|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$15.93
|
|
|
Service Code
|
NDC 9900-0006-97
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$14.34 |
| Rate for Payer: Aetna American Axle |
$10.35
|
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.35
|
| Rate for Payer: Cash Price |
$12.74
|
| Rate for Payer: Cofinity Commercial |
$11.15
|
| Rate for Payer: Cofinity Commercial |
$13.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.74
|
| Rate for Payer: Healthscope Commercial |
$14.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.54
|
| Rate for Payer: PHP Commercial |
$13.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.15
|
| Rate for Payer: Priority Health SBD |
$10.04
|
| Rate for Payer: UMR Bronson Commercial |
$7.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.95
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 9900-0000-08
|
| Hospital Charge Code |
4571
|
|
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
|
|
|
LORAZEPAM (BULK) 100 % POWDER
|
Facility
|
IP
|
$122.61
|
|
|
Service Code
|
NDC 38779-0927-3
|
| Hospital Charge Code |
26060
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$110.35 |
| Rate for Payer: Aetna American Axle |
$79.70
|
| Rate for Payer: Aetna Commercial |
$104.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.70
|
| Rate for Payer: Cash Price |
$98.09
|
| Rate for Payer: Cofinity Commercial |
$105.44
|
| Rate for Payer: Cofinity Commercial |
$85.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.09
|
| Rate for Payer: Healthscope Commercial |
$110.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.22
|
| Rate for Payer: PHP Commercial |
$104.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.83
|
| Rate for Payer: Priority Health SBD |
$77.24
|
| Rate for Payer: UMR Bronson Commercial |
$53.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.96
|
|
|
LORAZEPAM IV 0.5 MG/ML INJECTION (NICU)
|
Facility
|
IP
|
$30.90
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
500547
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$27.81 |
| Rate for Payer: Aetna American Axle |
$20.08
|
| Rate for Payer: Aetna Commercial |
$26.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.08
|
| Rate for Payer: Cash Price |
$24.72
|
| Rate for Payer: Cofinity Commercial |
$21.63
|
| Rate for Payer: Cofinity Commercial |
$26.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.72
|
| Rate for Payer: Healthscope Commercial |
$27.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.26
|
| Rate for Payer: PHP Commercial |
$26.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.63
|
| Rate for Payer: Priority Health SBD |
$19.47
|
| Rate for Payer: UMR Bronson Commercial |
$13.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.18
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
NDC 50268-504-11
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Aetna American Axle |
$1.50
|
| Rate for Payer: Aetna Commercial |
$1.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.50
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Cofinity Commercial |
$1.61
|
| Rate for Payer: Cofinity Commercial |
$1.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.84
|
| Rate for Payer: Healthscope Commercial |
$2.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.96
|
| Rate for Payer: PHP Commercial |
$1.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.45
|
| Rate for Payer: UMR Bronson Commercial |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.72
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 68084-346-01
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.18 |
| Max. Negotiated Rate |
$274.46 |
| Rate for Payer: Aetna American Axle |
$198.22
|
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.22
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$213.46
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.21
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.46
|
| Rate for Payer: Priority Health SBD |
$192.12
|
| Rate for Payer: UMR Bronson Commercial |
$134.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$114.95
|
|
|
Service Code
|
NDC 50268-504-15
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.58 |
| Max. Negotiated Rate |
$103.46 |
| Rate for Payer: Aetna American Axle |
$74.72
|
| Rate for Payer: Aetna Commercial |
$97.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.72
|
| Rate for Payer: Cash Price |
$91.96
|
| Rate for Payer: Cofinity Commercial |
$80.46
|
| Rate for Payer: Cofinity Commercial |
$98.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.96
|
| Rate for Payer: Healthscope Commercial |
$103.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$80.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97.71
|
| Rate for Payer: PHP Commercial |
$97.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.46
|
| Rate for Payer: Priority Health SBD |
$72.42
|
| Rate for Payer: UMR Bronson Commercial |
$50.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.21
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 68084-346-11
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna American Axle |
$1.98
|
