|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS
|
Facility
|
IP
|
$88.92
|
|
|
Service Code
|
NDC 39328004715
|
| Hospital Charge Code |
3782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.12 |
| Max. Negotiated Rate |
$80.03 |
| Rate for Payer: Aetna American Axle |
$57.80
|
| Rate for Payer: Aetna Commercial |
$75.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.80
|
| Rate for Payer: Cash Price |
$71.14
|
| Rate for Payer: Cofinity Commercial |
$62.24
|
| Rate for Payer: Cofinity Commercial |
$76.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.14
|
| Rate for Payer: Healthscope Commercial |
$80.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.58
|
| Rate for Payer: PHP Commercial |
$75.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.80
|
| Rate for Payer: Priority Health SBD |
$56.02
|
| Rate for Payer: UMR Bronson Commercial |
$39.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.69
|
|
|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
NDC 54838050615
|
| Hospital Charge Code |
3782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.94 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna American Axle |
$40.30
|
| Rate for Payer: Aetna Commercial |
$52.70
|
| Rate for Payer: Aetna Medicare |
$31.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.30
|
| Rate for Payer: BCBS Complete |
$24.80
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Cofinity Commercial |
$43.40
|
| Rate for Payer: Cofinity Commercial |
$53.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.60
|
| Rate for Payer: Healthscope Commercial |
$55.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.70
|
| Rate for Payer: PHP Commercial |
$52.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.30
|
| Rate for Payer: Priority Health SBD |
$39.06
|
| Rate for Payer: UMR Bronson Commercial |
$22.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.50
|
|
|
HYOSCYAMINE 0.125 MG/ML ORAL DROPS
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
NDC 54838050615
|
| Hospital Charge Code |
3782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.28 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna American Axle |
$40.30
|
| Rate for Payer: Aetna Commercial |
$52.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.30
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Cofinity Commercial |
$43.40
|
| Rate for Payer: Cofinity Commercial |
$53.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.60
|
| Rate for Payer: Healthscope Commercial |
$55.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.70
|
| Rate for Payer: PHP Commercial |
$52.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.30
|
| Rate for Payer: Priority Health SBD |
$39.06
|
| Rate for Payer: UMR Bronson Commercial |
$27.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.50
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$406.60
|
|
|
Service Code
|
NDC 42192033901
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.90 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna American Axle |
$264.29
|
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.29
|
| Rate for Payer: Priority Health SBD |
$256.16
|
| Rate for Payer: UMR Bronson Commercial |
$178.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.95
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 43199001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.29 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Commercial |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.87
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UMR Bronson Commercial |
$164.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$406.60
|
|
|
Service Code
|
NDC 42192033901
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.44 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna American Axle |
$264.29
|
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna Medicare |
$203.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: BCBS Complete |
$162.64
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.29
|
| Rate for Payer: Priority Health SBD |
$256.16
|
| Rate for Payer: UMR Bronson Commercial |
$150.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.95
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$303.36
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.24 |
| Max. Negotiated Rate |
$273.02 |
| Rate for Payer: Aetna American Axle |
$197.18
|
| Rate for Payer: Aetna Commercial |
$257.86
|
| Rate for Payer: Aetna Medicare |
$151.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.18
|
| Rate for Payer: BCBS Complete |
$121.34
|
| Rate for Payer: Cash Price |
$242.69
|
| Rate for Payer: Cofinity Commercial |
$212.35
|
| Rate for Payer: Cofinity Commercial |
$260.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$212.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.69
|
| Rate for Payer: Healthscope Commercial |
$273.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$212.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$227.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.86
|
| Rate for Payer: PHP Commercial |
$257.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.18
|
| Rate for Payer: Priority Health SBD |
$191.12
|
| Rate for Payer: UMR Bronson Commercial |
$112.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$227.52
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$357.20
|
|
|
Service Code
|
NDC 62559042401
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.17 |
| Max. Negotiated Rate |
$321.48 |
| Rate for Payer: Aetna American Axle |
$232.18
|
| Rate for Payer: Aetna Commercial |
$303.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$232.18
|
| Rate for Payer: Cash Price |
$285.76
|
| Rate for Payer: Cofinity Commercial |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$307.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$250.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.76
|
| Rate for Payer: Healthscope Commercial |
$321.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$250.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$303.62
|
| Rate for Payer: PHP Commercial |
$303.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.18
|
| Rate for Payer: Priority Health SBD |
$225.04
|
| Rate for Payer: UMR Bronson Commercial |
$157.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.90
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$357.20
|
|
|
Service Code
|
NDC 62559042401
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.16 |
| Max. Negotiated Rate |
$321.48 |
| Rate for Payer: Aetna American Axle |
$232.18
|
| Rate for Payer: Aetna Commercial |
$303.62
|
| Rate for Payer: Aetna Medicare |
$178.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$232.18
|
| Rate for Payer: BCBS Complete |
$142.88
|
| Rate for Payer: Cash Price |
$285.76
|
| Rate for Payer: Cofinity Commercial |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$307.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$250.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.76
|
| Rate for Payer: Healthscope Commercial |
$321.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$250.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$303.62
|
| Rate for Payer: PHP Commercial |
