|
LYSIS INTRANASAL SYNECHIA
|
Facility
|
OP
|
$1,539.60
|
|
|
Service Code
|
CPT 30560
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$149.97 |
| Max. Negotiated Rate |
$1,539.60 |
| Rate for Payer: Aetna Medicare |
$508.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$611.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$611.32
|
| Rate for Payer: BCBS Complete |
$280.92
|
| Rate for Payer: BCBS MAPPO |
$489.06
|
| Rate for Payer: BCBS Trust/PPO |
$355.19
|
| Rate for Payer: BCN Medicare Advantage |
$489.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$489.06
|
| Rate for Payer: Mclaren Medicaid |
$267.52
|
| Rate for Payer: Mclaren Medicare |
$489.06
|
| Rate for Payer: Meridian Medicaid |
$280.92
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$513.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$562.42
|
| Rate for Payer: PACE Medicare |
$464.61
|
| Rate for Payer: PACE SWMI |
$489.06
|
| Rate for Payer: PHP Medicare Advantage |
$489.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$267.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,539.60
|
| Rate for Payer: Priority Health Medicare |
$489.06
|
| Rate for Payer: Priority Health Narrow Network |
$1,231.68
|
| Rate for Payer: Railroad Medicare Medicare |
$489.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$164.97
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$489.06
|
| Rate for Payer: UHC Exchange |
$149.97
|
| Rate for Payer: UHC Medicare Advantage |
$503.73
|
| Rate for Payer: VA VA |
$489.06
|
|
|
LYSIS OF LABIAL ADHESIONS
|
Facility
|
OP
|
$8,748.29
|
|
|
Service Code
|
CPT 56441
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$154.23 |
| Max. Negotiated Rate |
$8,748.29 |
| Rate for Payer: Aetna Medicare |
$2,890.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,473.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,473.69
|
| Rate for Payer: BCBS Complete |
$1,596.23
|
| Rate for Payer: BCBS MAPPO |
$2,778.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,583.45
|
| Rate for Payer: BCN Medicare Advantage |
$2,778.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,778.95
|
| Rate for Payer: Mclaren Medicaid |
$1,520.09
|
| Rate for Payer: Mclaren Medicare |
$2,778.95
|
| Rate for Payer: Meridian Medicaid |
$1,596.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,917.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,195.79
|
| Rate for Payer: PACE Medicare |
$2,640.00
|
| Rate for Payer: PACE SWMI |
$2,778.95
|
| Rate for Payer: PHP Medicare Advantage |
$2,778.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,520.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,748.29
|
| Rate for Payer: Priority Health Medicare |
$2,778.95
|
| Rate for Payer: Priority Health Narrow Network |
$6,998.63
|
| Rate for Payer: Railroad Medicare Medicare |
$2,778.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.65
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,778.95
|
| Rate for Payer: UHC Exchange |
$154.23
|
| Rate for Payer: UHC Medicare Advantage |
$2,862.32
|
| Rate for Payer: VA VA |
$2,778.95
|
|
|
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS
|
Facility
|
OP
|
$5,699.47
|
|
|
Service Code
|
CPT 54162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$197.12 |
| Max. Negotiated Rate |
$5,699.47 |
| Rate for Payer: Aetna Medicare |
$1,882.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,263.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,263.10
|
| Rate for Payer: BCBS Complete |
$1,039.94
|
| Rate for Payer: BCBS MAPPO |
$1,810.48
|
| Rate for Payer: BCBS Trust/PPO |
$1,796.10
|
| Rate for Payer: BCN Medicare Advantage |
$1,810.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,810.48
|
| Rate for Payer: Mclaren Medicaid |
$990.33
|
| Rate for Payer: Mclaren Medicare |
$1,810.48
|
| Rate for Payer: Meridian Medicaid |
$1,039.94
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,901.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,082.05
|
| Rate for Payer: PACE Medicare |
$1,719.96
|
| Rate for Payer: PACE SWMI |
$1,810.48
|
| Rate for Payer: PHP Medicare Advantage |
$1,810.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$990.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,699.47
|
| Rate for Payer: Priority Health Medicare |
$1,810.48
|
| Rate for Payer: Priority Health Narrow Network |
$4,559.58
|
| Rate for Payer: Railroad Medicare Medicare |
$1,810.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$216.83
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,810.48
|
| Rate for Payer: UHC Exchange |
$197.12
|
| Rate for Payer: UHC Medicare Advantage |
$1,864.79
|
| Rate for Payer: VA VA |
$1,810.48
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$2,310.34
|
|
|
Service Code
|
NDC 49884-902-78
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,016.55 |
| Max. Negotiated Rate |
$2,079.31 |
| Rate for Payer: Aetna American Axle |
$1,501.72
|
| Rate for Payer: Aetna Commercial |
$1,963.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,501.72
|
| Rate for Payer: Cash Price |
$1,848.27
|
| Rate for Payer: Cofinity Commercial |
$1,617.24
|
| Rate for Payer: Cofinity Commercial |
$1,986.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,848.27
|
| Rate for Payer: Healthscope Commercial |
$2,079.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,617.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,732.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,963.79
|
| Rate for Payer: PHP Commercial |
$1,963.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,617.24
|
