|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
IP
|
$472.32
|
|
|
Service Code
|
NDC 51862-320-01
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.82 |
| Max. Negotiated Rate |
$425.09 |
| Rate for Payer: Aetna American Axle |
$307.01
|
| Rate for Payer: Aetna Commercial |
$401.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.01
|
| Rate for Payer: Cash Price |
$377.86
|
| Rate for Payer: Cofinity Commercial |
$330.62
|
| Rate for Payer: Cofinity Commercial |
$406.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.86
|
| Rate for Payer: Healthscope Commercial |
$425.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$354.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$401.47
|
| Rate for Payer: PHP Commercial |
$401.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$330.62
|
| Rate for Payer: Priority Health SBD |
$297.56
|
| Rate for Payer: UMR Bronson Commercial |
$207.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$354.24
|
|
|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
IP
|
$353.40
|
|
|
Service Code
|
NDC 42794-018-02
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna American Axle |
$229.71
|
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$247.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$265.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$300.39
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.38
|
| Rate for Payer: Priority Health SBD |
$222.64
|
| Rate for Payer: UMR Bronson Commercial |
$155.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$265.05
|
|
|
LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$1,429.31
|
|
|
Service Code
|
NDC 0032-1212-01
|
| Hospital Charge Code |
98035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$628.90 |
| Max. Negotiated Rate |
$1,286.38 |
| Rate for Payer: Aetna American Axle |
$929.05
|
| Rate for Payer: Aetna Commercial |
$1,214.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.05
|
| Rate for Payer: Cash Price |
$1,143.45
|
| Rate for Payer: Cofinity Commercial |
$1,000.52
|
| Rate for Payer: Cofinity Commercial |
$1,229.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.45
|
| Rate for Payer: Healthscope Commercial |
$1,286.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,000.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,071.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,214.91
|
| Rate for Payer: PHP Commercial |
$1,214.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,000.52
|
| Rate for Payer: Priority Health SBD |
$900.47
|
| Rate for Payer: UMR Bronson Commercial |
$628.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,071.98
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$6,635.95
|
|
|
Service Code
|
NDC 0032-1224-07
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,919.82 |
| Max. Negotiated Rate |
$5,972.36 |
| Rate for Payer: Aetna American Axle |
$4,313.37
|
| Rate for Payer: Aetna Commercial |
$5,640.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,313.37
|
| Rate for Payer: Cash Price |
$5,308.76
|
| Rate for Payer: Cofinity Commercial |
$4,645.16
|
| Rate for Payer: Cofinity Commercial |
$5,706.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,308.76
|
| Rate for Payer: Healthscope Commercial |
$5,972.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,645.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,976.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,640.56
|
| Rate for Payer: PHP Commercial |
$5,640.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,645.16
|
| Rate for Payer: Priority Health SBD |
$4,180.65
|
| Rate for Payer: UMR Bronson Commercial |
$2,919.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,976.96
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$2,832.72
|
|
|
Service Code
|
NDC 0032-1224-01
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,246.40 |
| Max. Negotiated Rate |
$2,549.45 |
| Rate for Payer: Aetna American Axle |
$1,841.27
|
| Rate for Payer: Aetna Commercial |
$2,407.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,841.27
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$1,982.90
|
| Rate for Payer: Cofinity Commercial |
$2,436.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,266.18
|
| Rate for Payer: Healthscope Commercial |
$2,549.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,982.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,124.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,407.81
|
| Rate for Payer: PHP Commercial |
$2,407.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,982.90
|
| Rate for Payer: Priority Health SBD |
$1,784.61
|
| Rate for Payer: UMR Bronson Commercial |
$1,246.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,124.54
|
|
|
LIPASE-PROTEASE-AMYLASE 3,000-9,500-15,000 UNIT CAPSULE, DELAYED REL
|
Facility
|
IP
|
$548.36
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
153195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.28 |
| Max. Negotiated Rate |
$493.52 |
| Rate for Payer: Aetna American Axle |
$356.43
|
| Rate for Payer: Aetna Commercial |
$466.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$356.43
|
| Rate for Payer: Cash Price |
$438.69
|
| Rate for Payer: Cofinity Commercial |
$383.85
|
| Rate for Payer: Cofinity Commercial |
$471.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$438.69
|
| Rate for Payer: Healthscope Commercial |
$493.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$383.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$411.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$466.11
|
| Rate for Payer: PHP Commercial |
$466.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$383.85
|
| Rate for Payer: Priority Health SBD |
$345.47
|
| Rate for Payer: UMR Bronson Commercial |
$241.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$411.27
|
|
|
LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL
|
Facility
|
IP
|
$4,301.25
|
|
|
Service Code
|
NDC 0032-3016-13
|
| Hospital Charge Code |
166135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,892.55 |
| Max. Negotiated Rate |
$3,871.12 |
| Rate for Payer: Aetna American Axle |
$2,795.81
|
| Rate for Payer: Aetna Commercial |