$303.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.18
|
| Rate for Payer: Priority Health SBD |
$225.04
|
| Rate for Payer: UMR Bronson Commercial |
$132.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.90
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$373.65
|
|
|
Service Code
|
NDC 43199001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$336.29 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna Medicare |
$186.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: BCBS Complete |
$149.46
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Commercial |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.87
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UMR Bronson Commercial |
$138.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$303.36
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.48 |
| Max. Negotiated Rate |
$273.02 |
| Rate for Payer: Aetna American Axle |
$197.18
|
| Rate for Payer: Aetna Commercial |
$257.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.18
|
| Rate for Payer: Cash Price |
$242.69
|
| Rate for Payer: Cofinity Commercial |
$212.35
|
| Rate for Payer: Cofinity Commercial |
$260.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$212.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.69
|
| Rate for Payer: Healthscope Commercial |
$273.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$212.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$227.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.86
|
| Rate for Payer: PHP Commercial |
$257.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.18
|
| Rate for Payer: Priority Health SBD |
$191.12
|
| Rate for Payer: UMR Bronson Commercial |
$133.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$227.52
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS
|
Facility
|
IP
|
$88.05
|
|
|
Service Code
|
NDC 17478006412
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$79.25 |
| Rate for Payer: Aetna American Axle |
$57.23
|
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cofinity Commercial |
$61.63
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Healthscope Commercial |
$79.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.84
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.23
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: UMR Bronson Commercial |
$38.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.04
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS
|
Facility
|
OP
|
$22.89
|
|
|
Service Code
|
NDC 59390018213
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna Medicare |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.88
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$8.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS
|
Facility
|
OP
|
$88.05
|
|
|
Service Code
|
NDC 17478006412
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.58 |
| Max. Negotiated Rate |
$79.25 |
| Rate for Payer: Aetna American Axle |
$57.23
|
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna Medicare |
$44.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: BCBS Complete |
$35.22
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cofinity Commercial |
$61.63
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Healthscope Commercial |
$79.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.84
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.23
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: UMR Bronson Commercial |
$32.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.04
|
|
|
HYPROMELLOSE 2.5 % EYE DROPS
|
Facility
|
IP
|
$22.89
|
|
|
Service Code
|
NDC 59390018213
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.88
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$10.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 58560
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 58559
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 58562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$429.20
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
70544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.85 |
| Max. Negotiated Rate |
$386.28 |
| Rate for Payer: Aetna American Axle |
$278.98
|
| Rate for Payer: Aetna Commercial |
$364.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.98
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cofinity Commercial |
$300.44
|
| Rate for Payer: Cofinity Commercial |
$369.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.36
|
| Rate for Payer: Healthscope Commercial |
$386.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$300.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.82
|
| Rate for Payer: PHP Commercial |
$364.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.98
|
| Rate for Payer: Priority Health SBD |
$270.40
|
| Rate for Payer: UMR Bronson Commercial |
$188.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.90
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$256.21
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
70544
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.80 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna American Axle |
$166.54
|
| Rate for Payer: Aetna American Axle |
$278.98
|
| Rate for Payer: Aetna Commercial |
$217.78
|
| Rate for Payer: Aetna Commercial |
$364.82
|
| Rate for Payer: Aetna Medicare |
$128.10
|
| Rate for Payer: Aetna Medicare |
$214.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.98
|
| Rate for Payer: BCBS Complete |
$102.48
|
| Rate for Payer: BCBS Complete |
$171.68
|
| Rate for Payer: Cash Price |
$204.97
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cofinity Commercial |
$220.34
|
| Rate for Payer: Cofinity Commercial |
$179.35
|
| Rate for Payer: Cofinity Commercial |
$369.11
|
| Rate for Payer: Cofinity Commercial |
$300.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.97
|
| Rate for Payer: Healthscope Commercial |
$230.59
|
| Rate for Payer: Healthscope Commercial |
$386.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$300.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.78
|
| Rate for Payer: PHP Commercial |
$364.82
|
| Rate for Payer: PHP Commercial |
$217.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.98
|
| Rate for Payer: Priority Health SBD |
$270.40
|
| Rate for Payer: Priority Health SBD |
$161.41
|
| Rate for Payer: UMR Bronson Commercial |
$94.80
|
| Rate for Payer: UMR Bronson Commercial |
$158.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.90
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.81
|
|
|
Service Code
|
NDC 68094050359
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$5.23 |
| Rate for Payer: Aetna American Axle |
$3.78
|
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.78
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cofinity Commercial |
$4.07
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.65
|
| Rate for Payer: Healthscope Commercial |
$5.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.94
|
| Rate for Payer: PHP Commercial |
$4.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.78
|
| Rate for Payer: Priority Health SBD |
$3.66
|
| Rate for Payer: UMR Bronson Commercial |
$2.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.36
|
|