| Rate for Payer: Priority Health SBD |
$1,455.51
|
| Rate for Payer: UMR Bronson Commercial |
$1,016.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,732.76
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$462.07
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.31 |
| Max. Negotiated Rate |
$415.86 |
| Rate for Payer: Aetna American Axle |
$300.35
|
| Rate for Payer: Aetna Commercial |
$392.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$300.35
|
| Rate for Payer: Cash Price |
$369.66
|
| Rate for Payer: Cofinity Commercial |
$323.45
|
| Rate for Payer: Cofinity Commercial |
$397.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$369.66
|
| Rate for Payer: Healthscope Commercial |
$415.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$323.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$346.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$392.76
|
| Rate for Payer: PHP Commercial |
$392.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$323.45
|
| Rate for Payer: Priority Health SBD |
$291.10
|
| Rate for Payer: UMR Bronson Commercial |
$203.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$346.55
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$3,767.30
|
|
|
Service Code
|
NDC 51079-624-85
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,657.61 |
| Max. Negotiated Rate |
$3,390.57 |
| Rate for Payer: Aetna American Axle |
$2,448.74
|
| Rate for Payer: Aetna Commercial |
$3,202.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,448.74
|
| Rate for Payer: Cash Price |
$3,013.84
|
| Rate for Payer: Cofinity Commercial |
$2,637.11
|
| Rate for Payer: Cofinity Commercial |
$3,239.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,013.84
|
| Rate for Payer: Healthscope Commercial |
$3,390.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,637.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,825.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,202.20
|
| Rate for Payer: PHP Commercial |
$3,202.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,637.11
|
| Rate for Payer: Priority Health SBD |
$2,373.40
|
| Rate for Payer: UMR Bronson Commercial |
$1,657.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,825.48
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$753.46
|
|
|
Service Code
|
NDC 51079-624-84
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.52 |
| Max. Negotiated Rate |
$678.11 |
| Rate for Payer: Aetna American Axle |
$489.75
|
| Rate for Payer: Aetna Commercial |
$640.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.75
|
| Rate for Payer: Cash Price |
$602.77
|
| Rate for Payer: Cofinity Commercial |
$527.42
|
| Rate for Payer: Cofinity Commercial |
$647.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.77
|
| Rate for Payer: Healthscope Commercial |
$678.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$527.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$565.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$640.44
|
| Rate for Payer: PHP Commercial |
$640.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$527.42
|
| Rate for Payer: Priority Health SBD |
$474.68
|
| Rate for Payer: UMR Bronson Commercial |
$331.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$565.10
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$1,624.12
|
|
|
Service Code
|
NDC 16571-723-48
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$714.61 |
| Max. Negotiated Rate |
$1,461.71 |
| Rate for Payer: Aetna American Axle |
$1,055.68
|
| Rate for Payer: Aetna Commercial |
$1,380.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,055.68
|
| Rate for Payer: Cash Price |
$1,299.30
|
| Rate for Payer: Cofinity Commercial |
$1,136.88
|
| Rate for Payer: Cofinity Commercial |
$1,396.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,299.30
|
| Rate for Payer: Healthscope Commercial |
$1,461.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,136.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,218.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,380.50
|
| Rate for Payer: PHP Commercial |
$1,380.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,136.88
|
| Rate for Payer: Priority Health SBD |
$1,023.20
|
| Rate for Payer: UMR Bronson Commercial |
$714.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,218.09
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$1,362.17
|
|
|
Service Code
|
NDC 51079-623-83
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$599.35 |
| Max. Negotiated Rate |
$1,225.95 |
| Rate for Payer: Aetna American Axle |
$885.41
|
| Rate for Payer: Aetna Commercial |
$1,157.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$885.41
|
| Rate for Payer: Cash Price |
$1,089.74
|
| Rate for Payer: Cofinity Commercial |
$1,171.47
|
| Rate for Payer: Cofinity Commercial |
$953.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,089.74
|
| Rate for Payer: Healthscope Commercial |
$1,225.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$953.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,021.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,157.84
|
| Rate for Payer: PHP Commercial |
$1,157.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$953.52
|
| Rate for Payer: Priority Health SBD |
$858.17
|
| Rate for Payer: UMR Bronson Commercial |
$599.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,021.63
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$197.66
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.97 |
| Max. Negotiated Rate |
$177.89 |
| Rate for Payer: Aetna American Axle |
$128.48
|
| Rate for Payer: Aetna Commercial |
