|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$452.20
|
|
|
Service Code
|
NDC 68084-376-01
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.97 |
| Max. Negotiated Rate |
$406.98 |
| Rate for Payer: Aetna American Axle |
$293.93
|
| Rate for Payer: Aetna Commercial |
$384.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.93
|
| Rate for Payer: Cash Price |
$361.76
|
| Rate for Payer: Cofinity Commercial |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.76
|
| Rate for Payer: Healthscope Commercial |
$406.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$316.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$384.37
|
| Rate for Payer: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.54
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| Rate for Payer: UMR Bronson Commercial |
$198.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.15
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$253.44
|
|
|
Service Code
|
NDC 51079-905-20
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.51 |
| Max. Negotiated Rate |
$228.10 |
| Rate for Payer: Aetna American Axle |
$164.74
|
| Rate for Payer: Aetna Commercial |
$215.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.74
|
| Rate for Payer: Cash Price |
$202.75
|
| Rate for Payer: Cofinity Commercial |
$177.41
|
| Rate for Payer: Cofinity Commercial |
$217.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.75
|
| Rate for Payer: Healthscope Commercial |
$228.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$215.42
|
| Rate for Payer: PHP Commercial |
$215.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.41
|
| Rate for Payer: Priority Health SBD |
$159.67
|
| Rate for Payer: UMR Bronson Commercial |
$111.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.08
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE
|
Facility
|
IP
|
$616.80
|
|
|
Service Code
|
NDC 0071-3740-66
|
| Hospital Charge Code |
11019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.39 |
| Max. Negotiated Rate |
$555.12 |
| Rate for Payer: Aetna American Axle |
$400.92
|
| Rate for Payer: Aetna Commercial |
$524.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$400.92
|
| Rate for Payer: Cash Price |
$493.44
|
| Rate for Payer: Cofinity Commercial |
$431.76
|
| Rate for Payer: Cofinity Commercial |
$530.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$493.44
|
| Rate for Payer: Healthscope Commercial |
$555.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$431.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$462.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$524.28
|
| Rate for Payer: PHP Commercial |
$524.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$431.76
|
| Rate for Payer: Priority Health SBD |
$388.58
|
| Rate for Payer: UMR Bronson Commercial |
$271.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$462.60
|
|
|
PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$475.88
|
|
|
Service Code
|
CPT 99195
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$62.11 |
| Max. Negotiated Rate |
$475.88 |
| Rate for Payer: Aetna Medicare |
$118.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$141.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$141.94
|
| Rate for Payer: BCBS Complete |
$65.22
|
| Rate for Payer: BCBS MAPPO |
$113.55
|
| Rate for Payer: BCBS Trust/PPO |
$475.88
|
| Rate for Payer: BCN Medicare Advantage |
$113.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$113.55
|
| Rate for Payer: Mclaren Medicaid |
$62.11
|
| Rate for Payer: Mclaren Medicare |
$113.55
|
| Rate for Payer: Meridian Medicaid |
$65.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$119.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$130.58
|
| Rate for Payer: PACE Medicare |
$107.87
|
| Rate for Payer: PACE SWMI |
$113.55
|
| Rate for Payer: PHP Medicare Advantage |
$113.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$62.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$357.43
|
| Rate for Payer: Priority Health Medicare |
$113.55
|
| Rate for Payer: Priority Health Narrow Network |
$285.94
|
| Rate for Payer: Railroad Medicare Medicare |
$113.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$103.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$113.55
|
| Rate for Payer: UHC Exchange |
$93.98
|
| Rate for Payer: UHC Medicare Advantage |
$116.96
|
| Rate for Payer: VA VA |
$113.55
|
|
|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L
|
Facility
|
IP
|
$440.80
|
|
|
Service Code
|
NDC 24571-117-06
|
| Hospital Charge Code |
177187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.95 |
| Max. Negotiated Rate |
$396.72 |
| Rate for Payer: Aetna American Axle |
$286.52
|
| Rate for Payer: Aetna Commercial |
$374.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.52
|
| Rate for Payer: Cash Price |
$352.64
|
| Rate for Payer: Cofinity Commercial |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$379.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.64
|
| Rate for Payer: Healthscope Commercial |
$396.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$374.68
