|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$352.50
|
|
|
Service Code
|
NDC 00904661761
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.10 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna American Axle |
$229.12
|
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.12
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$246.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$246.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health SBD |
$222.08
|
| Rate for Payer: UMR Bronson Commercial |
$155.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$281.20
|
|
|
Service Code
|
NDC 68084025401
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.04 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna American Axle |
$182.78
|
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: Aetna Medicare |
$140.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.78
|
| Rate for Payer: BCBS Complete |
$112.48
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$196.84
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health SBD |
$177.16
|
| Rate for Payer: UMR Bronson Commercial |
$104.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$352.50
|
|
|
Service Code
|
NDC 00904661761
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna American Axle |
$229.12
|
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: Aetna Medicare |
$176.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.12
|
| Rate for Payer: BCBS Complete |
$141.00
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$246.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$246.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health SBD |
$222.08
|
| Rate for Payer: UMR Bronson Commercial |
$130.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$281.20
|
|
|
Service Code
|
NDC 68084025401
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.73 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna American Axle |
$182.78
|
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.78
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$196.84
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health SBD |
$177.16
|
| Rate for Payer: UMR Bronson Commercial |
$123.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 68084025411
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
HYMENOTOMY, SIMPLE INCISION
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 56442
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$45.67 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,660.74
|
| Rate for Payer: BCN Commercial |
$1,660.74
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.24
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$45.67
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,669.77
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
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
|
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/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
|
OP
|
$88.92
|
|
|
Service Code
|
NDC 39328004715
|
| Hospital Charge Code |
3782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$80.03 |
| Rate for Payer: Aetna American Axle |
$57.80
|
| Rate for Payer: Aetna Commercial |
$75.58
|
| Rate for Payer: Aetna Medicare |
$44.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.80
|
| Rate for Payer: BCBS Complete |
$35.57
|
| 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 |
$32.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.69
|
|
|
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
|
$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
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 43199001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.28 |
| 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 |
$336.28
|
| 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
|
$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
|
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
|
|
|
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 |
$336.28 |
| 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 |
$336.28
|
| 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
|
$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
|
|
|
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 |
$11.44
|
| 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
|
IP
|
$88.05
|
|
|
Service Code
|
NDC 17478006412
|
| Hospital Charge Code |
38092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$79.24 |
| 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 |
$61.64
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Healthscope Commercial |
$79.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.64
|
| 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
|
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
|
|
|
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 |
$79.24 |
| 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 |
$61.64
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Healthscope Commercial |
$79.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.64
|
| 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
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$146.63 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,685.09
|
| Rate for Payer: BCN Commercial |
$1,685.09
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$161.29
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$146.63
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,669.77
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)
|
Facility
|
OP
|
$15,201.47
|
|
|
Service Code
|
CPT 58560
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$304.07 |
| Max. Negotiated Rate |
$15,201.47 |
| Rate for Payer: Aetna Medicare |
$5,030.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,045.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,045.79
|
| Rate for Payer: BCBS Complete |
$2,722.06
|
| Rate for Payer: BCBS MAPPO |
$4,836.63
|
| Rate for Payer: BCBS Trust/PPO |
$3,264.60
|
| Rate for Payer: BCN Commercial |
$3,264.60
|
| Rate for Payer: BCN Medicare Advantage |
$4,836.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,836.63
|
| Rate for Payer: Mclaren Medicaid |
$2,592.43
|
| Rate for Payer: Mclaren Medicare |
$4,836.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,078.46
|
| Rate for Payer: Meridian Medicaid |
$2,722.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,562.12
|
| Rate for Payer: Nomi Health Commercial |
$10,156.92
|
| Rate for Payer: PACE Medicare |
$4,594.80
|
| Rate for Payer: PACE SWMI |
$4,836.63
|
| Rate for Payer: PHP Medicare Advantage |
$4,836.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,592.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,201.47
|
| Rate for Payer: Priority Health Medicare |
$4,836.63
|
| Rate for Payer: Priority Health Narrow Network |
$12,161.18
|
| Rate for Payer: Railroad Medicare Medicare |
$4,836.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$334.48
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,836.63
|
| Rate for Payer: UHC Exchange |
$304.07
|
| Rate for Payer: UHC Medicare Advantage |
$4,836.63
|
| Rate for Payer: UHCCP Medicaid |
$2,592.43
|
| Rate for Payer: VA VA |
$4,836.63
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$15,201.47
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$238.71 |
| Max. Negotiated Rate |
$15,201.47 |
| Rate for Payer: Aetna Medicare |
$5,030.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,045.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,045.79
|
| Rate for Payer: BCBS Complete |
$2,722.06
|
| Rate for Payer: BCBS MAPPO |
$4,836.63
|
| Rate for Payer: BCBS Trust/PPO |
$3,559.58
|
| Rate for Payer: BCN Commercial |
$3,559.58
|
| Rate for Payer: BCN Medicare Advantage |
$4,836.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,836.63
|
| Rate for Payer: Mclaren Medicaid |
$2,592.43
|
| Rate for Payer: Mclaren Medicare |
$4,836.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,078.46
|
| Rate for Payer: Meridian Medicaid |
$2,722.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,562.12
|
| Rate for Payer: Nomi Health Commercial |
$10,156.92
|
| Rate for Payer: PACE Medicare |
$4,594.80
|
| Rate for Payer: PACE SWMI |
$4,836.63
|
| Rate for Payer: PHP Medicare Advantage |
$4,836.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,592.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,201.47
|
| Rate for Payer: Priority Health Medicare |
$4,836.63
|
| Rate for Payer: Priority Health Narrow Network |
$12,161.18
|
| Rate for Payer: Railroad Medicare Medicare |
$4,836.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.58
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,836.63
|
| Rate for Payer: UHC Exchange |
$238.71
|
| Rate for Payer: UHC Medicare Advantage |
$4,836.63
|
| Rate for Payer: UHCCP Medicaid |
$2,592.43
|
| Rate for Payer: VA VA |
$4,836.63
|
|