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.98
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1.92
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$48.65
|
|
|
Service Code
|
NDC 65862-201-90
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna American Axle |
$31.62
|
| Rate for Payer: Aetna Commercial |
$41.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.62
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Cofinity Commercial |
$34.06
|
| Rate for Payer: Cofinity Commercial |
$41.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.92
|
| Rate for Payer: Healthscope Commercial |
$43.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.35
|
| Rate for Payer: PHP Commercial |
$41.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.06
|
| Rate for Payer: Priority Health SBD |
$30.65
|
| Rate for Payer: UMR Bronson Commercial |
$21.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.49
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$404.70
|
|
|
Service Code
|
NDC 63739-673-10
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.07 |
| Max. Negotiated Rate |
$364.23 |
| Rate for Payer: Aetna American Axle |
$263.06
|
| Rate for Payer: Aetna Commercial |
$344.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.06
|
| Rate for Payer: Cash Price |
$323.76
|
| Rate for Payer: Cofinity Commercial |
$283.29
|
| Rate for Payer: Cofinity Commercial |
$348.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.76
|
| Rate for Payer: Healthscope Commercial |
$364.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$344.00
|
| Rate for Payer: PHP Commercial |
$344.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$283.29
|
| Rate for Payer: Priority Health SBD |
$254.96
|
| Rate for Payer: UMR Bronson Commercial |
$178.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.52
|
|
|
LOSARTAN 25 MG TABLET
|
Facility
|
IP
|
$274.95
|
|
|
Service Code
|
NDC 0781-5700-92
|
| Hospital Charge Code |
14823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.98 |
| Max. Negotiated Rate |
$247.46 |
| Rate for Payer: Aetna American Axle |
$178.72
|
| Rate for Payer: Aetna Commercial |
$233.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.72
|
| Rate for Payer: Cash Price |
$219.96
|
| Rate for Payer: Cofinity Commercial |
$192.46
|
| Rate for Payer: Cofinity Commercial |
$236.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.96
|
| Rate for Payer: Healthscope Commercial |
$247.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$192.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$206.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$233.71
|
| Rate for Payer: PHP Commercial |
$233.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.46
|
| Rate for Payer: Priority Health SBD |
$173.22
|
| Rate for Payer: UMR Bronson Commercial |
$120.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.21
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 68084-347-11
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.07 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.60
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$99.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 0904-7048-61
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.07 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.60
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$99.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 68084-347-01
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.07 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.60
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$99.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$374.36
|
|
|
Service Code
|
NDC 0781-5701-92
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.72 |
| Max. Negotiated Rate |
$336.92 |
| Rate for Payer: Aetna American Axle |
$243.33
|
| Rate for Payer: Aetna Commercial |
$318.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.33
|
| Rate for Payer: Cash Price |
$299.49
|
| Rate for Payer: Cofinity Commercial |
$262.05
|
| Rate for Payer: Cofinity Commercial |
$321.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.49
|
| Rate for Payer: Healthscope Commercial |
$336.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$262.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$318.21
|
| Rate for Payer: PHP Commercial |
$318.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.05
|
| Rate for Payer: Priority Health SBD |
$235.85
|
| Rate for Payer: UMR Bronson Commercial |
$164.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.77
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$54.99
|
|
|
Service Code
|
NDC 65862-202-90
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.20 |
| Max. Negotiated Rate |
$49.49 |
| Rate for Payer: Aetna American Axle |
$35.74
|
| Rate for Payer: Aetna Commercial |
$46.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.74
|
| Rate for Payer: Cash Price |
$43.99
|
| Rate for Payer: Cofinity Commercial |
$38.49
|
| Rate for Payer: Cofinity Commercial |
$47.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.99
|
| Rate for Payer: Healthscope Commercial |
$49.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.74