$168.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.48
|
| Rate for Payer: Cash Price |
$158.13
|
| Rate for Payer: Cofinity Commercial |
$138.36
|
| Rate for Payer: Cofinity Commercial |
$169.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.13
|
| Rate for Payer: Healthscope Commercial |
$177.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.01
|
| Rate for Payer: PHP Commercial |
$168.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.36
|
| Rate for Payer: Priority Health SBD |
$124.53
|
| Rate for Payer: UMR Bronson Commercial |
$86.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.24
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$235.76
|
|
|
Service Code
|
NDC 16571-723-60
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.73 |
| Max. Negotiated Rate |
$212.18 |
| Rate for Payer: Aetna American Axle |
$153.24
|
| Rate for Payer: Aetna Commercial |
$200.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.24
|
| Rate for Payer: Cash Price |
$188.61
|
| Rate for Payer: Cofinity Commercial |
$165.03
|
| Rate for Payer: Cofinity Commercial |
$202.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.61
|
| Rate for Payer: Healthscope Commercial |
$212.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$176.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$200.40
|
| Rate for Payer: PHP Commercial |
$200.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.03
|
| Rate for Payer: Priority Health SBD |
$148.53
|
| Rate for Payer: UMR Bronson Commercial |
$103.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$176.82
|
|
|
MAGIC PERICREAM
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 9900-0007-14
|
| Hospital Charge Code |
150680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
MAGIC PERICREAM WITH NYSTATIN
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 9900-0007-15
|
| Hospital Charge Code |
150679
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$104.34
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
118625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.91 |
| Max. Negotiated Rate |
$93.91 |
| Rate for Payer: Aetna American Axle |
$67.82
|
| Rate for Payer: Aetna Commercial |
$88.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.82
|
| Rate for Payer: Cash Price |
$83.47
|
| Rate for Payer: Cofinity Commercial |
$73.04
|
| Rate for Payer: Cofinity Commercial |
$89.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.47
|
| Rate for Payer: Healthscope Commercial |
$93.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$73.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.69
|
| Rate for Payer: PHP Commercial |
$88.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$73.04
|
| Rate for Payer: Priority Health SBD |
$65.73
|
| Rate for Payer: UMR Bronson Commercial |
$45.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.26
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$108.57
|
|
|
Service Code
|
NDC 1000670013
|
| Hospital Charge Code |
118625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$97.71 |
| Rate for Payer: Aetna American Axle |
$70.57
|
| Rate for Payer: Aetna Commercial |
$92.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.57
|
| Rate for Payer: Cash Price |
$86.86
|
| Rate for Payer: Cofinity Commercial |
$76.00
|
| Rate for Payer: Cofinity Commercial |
$93.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.86
|
| Rate for Payer: Healthscope Commercial |
$97.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.28
|
| Rate for Payer: PHP Commercial |
$92.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.00
|
| Rate for Payer: Priority Health SBD |
$68.40
|
| Rate for Payer: UMR Bronson Commercial |
$47.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.43
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399-0051-1
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna American Axle |
$11.26
|
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.12
|
| Rate for Payer: Priority Health SBD |
$10.91
|
| Rate for Payer: UMR Bronson Commercial |
$7.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.99
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399-7889-1
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna American Axle |
$11.26
|
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.12
|
| Rate for Payer: Priority Health SBD |
$10.91
|
| Rate for Payer: UMR Bronson Commercial |
$7.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.99
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0121-0431-30
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Aetna American Axle |
$5.62
|
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.62
|
| Rate for Payer: Cash Price |
$6.91
|
| Rate for Payer: Cofinity Commercial |
$6.05
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.91
|
| Rate for Payer: Healthscope Commercial |
$7.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.34
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.05
|
| Rate for Payer: Priority Health SBD |
$5.44
|
| Rate for Payer: UMR Bronson Commercial |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.48
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 9900-0001-48
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Aetna American Axle |
$5.62
|
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.62
|
| Rate for Payer: Cash Price |
$6.91
|
| Rate for Payer: Cofinity Commercial |
$6.05
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.91
|
| Rate for Payer: Healthscope Commercial |
$7.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.34
