|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$470.20
|
|
|
Service Code
|
NDC 55111-763-03
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.89 |
| Max. Negotiated Rate |
$423.18 |
| Rate for Payer: Aetna American Axle |
$305.63
|
| Rate for Payer: Aetna Commercial |
$399.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.63
|
| Rate for Payer: Cash Price |
$376.16
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Cofinity Commercial |
$404.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.16
|
| Rate for Payer: Healthscope Commercial |
$423.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$399.67
|
| Rate for Payer: PHP Commercial |
$399.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.14
|
| Rate for Payer: Priority Health SBD |
$296.23
|
| Rate for Payer: UMR Bronson Commercial |
$206.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.65
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$88.35
|
|
|
Service Code
|
NDC 13668-080-30
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.87 |
| Max. Negotiated Rate |
$79.52 |
| Rate for Payer: Aetna American Axle |
$57.43
|
| Rate for Payer: Aetna Commercial |
$75.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.43
|
| Rate for Payer: Cash Price |
$70.68
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Cofinity Commercial |
$75.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.68
|
| Rate for Payer: Healthscope Commercial |
$79.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.10
|
| Rate for Payer: PHP Commercial |
$75.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.84
|
| Rate for Payer: Priority Health SBD |
$55.66
|
| Rate for Payer: UMR Bronson Commercial |
$38.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.26
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$112.61
|
|
|
Service Code
|
NDC 0054-0289-13
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.55 |
| Max. Negotiated Rate |
$101.35 |
| Rate for Payer: Aetna American Axle |
$73.20
|
| Rate for Payer: Aetna Commercial |
$95.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.20
|
| Rate for Payer: Cash Price |
$90.09
|
| Rate for Payer: Cofinity Commercial |
$78.83
|
| Rate for Payer: Cofinity Commercial |
$96.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.09
|
| Rate for Payer: Healthscope Commercial |
$101.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$95.72
|
| Rate for Payer: PHP Commercial |
$95.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.83
|
| Rate for Payer: Priority Health SBD |
$70.94
|
| Rate for Payer: UMR Bronson Commercial |
$49.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.46
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$101.38
|
|
|
Service Code
|
NDC 0781-5555-31
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.61 |
| Max. Negotiated Rate |
$91.24 |
| Rate for Payer: Aetna American Axle |
$65.90
|
| Rate for Payer: Aetna Commercial |
$86.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.90
|
| Rate for Payer: Cash Price |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$70.97
|
| Rate for Payer: Cofinity Commercial |
$87.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.10
|
| Rate for Payer: Healthscope Commercial |
$91.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.17
|
| Rate for Payer: PHP Commercial |
$86.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.97
|
| Rate for Payer: Priority Health SBD |
$63.87
|
| Rate for Payer: UMR Bronson Commercial |
$44.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.04
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 33342-111-07
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
MORPHINE 0.1 MG/ML INJECTION (NICU)
|
Facility
|
IP
|
$14.90
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
500539
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$13.41 |
| Rate for Payer: Aetna American Axle |
$9.68
|
| Rate for Payer: Aetna Commercial |
$12.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.68
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$12.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.92
|
| Rate for Payer: Healthscope Commercial |
$13.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.66
|
| Rate for Payer: PHP Commercial |
$12.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| Rate for Payer: Priority Health SBD |
$9.39
|
| Rate for Payer: UMR Bronson Commercial |
$6.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.18
|
|
|
MORPHINE 0.2 MG/ML 1 ML ORAL SOLUTION
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 9900-0004-28
|
| Hospital Charge Code |
165001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna American Axle |
$0.36
|
| Rate for Payer: Aetna Commercial |
$0.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.36
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cofinity Commercial |
$0.39
|
| Rate for Payer: Cofinity Commercial |
$0.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.44
|
| Rate for Payer: Healthscope Commercial |
$0.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.47
|
| Rate for Payer: PHP Commercial |
$0.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.39
|
| Rate for Payer: Priority Health SBD |
$0.35
|
| Rate for Payer: UMR Bronson Commercial |
$0.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.41