|
| Rate for Payer: PHP Commercial |
$46.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.49
|
| Rate for Payer: Priority Health SBD |
$34.64
|
| Rate for Payer: UMR Bronson Commercial |
$24.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.24
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$49,205.09
|
|
|
Service Code
|
MS-DRG 493
|
| Min. Negotiated Rate |
$18,068.94 |
| Max. Negotiated Rate |
$49,205.09 |
| Rate for Payer: Aetna Medicare |
$19,780.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,774.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,774.92
|
| Rate for Payer: BCBS MAPPO |
$19,019.94
|
| Rate for Payer: BCBS Trust/PPO |
$49,205.09
|
| Rate for Payer: BCN Medicare Advantage |
$19,019.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,019.94
|
| Rate for Payer: Mclaren Medicare |
$19,019.94
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,970.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,872.93
|
| Rate for Payer: PACE Medicare |
$18,068.94
|
| Rate for Payer: PACE SWMI |
$19,019.94
|
| Rate for Payer: PHP Medicare Advantage |
$19,019.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,464.20
|
| Rate for Payer: Priority Health Medicare |
$19,019.94
|
| Rate for Payer: Priority Health Narrow Network |
$27,571.36
|
| Rate for Payer: Railroad Medicare Medicare |
$19,019.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36,635.53
|
| Rate for Payer: UHC Core |
$30,040.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$19,019.94
|
| Rate for Payer: UHC Exchange |
$23,882.50
|
| Rate for Payer: UHC Medicare Advantage |
$19,590.54
|
| Rate for Payer: VA VA |
$19,019.94
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$61,201.68
|
|
|
Service Code
|
MS-DRG 492
|
| Min. Negotiated Rate |
$25,831.84 |
| Max. Negotiated Rate |
$61,201.68 |
| Rate for Payer: Aetna Medicare |
$28,279.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33,989.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33,989.26
|
| Rate for Payer: BCBS MAPPO |
$27,191.41
|
| Rate for Payer: BCBS Trust/PPO |
$61,201.68
|
| Rate for Payer: BCN Medicare Advantage |
$27,191.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27,191.41
|
| Rate for Payer: Mclaren Medicare |
$27,191.41
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$28,550.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31,270.12
|
| Rate for Payer: PACE Medicare |
$25,831.84
|
| Rate for Payer: PACE SWMI |
$27,191.41
|
| Rate for Payer: PHP Medicare Advantage |
$27,191.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49,680.86
|
| Rate for Payer: Priority Health Medicare |
$27,191.41
|
| Rate for Payer: Priority Health Narrow Network |
$39,744.69
|
| Rate for Payer: Railroad Medicare Medicare |
$27,191.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52,810.87
|
| Rate for Payer: UHC Core |
$43,303.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$27,191.41
|
| Rate for Payer: UHC Exchange |
$34,427.12
|
| Rate for Payer: UHC Medicare Advantage |
$28,007.15
|
| Rate for Payer: VA VA |
$27,191.41
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$35,163.01
|
|
|
Service Code
|
MS-DRG 494
|
| Min. Negotiated Rate |
$14,170.66 |
| Max. Negotiated Rate |
$35,163.01 |
| Rate for Payer: Aetna Medicare |
$15,513.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,645.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,645.60
|
| Rate for Payer: BCBS MAPPO |
$14,916.48
|
| Rate for Payer: BCBS Trust/PPO |
$35,163.01
|
| Rate for Payer: BCN Medicare Advantage |
$14,916.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,916.48
|
| Rate for Payer: Mclaren Medicare |
$14,916.48
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15,662.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,153.95
|
| Rate for Payer: PACE Medicare |
$14,170.66
|
| Rate for Payer: PACE SWMI |
$14,916.48
|
| Rate for Payer: PHP Medicare Advantage |
$14,916.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,822.87
|
| Rate for Payer: Priority Health Medicare |
$14,916.48
|
| Rate for Payer: Priority Health Narrow Network |
$21,458.30
|
| Rate for Payer: Railroad Medicare Medicare |
$14,916.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28,512.78
|
| Rate for Payer: UHC Core |
$23,379.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$14,916.48
|
| Rate for Payer: UHC Exchange |
$18,587.32
|
| Rate for Payer: UHC Medicare Advantage |
$15,363.97
|
| Rate for Payer: VA VA |
$14,916.48
|
|
|
LOXAPINE SUCCINATE 10 MG CAPSULE
|
Facility
|
IP
|
$321.12
|
|
|
Service Code
|
NDC 0591-0370-01
|
| Hospital Charge Code |
4599
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.29 |
| Max. Negotiated Rate |
$289.01 |
| Rate for Payer: Aetna American Axle |
$208.73
|
| Rate for Payer: Aetna Commercial |
$272.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.73
|
| Rate for Payer: Cash Price |
$256.90
|
| Rate for Payer: Cofinity Commercial |
$224.78
|
| Rate for Payer: Cofinity Commercial |
$276.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.90
|
| Rate for Payer: Healthscope Commercial |