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.05
|
| Rate for Payer: Priority Health SBD |
$5.44
|
| Rate for Payer: UMR Bronson Commercial |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.48
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
NDC 63739-354-10
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.24 |
| Max. Negotiated Rate |
$266.40 |
| Rate for Payer: Aetna American Axle |
$192.40
|
| Rate for Payer: Aetna Commercial |
$251.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.40
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Cofinity Commercial |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$254.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.80
|
| Rate for Payer: Healthscope Commercial |
$266.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$207.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$251.60
|
| Rate for Payer: PHP Commercial |
$251.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.20
|
| Rate for Payer: Priority Health SBD |
$186.48
|
| Rate for Payer: UMR Bronson Commercial |
$130.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.00
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$158.76
|
|
|
Service Code
|
NDC 1000673038
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.85 |
| Max. Negotiated Rate |
$142.88 |
| Rate for Payer: Aetna American Axle |
$103.19
|
| Rate for Payer: Aetna Commercial |
$134.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.19
|
| Rate for Payer: Cash Price |
$127.01
|
| Rate for Payer: Cofinity Commercial |
$111.13
|
| Rate for Payer: Cofinity Commercial |
$136.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.01
|
| Rate for Payer: Healthscope Commercial |
$142.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$134.95
|
| Rate for Payer: PHP Commercial |
$134.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.13
|
| Rate for Payer: Priority Health SBD |
$100.02
|
| Rate for Payer: UMR Bronson Commercial |
$69.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.07
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$145.20
|
|
|
Service Code
|
NDC 6498033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.89 |
| Max. Negotiated Rate |
$130.68 |
| Rate for Payer: Aetna American Axle |
$94.38
|
| Rate for Payer: Aetna Commercial |
$123.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.38
|
| Rate for Payer: Cash Price |
$116.16
|
| Rate for Payer: Cofinity Commercial |
$101.64
|
| Rate for Payer: Cofinity Commercial |
$124.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.16
|
| Rate for Payer: Healthscope Commercial |
$130.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.42
|
| Rate for Payer: PHP Commercial |
$123.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.64
|
| Rate for Payer: Priority Health SBD |
$91.48
|
| Rate for Payer: UMR Bronson Commercial |
$63.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.90
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$158.40
|
|
|
Service Code
|
NDC 5789663412
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.70 |
| Max. Negotiated Rate |
$142.56 |
| Rate for Payer: Aetna American Axle |
$102.96
|
| Rate for Payer: Aetna Commercial |
$134.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.96
|
| Rate for Payer: Cash Price |
$126.72
|
| Rate for Payer: Cofinity Commercial |
$136.22
|
| Rate for Payer: Cofinity Commercial |
$110.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.72
|
| Rate for Payer: Healthscope Commercial |
$142.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$110.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$118.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$134.64
|
| Rate for Payer: PHP Commercial |
$134.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.88
|
| Rate for Payer: Priority Health SBD |
$99.79
|
| Rate for Payer: UMR Bronson Commercial |
$69.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$118.80
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$206.40
|
|
|
Service Code
|
NDC 6498033912
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.82 |
| Max. Negotiated Rate |
$185.76 |
| Rate for Payer: Aetna American Axle |
$134.16
|
| Rate for Payer: Aetna Commercial |
$175.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.16
|
| Rate for Payer: Cash Price |
$165.12
|
| Rate for Payer: Cofinity Commercial |
$144.48
|
| Rate for Payer: Cofinity Commercial |
$177.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.12
|
| Rate for Payer: Healthscope Commercial |
$185.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.44
|
| Rate for Payer: PHP Commercial |
$175.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.48
|
| Rate for Payer: Priority Health SBD |
$130.03
|
| Rate for Payer: UMR Bronson Commercial |
$90.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.80
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 6498033990
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna American Axle |
$0.95
|
| Rate for Payer: Aetna Commercial |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.95
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cofinity Commercial |
$1.02
|
| Rate for Payer: Cofinity Commercial |
$1.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.17
|
| Rate for Payer: Healthscope Commercial |
$1.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.24
|
| Rate for Payer: PHP Commercial |
$1.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: Priority Health SBD |
$0.92
|
| Rate for Payer: UMR Bronson Commercial |
$0.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.10
|
|