|
|
|
MORPHINE 100MG/100ML AVERAGE PCA IV SOLUTION
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
190319
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.64 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna American Axle |
$52.65
|
| Rate for Payer: Aetna Commercial |
$68.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.65
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cofinity Commercial |
$56.70
|
| Rate for Payer: Cofinity Commercial |
$69.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.80
|
| Rate for Payer: Healthscope Commercial |
$72.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.85
|
| Rate for Payer: PHP Commercial |
$68.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.70
|
| Rate for Payer: Priority Health SBD |
$51.03
|
| Rate for Payer: UMR Bronson Commercial |
$35.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.75
|
|
|
MORPHINE 100MG/100ML PCA IV SOLUTION
|
Facility
|
IP
|
$227.49
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
150918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$204.74 |
| Rate for Payer: Aetna American Axle |
$147.87
|
| Rate for Payer: Aetna American Axle |
$52.65
|
| Rate for Payer: Aetna Commercial |
$68.85
|
| Rate for Payer: Aetna Commercial |
$193.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.65
|
| Rate for Payer: Cash Price |
$181.99
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cofinity Commercial |
$69.66
|
| Rate for Payer: Cofinity Commercial |
$195.64
|
| Rate for Payer: Cofinity Commercial |
$159.24
|
| Rate for Payer: Cofinity Commercial |
$56.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.99
|
| Rate for Payer: Healthscope Commercial |
$72.90
|
| Rate for Payer: Healthscope Commercial |
$204.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.37
|
| Rate for Payer: PHP Commercial |
$193.37
|
| Rate for Payer: PHP Commercial |
$68.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.70
|
| Rate for Payer: Priority Health SBD |
$51.03
|
| Rate for Payer: Priority Health SBD |
$143.32
|
| Rate for Payer: UMR Bronson Commercial |
$100.10
|
| Rate for Payer: UMR Bronson Commercial |
$35.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.62
|
|
|
MORPHINE 100MG/100ML TOLERANT PCA IV SOLUTION
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
190325
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.64 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna American Axle |
$52.65
|
| Rate for Payer: Aetna Commercial |
$68.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.65
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cofinity Commercial |
$56.70
|
| Rate for Payer: Cofinity Commercial |
$69.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.80
|
| Rate for Payer: Healthscope Commercial |
$72.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.85
|
| Rate for Payer: PHP Commercial |
$68.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.70
|
| Rate for Payer: Priority Health SBD |
$51.03
|
| Rate for Payer: UMR Bronson Commercial |
$35.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.75
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
NDC 62559-170-01
|
| Hospital Charge Code |
5176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna American Axle |
$95.55
|
| Rate for Payer: Aetna Commercial |
$124.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.55
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cofinity Commercial |
$102.90
|
| Rate for Payer: Cofinity Commercial |
$126.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.60
|
| Rate for Payer: Healthscope Commercial |
$132.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.95
|
| Rate for Payer: PHP Commercial |
$124.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.90
|
| Rate for Payer: Priority Health SBD |
$92.61
|
| Rate for Payer: UMR Bronson Commercial |
$64.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.25
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$7.44
|
|
|
Service Code
|
NDC 0990-0001-03
|
| Hospital Charge Code |
5176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna American Axle |
$4.84
|
| Rate for Payer: Aetna Commercial |
$6.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.84
|
| Rate for Payer: Cash Price |
$5.95
|
| Rate for Payer: Cofinity Commercial |
$5.21
|
| Rate for Payer: Cofinity Commercial |
$6.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.95
|
| Rate for Payer: Healthscope Commercial |
$6.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.32
|
| Rate for Payer: PHP Commercial |
$6.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.21
|
| Rate for Payer: Priority Health SBD |
$4.69
|
| Rate for Payer: UMR Bronson Commercial |
$3.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.58
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 9900-0000-30
|
| Hospital Charge Code |
5176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna American Axle |
$0.49
|
| Rate for Payer: Aetna Commercial |
$0.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.49
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cofinity Commercial |
$0.53
|
| Rate for Payer: Cofinity Commercial |
$0.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.60
|
| Rate for Payer: Healthscope Commercial |