|
| Rate for Payer: PHP Commercial |
$374.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.56
|
| Rate for Payer: Priority Health SBD |
$277.70
|
| Rate for Payer: UMR Bronson Commercial |
$193.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.60
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$258.47
|
|
|
Service Code
|
NDC 17478-510-02
|
| Hospital Charge Code |
6270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.73 |
| Max. Negotiated Rate |
$232.62 |
| Rate for Payer: Aetna American Axle |
$168.01
|
| Rate for Payer: Aetna Commercial |
$219.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.01
|
| Rate for Payer: Cash Price |
$206.78
|
| Rate for Payer: Cofinity Commercial |
$180.93
|
| Rate for Payer: Cofinity Commercial |
$222.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.78
|
| Rate for Payer: Healthscope Commercial |
$232.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$219.70
|
| Rate for Payer: PHP Commercial |
$219.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.93
|
| Rate for Payer: Priority Health SBD |
$162.84
|
| Rate for Payer: UMR Bronson Commercial |
$113.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.85
|
|
|
PHYTONADIONE ORAL SOLUTION 10 MG/ML
|
Facility
|
IP
|
$88.13
|
|
|
Service Code
|
NDC 0409-9158-01
|
| Hospital Charge Code |
150708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.78 |
| Max. Negotiated Rate |
$79.32 |
| Rate for Payer: Aetna American Axle |
$57.28
|
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.28
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cofinity Commercial |
$61.69
|
| Rate for Payer: Cofinity Commercial |
$75.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.50
|
| Rate for Payer: Healthscope Commercial |
$79.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.91
|
| Rate for Payer: PHP Commercial |
$74.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.69
|
| Rate for Payer: Priority Health SBD |
$55.52
|
| Rate for Payer: UMR Bronson Commercial |
$38.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.10
|
|
|
PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 510501050
|
| Hospital Charge Code |
196288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.88 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.14
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.14
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.53
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$117.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$105.99
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.64 |
| Max. Negotiated Rate |
$95.39 |
| Rate for Payer: Aetna American Axle |
$68.89
|
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.89
|
| Rate for Payer: Cash Price |
$84.79
|
| Rate for Payer: Cofinity Commercial |
$74.19
|
| Rate for Payer: Cofinity Commercial |
$91.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.79
|
| Rate for Payer: Healthscope Commercial |
$95.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.09
|
| Rate for Payer: PHP Commercial |
$90.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.19
|
| Rate for Payer: Priority Health SBD |
$66.77
|
| Rate for Payer: UMR Bronson Commercial |
$46.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.49
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$105.99
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$95.39 |
| Rate for Payer: Aetna American Axle |
$68.89
|
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.89
|
| Rate for Payer: BCBS Complete |
$42.40
|
| Rate for Payer: BCBS Trust/PPO |
$9.36
|
| Rate for Payer: Cash Price |
$84.79
|
| Rate for Payer: Cash Price |
$84.79
|
| Rate for Payer: Cofinity Commercial |
$74.19
|
| Rate for Payer: Cofinity Commercial |
$91.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.79
|
| Rate for Payer: Healthscope Commercial |
$95.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.09
|
| Rate for Payer: PHP Commercial |
$90.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.19
|
| Rate for Payer: Priority Health SBD |
$66.77
|
| Rate for Payer: UMR Bronson Commercial |
$39.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.49
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION
|
Facility
|
IP
|
$27.88
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
108266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.27 |
| Max. Negotiated Rate |
$25.09 |
| Rate for Payer: Aetna American Axle |
$18.12
|
| Rate for Payer: Aetna American Axle |
$13.46
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna Commercial |
$23.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.12
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$22.30
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$23.98
|
| Rate for Payer: Cofinity Commercial |
$19.52
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.30
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$25.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.60
|
| Rate for Payer: PHP Commercial |
$23.70
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.52