$3,656.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,795.81
|
| Rate for Payer: Cash Price |
$3,441.00
|
| Rate for Payer: Cofinity Commercial |
$3,010.88
|
| Rate for Payer: Cofinity Commercial |
$3,699.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,441.00
|
| Rate for Payer: Healthscope Commercial |
$3,871.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,010.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,225.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,656.06
|
| Rate for Payer: PHP Commercial |
$3,656.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,010.88
|
| Rate for Payer: Priority Health SBD |
$2,709.79
|
| Rate for Payer: UMR Bronson Commercial |
$1,892.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,225.94
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$2,209.20
|
|
|
Service Code
|
NDC 0032-1206-07
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$972.05 |
| Max. Negotiated Rate |
$1,988.28 |
| Rate for Payer: Aetna American Axle |
$1,435.98
|
| Rate for Payer: Aetna Commercial |
$1,877.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.98
|
| Rate for Payer: Cash Price |
$1,767.36
|
| Rate for Payer: Cofinity Commercial |
$1,546.44
|
| Rate for Payer: Cofinity Commercial |
$1,899.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.36
|
| Rate for Payer: Healthscope Commercial |
$1,988.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,877.82
|
| Rate for Payer: PHP Commercial |
$1,877.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,546.44
|
| Rate for Payer: Priority Health SBD |
$1,391.80
|
| Rate for Payer: UMR Bronson Commercial |
$972.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.90
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$927.36
|
|
|
Service Code
|
NDC 0032-1206-01
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$408.04 |
| Max. Negotiated Rate |
$834.62 |
| Rate for Payer: Aetna American Axle |
$602.78
|
| Rate for Payer: Aetna Commercial |
$788.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$602.78
|
| Rate for Payer: Cash Price |
$741.89
|
| Rate for Payer: Cofinity Commercial |
$649.15
|
| Rate for Payer: Cofinity Commercial |
$797.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$741.89
|
| Rate for Payer: Healthscope Commercial |
$834.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$649.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$695.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$788.26
|
| Rate for Payer: PHP Commercial |
$788.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.15
|
| Rate for Payer: Priority Health SBD |
$584.24
|
| Rate for Payer: UMR Bronson Commercial |
$408.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$695.52
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$135.60
|
|
|
Service Code
|
NDC 9900-0001-07
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.66 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.92
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$59.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$73.42
|
|
|
Service Code
|
NDC 0090-0002-39
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.41
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.39
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UMR Bronson Commercial |
$32.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$110.16
|
|
|
Service Code
|
NDC 9900-0001-05
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.47 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna American Axle |
$71.60
|
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.11
|
| Rate for Payer: Priority Health SBD |
$69.40
|
| Rate for Payer: UMR Bronson Commercial |
$48.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.62
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$108.48
|
|
|
Service Code
|
NDC 9900-0001-06
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.73 |
| Max. Negotiated Rate |
$97.63 |
| Rate for Payer: Aetna American Axle |
$70.51
|
| Rate for Payer: Aetna Commercial |
$92.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.51
|
| Rate for Payer: Cash Price |
$86.78
|
| Rate for Payer: Cofinity Commercial |
$75.94
|
| Rate for Payer: Cofinity Commercial |
$93.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.78
|
| Rate for Payer: Healthscope Commercial |
$97.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.21
|
| Rate for Payer: PHP Commercial |
$92.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.94
|
| Rate for Payer: Priority Health SBD |
$68.34
|
| Rate for Payer: UMR Bronson Commercial |
$47.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.36
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
NDC 9900-0001-03
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna American Axle |
$41.47
|
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.47
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.23
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.66
|
| Rate for Payer: Priority Health SBD |
$40.19
|
| Rate for Payer: UMR Bronson Commercial |
$28.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.85
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$73.44
|
|
|
Service Code
|
NDC 9900-0001-04
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.31 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Commercial |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.42
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.41
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UMR Bronson Commercial |
$32.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
NDC 0338-0519-09
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.68 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna American Axle |
$301.60
|
| Rate for Payer: Aetna Commercial |
$394.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$301.60
|
| Rate for Payer: BCBS Complete |
$185.60
|
| Rate for Payer: Cash Price |
$371.20
|
| Rate for Payer: Cofinity Commercial |
$324.80
|
| Rate for Payer: Cofinity Commercial |
$399.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.20
|
| Rate for Payer: Healthscope Commercial |
