rate |
$301.81 |
| Rate for Payer: Aetna American Axle |
$217.98
|
| Rate for Payer: Aetna Commercial |
$285.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.98
|
| Rate for Payer: Cash Price |
$268.28
|
| Rate for Payer: Cofinity Advantage |
$234.75
|
| Rate for Payer: Cofinity Commercial |
$288.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.28
|
| Rate for Payer: Healthscope Commercial |
$301.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$251.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$251.51
|
| Rate for Payer: PHP Commercial |
$285.05
|
| Rate for Payer: Priority Health SBD |
$211.27
|
| Rate for Payer: UMR Bronson Commercial |
$147.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$251.51
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$373.65
|
|
|
Service Code
|
NDC 64380071206
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$336.29 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna Medicare |
$186.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: BCBS Complete |
$149.46
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Advantage |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$298.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.24
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$242.87
|
| Rate for Payer: UHC Core |
$194.67
|
| Rate for Payer: UHC Exchange |
$146.84
|
| Rate for Payer: UMR Bronson Commercial |
$138.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$371.30
|
|
|
Service Code
|
NDC 67877057301
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.37 |
| Max. Negotiated Rate |
$334.17 |
| Rate for Payer: Aetna American Axle |
$241.34
|
| Rate for Payer: Aetna Commercial |
$315.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.34
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Advantage |
$259.91
|
| Rate for Payer: Cofinity Commercial |
$319.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$334.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$278.48
|
| Rate for Payer: PHP Commercial |
$315.61
|
| Rate for Payer: Priority Health SBD |
$233.92
|
| Rate for Payer: UMR Bronson Commercial |
$163.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.48
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$264.10
|
|
|
Service Code
|
NDC 62332042631
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna American Axle |
$171.66
|
| Rate for Payer: Aetna Commercial |
$224.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Advantage |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.07
|
| Rate for Payer: PHP Commercial |
$224.49
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UMR Bronson Commercial |
$116.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.07
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$162.15
|
|
|
Service Code
|
NDC 42806071401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna Medicare |
$81.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: BCBS Complete |
$64.86
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Advantage |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$129.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$121.61
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.40
|
| Rate for Payer: UHC Core |
$84.48
|
| Rate for Payer: UHC Exchange |
$63.72
|
| Rate for Payer: UMR Bronson Commercial |
$60.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$335.35
|
|
|
Service Code
|
NDC 00904715361
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.08 |
| Max. Negotiated Rate |
$301.81 |
| Rate for Payer: Aetna American Axle |
$217.98
|
| Rate for Payer: Aetna Commercial |
$285.05
|
| Rate for Payer: Aetna Medicare |
$167.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.98
|
| Rate for Payer: BCBS Complete |
$134.14
|
| Rate for Payer: Cash Price |
$268.28
|
| Rate for Payer: Cofinity Advantage |
$234.75
|
| Rate for Payer: Cofinity Commercial |
$288.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.28
|
| Rate for Payer: Healthscope Commercial |
$301.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$251.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$268.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$251.51
|
| Rate for Payer: PHP Commercial |
$285.05
|
| Rate for Payer: Priority Health SBD |
$211.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.98
|
| Rate for Payer: UHC Core |
$174.72
|
| Rate for Payer: UHC Exchange |
$131.79
|
| Rate for Payer: UMR Bronson Commercial |
$124.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$251.51
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 64380071206
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.29 |
| 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 Advantage |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.29
|
| 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 Commercial |
$317.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.24
|
| Rate for Payer: PHP Commercial |
$317.60
|
| 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
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$425.35
|
|
|
Service Code
|
NDC 00904656460
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.38 |
| Max. Negotiated Rate |
$382.81 |
| Rate for Payer: Aetna American Axle |
$276.48
|
| Rate for Payer: Aetna Commercial |
$361.55
|
| Rate for Payer: Aetna Medicare |
$212.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.48
|
| Rate for Payer: BCBS Complete |
$170.14
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Advantage |
$297.75
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$382.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$340.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.01
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health SBD |
$267.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.48
|
| Rate for Payer: UHC Core |
$221.61
|
| Rate for Payer: UHC Exchange |
$167.16
|
| Rate for Payer: UMR Bronson Commercial |
$157.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.01
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$103.47
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna American Axle |
$67.26
|
| Rate for Payer: Aetna American Axle |
$69.95
|
| Rate for Payer: Aetna Commercial |
$87.95
|
| Rate for Payer: Aetna Commercial |
$91.47
|
| Rate for Payer: Aetna Medicare |
$51.73
|
| Rate for Payer: Aetna Medicare |
$53.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.95
|
| Rate for Payer: BCBS Complete |
$43.04
|
| Rate for Payer: BCBS Complete |
$41.39
|
| Rate for Payer: BCBS Trust/PPO |
$44.78
|
| Rate for Payer: BCBS Trust/PPO |
$44.78
|
| Rate for Payer: BCN Commercial |
$44.78
|
| Rate for Payer: BCN Commercial |
$44.78
|
| Rate for Payer: Cash Price |
$82.78
|
| Rate for Payer: Cash Price |
$86.09
|
| Rate for Payer: Cash Price |
$82.78
|
| Rate for Payer: Cash Price |
$86.09
|
| Rate for Payer: Cofinity Advantage |
$72.43
|
| Rate for Payer: Cofinity Advantage |
$75.33
|
| Rate for Payer: Cofinity Commercial |
$88.98
|
| Rate for Payer: Cofinity Commercial |
$92.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.09
|
| Rate for Payer: Healthscope Commercial |
$93.12
|
| Rate for Payer: Healthscope Commercial |
$96.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.60
|
| Rate for Payer: PHP Commercial |
$87.95
|
| Rate for Payer: PHP Commercial |
$91.47
|
| Rate for Payer: Priority Health SBD |
$65.19
|
| Rate for Payer: Priority Health SBD |
$67.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.80
|
| Rate for Payer: UHC Core |
$22.80
|
| Rate for Payer: UHC Core |
$22.80
|
| Rate for Payer: UHC Exchange |
$22.80
|
| Rate for Payer: UHC Exchange |
$22.80
|
| Rate for Payer: UMR Bronson Commercial |
$38.28
|
| Rate for Payer: UMR Bronson Commercial |
$39.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.71
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$103.47
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.53 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna American Axle |
$67.26
|
| Rate for Payer: Aetna American Axle |
$69.95
|
| Rate for Payer: Aetna Commercial |
$87.95
|
| Rate for Payer: Aetna Commercial |
$91.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.95
|
| Rate for Payer: Cash Price |
$82.78
|
| Rate for Payer: Cash Price |
$86.09
|
| Rate for Payer: Cofinity Advantage |
$75.33
|
| Rate for Payer: Cofinity Advantage |
$72.43
|
| Rate for Payer: Cofinity Commercial |
$92.54
|
| Rate for Payer: Cofinity Commercial |
$88.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.09
|
| Rate for Payer: Healthscope Commercial |
$93.12
|
| Rate for Payer: Healthscope Commercial |
$96.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.71
|
| Rate for Payer: PHP Commercial |
$87.95
|
| Rate for Payer: PHP Commercial |
$91.47
|
| Rate for Payer: Priority Health SBD |
$67.79
|
| Rate for Payer: Priority Health SBD |
$65.19
|
| Rate for Payer: UMR Bronson Commercial |
$45.53
|
| Rate for Payer: UMR Bronson Commercial |
$47.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.71
|
|