$289.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$224.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$240.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$272.95
|
| Rate for Payer: PHP Commercial |
$272.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.78
|
| Rate for Payer: Priority Health SBD |
$202.31
|
| Rate for Payer: UMR Bronson Commercial |
$141.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$240.84
|
|
|
LOXAPINE SUCCINATE 25 MG CAPSULE
|
Facility
|
IP
|
$470.25
|
|
|
Service Code
|
NDC 0527-1396-01
|
| Hospital Charge Code |
4600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.91 |
| Max. Negotiated Rate |
$423.22 |
| Rate for Payer: Aetna American Axle |
$305.66
|
| Rate for Payer: Aetna Commercial |
$399.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.66
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$329.18
|
| Rate for Payer: Cofinity Commercial |
$404.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$423.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$399.71
|
| Rate for Payer: PHP Commercial |
$399.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.18
|
| Rate for Payer: Priority Health SBD |
$296.26
|
| Rate for Payer: UMR Bronson Commercial |
$206.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.69
|
|
|
LOXAPINE SUCCINATE 25 MG CAPSULE
|
Facility
|
IP
|
$488.16
|
|
|
Service Code
|
NDC 0591-0371-01
|
| Hospital Charge Code |
4600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.79 |
| Max. Negotiated Rate |
$439.34 |
| Rate for Payer: Aetna American Axle |
$317.30
|
| Rate for Payer: Aetna Commercial |
$414.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$317.30
|
| Rate for Payer: Cash Price |
$390.53
|
| Rate for Payer: Cofinity Commercial |
$341.71
|
| Rate for Payer: Cofinity Commercial |
$419.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.53
|
| Rate for Payer: Healthscope Commercial |
$439.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$341.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$366.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$414.94
|
| Rate for Payer: PHP Commercial |
$414.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$341.71
|
| Rate for Payer: Priority Health SBD |
$307.54
|
| Rate for Payer: UMR Bronson Commercial |
$214.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$366.12
|
|
|
LOXAPINE SUCCINATE 25 MG CAPSULE
|
Facility
|
IP
|
$486.24
|
|
|
Service Code
|
NDC 0378-7025-01
|
| Hospital Charge Code |
4600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.95 |
| Max. Negotiated Rate |
$437.62 |
| Rate for Payer: Aetna American Axle |
$316.06
|
| Rate for Payer: Aetna Commercial |
$413.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$316.06
|
| Rate for Payer: Cash Price |
$388.99
|
| Rate for Payer: Cofinity Commercial |
$340.37
|
| Rate for Payer: Cofinity Commercial |
$418.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$388.99
|
| Rate for Payer: Healthscope Commercial |
$437.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$340.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$364.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$413.30
|
| Rate for Payer: PHP Commercial |
$413.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.37
|
| Rate for Payer: Priority Health SBD |
$306.33
|
| Rate for Payer: UMR Bronson Commercial |
$213.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$364.68
|
|
|
LOXAPINE SUCCINATE 5 MG CAPSULE
|
Facility
|
IP
|
$244.32
|
|
|
Service Code
|
NDC 0591-0369-01
|
| Hospital Charge Code |
4601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.50 |
| Max. Negotiated Rate |
$219.89 |
| Rate for Payer: Aetna American Axle |
$158.81
|
| Rate for Payer: Aetna Commercial |
$207.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.81
|
| Rate for Payer: Cash Price |
$195.46
|
| Rate for Payer: Cofinity Commercial |
$171.02
|
| Rate for Payer: Cofinity Commercial |
$210.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.46
|
| Rate for Payer: Healthscope Commercial |
$219.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.67
|
| Rate for Payer: PHP Commercial |
$207.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.02
|
| Rate for Payer: Priority Health SBD |
$153.92
|
| Rate for Payer: UMR Bronson Commercial |
$107.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.24
|
|
|
LOXAPINE SUCCINATE 5 MG CAPSULE
|
Facility
|
IP
|
$428.45
|
|
|
Service Code
|
NDC 0527-1394-01
|
| Hospital Charge Code |
4601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.52 |
| Max. Negotiated Rate |
$385.60 |
| Rate for Payer: Aetna American Axle |
$278.49
|
| Rate for Payer: Aetna Commercial |
$364.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.49
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$299.92
|
| Rate for Payer: Cofinity Commercial |
$368.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$385.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.18
|
| Rate for Payer: PHP Commercial |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.92
|
| Rate for Payer: Priority Health SBD |
$269.92
|
| Rate for Payer: UMR Bronson Commercial |
$188.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.34
|
|