$417.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$324.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$394.40
|
| Rate for Payer: PHP Commercial |
$394.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$324.80
|
| Rate for Payer: Priority Health SBD |
$292.32
|
| Rate for Payer: UMR Bronson Commercial |
$171.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.00
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 9900-0001-02
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417-101-10
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,745.45 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Commercial |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,371.89
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,776.85
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UMR Bronson Commercial |
$1,745.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$480.90
|
|
|
Service Code
|
NDC 43547-602-10
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.60 |
| Max. Negotiated Rate |
$432.81 |
| Rate for Payer: Aetna American Axle |
$312.58
|
| Rate for Payer: Aetna Commercial |
$408.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.58
|
| Rate for Payer: Cash Price |
$384.72
|
| Rate for Payer: Cofinity Commercial |
$336.63
|
| Rate for Payer: Cofinity Commercial |
$413.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$384.72
|
| Rate for Payer: Healthscope Commercial |
$432.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$336.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$360.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$408.76
|
| Rate for Payer: PHP Commercial |
$408.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.63
|
| Rate for Payer: Priority Health SBD |
$302.97
|
| Rate for Payer: UMR Bronson Commercial |
$211.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$360.68
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
IP
|
$480.90
|
|
|
Service Code
|
NDC 43547-604-10
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.60 |
| Max. Negotiated Rate |
$432.81 |
| Rate for Payer: Aetna American Axle |
$312.58
|
| Rate for Payer: Aetna Commercial |
$408.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.58
|
| Rate for Payer: Cash Price |
$384.72
|
| Rate for Payer: Cofinity Commercial |
$336.63
|
| Rate for Payer: Cofinity Commercial |
$413.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$384.72
|
| Rate for Payer: Healthscope Commercial |
$432.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$336.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$360.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$408.76
|
| Rate for Payer: PHP Commercial |
$408.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.63
|
| Rate for Payer: Priority Health SBD |
$302.97
|
| Rate for Payer: UMR Bronson Commercial |
$211.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$360.68
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
IP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417-103-10
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,745.45 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Commercial |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,371.89
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,776.85
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UMR Bronson Commercial |
$1,745.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 63739-349-10
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.87 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna American Axle |
$84.01
|
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.01
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Cofinity Commercial |
$90.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.48
|
| Rate for Payer: Priority Health SBD |
$81.43
|
| Rate for Payer: UMR Bronson Commercial |
$56.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.94
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$44.65
|
|
|
Service Code
|
NDC 68180-980-01
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.65 |
| Max. Negotiated Rate |
$40.18 |
| Rate for Payer: Aetna American Axle |
$29.02
|
| Rate for Payer: Aetna Commercial |
$37.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.02
|
| Rate for Payer: Cash Price |
$35.72
|
| Rate for Payer: Cofinity Commercial |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$38.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.72
|
| Rate for Payer: Healthscope Commercial |
$40.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.95
|
| Rate for Payer: PHP Commercial |
$37.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.26
|
| Rate for Payer: Priority Health SBD |
$28.13
|
| Rate for Payer: UMR Bronson Commercial |
$19.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.49
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$232.65
|
|
|
Service Code
|
NDC 60687-325-01
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.37 |
| Max. Negotiated Rate |
$209.38 |
| Rate for Payer: Aetna American Axle |
$151.22
|
| Rate for Payer: Aetna Commercial |
$197.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.22
|
| Rate for Payer: Cash Price |
$186.12
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Commercial |
$200.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.12
|
| Rate for Payer: Healthscope Commercial |
$209.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.75
|
| Rate for Payer: PHP Commercial |
$197.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health SBD |
$146.57
|
| Rate for Payer: UMR Bronson Commercial |
$102.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.49
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 0904-6798-61
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.56 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.26
|
| Rate for Payer: Aetna Commercial |
$91.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.26
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.88
|
| Rate for Payer: PHP Commercial |
$91.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.67
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$47.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