$0.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.64
|
| Rate for Payer: PHP Commercial |
$0.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.53
|
| Rate for Payer: Priority Health SBD |
$0.47
|
| Rate for Payer: UMR Bronson Commercial |
$0.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.56
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$148.75
|
|
|
Service Code
|
NDC 0054-0237-49
|
| Hospital Charge Code |
5176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna American Axle |
$96.69
|
| Rate for Payer: Aetna Commercial |
$126.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.69
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cofinity Commercial |
$104.12
|
| Rate for Payer: Cofinity Commercial |
$127.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.00
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.44
|
| Rate for Payer: PHP Commercial |
$126.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.12
|
| Rate for Payer: Priority Health SBD |
$93.71
|
| Rate for Payer: UMR Bronson Commercial |
$65.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.56
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 0990-0001-02
|
| Hospital Charge Code |
5176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
| Rate for Payer: Priority Health SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
MORPHINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$33.73
|
|
|
Service Code
|
HCPCS J2272
|
| Hospital Charge Code |
5168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$30.36 |
| Rate for Payer: Aetna American Axle |
$21.92
|
| Rate for Payer: Aetna Commercial |
$28.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.92
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cofinity Commercial |
$29.01
|
| Rate for Payer: Cofinity Commercial |
$23.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.98
|
| Rate for Payer: Healthscope Commercial |
$30.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.67
|
| Rate for Payer: PHP Commercial |
$28.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.61
|
| Rate for Payer: Priority Health SBD |
$21.25
|
| Rate for Payer: UMR Bronson Commercial |
$14.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.30
|
|
|
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$17.19
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
27390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$15.47 |
| Rate for Payer: Aetna American Axle |
$11.17
|
| Rate for Payer: Aetna Commercial |
$14.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.17
|
| Rate for Payer: Cash Price |
$13.75
|
| Rate for Payer: Cofinity Commercial |
$12.03
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.75
|
| Rate for Payer: Healthscope Commercial |
$15.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.61
|
| Rate for Payer: PHP Commercial |
$14.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.03
|
| Rate for Payer: Priority Health SBD |
$10.83
|
| Rate for Payer: UMR Bronson Commercial |
$7.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.89
|
|
|
MORPHINE 10 MG/ML INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$26.50
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
172788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$23.85 |
| Rate for Payer: Aetna American Axle |
$17.22
|
| Rate for Payer: Aetna Commercial |
$22.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.22
|
| Rate for Payer: Cash Price |
$21.20
|
| Rate for Payer: Cofinity Commercial |
$18.55
|
| Rate for Payer: Cofinity Commercial |
$22.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.20
|
| Rate for Payer: Healthscope Commercial |
$23.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.52
|
| Rate for Payer: PHP Commercial |
$22.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.55
|
| Rate for Payer: Priority Health SBD |
$16.70
|
| Rate for Payer: UMR Bronson Commercial |
$11.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.88
|
|
|
MORPHINE 10 MG/ML SYRINGE (CODE)
|
Facility
|
IP
|
$16.26
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
163726
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$14.63 |
| Rate for Payer: Aetna American Axle |
$10.57
|
| Rate for Payer: Aetna Commercial |
$13.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.57
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Cofinity Commercial |
$13.98
|
| Rate for Payer: Cofinity Commercial |
$11.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.01
|
| Rate for Payer: Healthscope Commercial |
$14.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.82
|
| Rate for Payer: PHP Commercial |
$13.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.38
|
| Rate for Payer: Priority Health SBD |
$10.24
|
| Rate for Payer: UMR Bronson Commercial |
$7.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.20
|
|
|
MORPHINE 10 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$217.58
|
|
|
Service Code
|
NDC 0574-7112-12
|
| Hospital Charge Code |
5180
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.74 |
| Max. Negotiated Rate |
$195.82 |
| Rate for Payer: Aetna American Axle |
$141.43
|
| Rate for Payer: Aetna Commercial |
$184.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.43
|
| Rate for Payer: Cash Price |
$174.06
|
| Rate for Payer: Cofinity Commercial |
$152.31
|
| Rate for Payer: Cofinity Commercial |
$187.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.06
|
| Rate for Payer: Healthscope Commercial |
$195.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.94
|
| Rate for Payer: PHP Commercial |
$184.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.31
|
| Rate for Payer: Priority Health SBD |
$137.08
|
| Rate for Payer: UMR Bronson Commercial |
$95.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.18
|
|
|
MORPHINE 15 MG IMMEDIATE RELEASE TABLET
|
Facility
|
IP
|
$123.38
|
|
|
Service Code
|
NDC 0054-0235-24
|
| Hospital Charge Code |
5178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.29 |
| Max. Negotiated Rate |
$111.04 |
| Rate for Payer: Aetna American Axle |
$80.20
|
| Rate for Payer: Aetna Commercial |
$104.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.20
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cofinity Commercial |
$106.11
|
| Rate for Payer: Cofinity Commercial |
$86.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.70
|
| Rate for Payer: Healthscope Commercial |
$111.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.87
|
| Rate for Payer: PHP Commercial |
$104.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.37
|
| Rate for Payer: Priority Health SBD |
$77.73
|
| Rate for Payer: UMR Bronson Commercial |
$54.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.54
|
|
|
MORPHINE 15 MG IMMEDIATE RELEASE TABLET
|
Facility
|
IP
|
$703.50
|
|
|
Service Code
|
NDC 51862-615-01
|
| Hospital Charge Code |
5178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.54 |
| Max. Negotiated Rate |
$633.15 |
| Rate for Payer: Aetna American Axle |
$457.28
|
| Rate for Payer: Aetna Commercial |
$597.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$457.28
|
| Rate for Payer: Cash Price |
$562.80
|
| Rate for Payer: Cofinity Commercial |
$492.45
|
| Rate for Payer: Cofinity Commercial |
$605.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$562.80
|
| Rate for Payer: Healthscope Commercial |
$633.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$492.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$527.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$597.98
|
| Rate for Payer: PHP Commercial |
$597.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$492.45
|
| Rate for Payer: Priority Health SBD |
$443.20
|
| Rate for Payer: UMR Bronson Commercial |
$309.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$527.62
|
|
|
MORPHINE 15 MG IMMEDIATE RELEASE TABLET
|
Facility
|
IP
|
$444.50
|
|
|
Service Code
|
NDC 0054-0235-25
|
| Hospital Charge Code |
5178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.58 |
| Max. Negotiated Rate |
$400.05 |
| Rate for Payer: Aetna American Axle |
$288.92
|
| Rate for Payer: Aetna Commercial |
$377.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.92
|
| Rate for Payer: Cash Price |
$355.60
|
| Rate for Payer: Cofinity Commercial |
$311.15
|
| Rate for Payer: Cofinity Commercial |
$382.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.60
|
| Rate for Payer: Healthscope Commercial |
$400.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$311.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$377.82
|
| Rate for Payer: PHP Commercial |
$377.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$311.15
|
| Rate for Payer: Priority Health SBD |
$280.04
|
| Rate for Payer: UMR Bronson Commercial |
$195.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.38
|
|
|
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS
|
Facility
|
IP
|
$33.50
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
30604
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$30.15 |
| Rate for Payer: Aetna American Axle |
$21.78
|
| Rate for Payer: Aetna Commercial |
$28.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.78
|
| Rate for Payer: Cash Price |
$26.80
|
| Rate for Payer: Cofinity Commercial |
$23.45
|
| Rate for Payer: Cofinity Commercial |
$28.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.80
|
| Rate for Payer: Healthscope Commercial |
$30.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.48
|
| Rate for Payer: PHP Commercial |
$28.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.45
|
| Rate for Payer: Priority Health SBD |
$21.10
|
| Rate for Payer: UMR Bronson Commercial |
$14.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.12
|
|
|
MORPHINE 1 MG/ML IN 0.9 % SODIUM CHLORIDE PEDIATRIC INFUSION
|
Facility
|
IP
|
$33.50
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
180632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$30.15 |
| Rate for Payer: Aetna American Axle |
$21.78
|
| Rate for Payer: Aetna Commercial |
$28.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.78
|
| Rate for Payer: Cash Price |
$26.80
|
| Rate for Payer: Cofinity Commercial |
$23.45
|
| Rate for Payer: Cofinity Commercial |
$28.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.80
|
| Rate for Payer: Healthscope Commercial |
$30.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.48
|
| Rate for Payer: PHP Commercial |
$28.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.45
|
| Rate for Payer: Priority Health SBD |
$21.10
|
| Rate for Payer: UMR Bronson Commercial |
$14.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.12
|
|