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$17.56
|
| Rate for Payer: UMR Bronson Commercial |
$9.11
|
| Rate for Payer: UMR Bronson Commercial |
$12.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.91
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
IP
|
$4,014.87
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,766.54 |
| Max. Negotiated Rate |
$3,613.38 |
| Rate for Payer: Aetna American Axle |
$2,609.67
|
| Rate for Payer: Aetna Commercial |
$3,412.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,609.67
|
| Rate for Payer: Cash Price |
$3,211.90
|
| Rate for Payer: Cofinity Commercial |
$2,810.41
|
| Rate for Payer: Cofinity Commercial |
$3,452.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,211.90
|
| Rate for Payer: Healthscope Commercial |
$3,613.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,810.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,011.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,412.64
|
| Rate for Payer: PHP Commercial |
$3,412.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,810.41
|
| Rate for Payer: Priority Health SBD |
$2,529.37
|
| Rate for Payer: UMR Bronson Commercial |
$1,766.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,011.15
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
IP
|
$134.35
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$120.92 |
| Rate for Payer: Aetna American Axle |
$87.33
|
| Rate for Payer: Aetna Commercial |
$114.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.33
|
| Rate for Payer: Cash Price |
$107.48
|
| Rate for Payer: Cofinity Commercial |
$115.54
|
| Rate for Payer: Cofinity Commercial |
$94.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.48
|
| Rate for Payer: Healthscope Commercial |
$120.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$114.20
|
| Rate for Payer: PHP Commercial |
$114.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.04
|
| Rate for Payer: Priority Health SBD |
$84.64
|
| Rate for Payer: UMR Bronson Commercial |
$59.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.76
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
IP
|
$304.61
|
|
|
Service Code
|
NDC 0998-0203-15
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.03 |
| Max. Negotiated Rate |
$274.15 |
| Rate for Payer: Aetna American Axle |
$198.00
|
| Rate for Payer: Aetna Commercial |
$258.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.00
|
| Rate for Payer: Cash Price |
$243.69
|
| Rate for Payer: Cofinity Commercial |
$213.23
|
| Rate for Payer: Cofinity Commercial |
$261.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.69
|
| Rate for Payer: Healthscope Commercial |
$274.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.92
|
| Rate for Payer: PHP Commercial |
$258.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.23
|
| Rate for Payer: Priority Health SBD |
$191.90
|
| Rate for Payer: UMR Bronson Commercial |
$134.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.46
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
IP
|
$156.93
|
|
|
Service Code
|
NDC 17478-223-12
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.05 |
| Max. Negotiated Rate |
$141.24 |
| Rate for Payer: Aetna American Axle |
$102.00
|
| Rate for Payer: Aetna Commercial |
$133.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.00
|
| Rate for Payer: Cash Price |
$125.54
|
| Rate for Payer: Cofinity Commercial |
$109.85
|
| Rate for Payer: Cofinity Commercial |
$134.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.54
|
| Rate for Payer: Healthscope Commercial |
$141.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.39
|
| Rate for Payer: PHP Commercial |
$133.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.85
|
| Rate for Payer: Priority Health SBD |
$98.87
|
| Rate for Payer: UMR Bronson Commercial |
$69.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.70
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
IP
|
$133.25
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.63 |
| Max. Negotiated Rate |
$119.92 |
| Rate for Payer: Aetna American Axle |
$86.61
|
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.61
|
| Rate for Payer: Cash Price |
$106.60
|
| Rate for Payer: Cofinity Commercial |
$114.60
|
| Rate for Payer: Cofinity Commercial |
$93.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.60
|
| Rate for Payer: Healthscope Commercial |
$119.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.26
|
| Rate for Payer: PHP Commercial |
$113.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.28
|
| Rate for Payer: Priority Health SBD |
$83.95
|
| Rate for Payer: UMR Bronson Commercial |
$58.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.94
|
|
|
PILOCARPINE 4 % EYE DROPS
|
Facility
|
IP
|
$149.37
|
|
|
Service Code
|
NDC 61314-206-15
|
| Hospital Charge Code |
6282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.72 |
| Max. Negotiated Rate |
$134.43 |
| Rate for Payer: Aetna American Axle |
$97.09
|
| Rate for Payer: Aetna Commercial |
$126.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.09
|
| Rate for Payer: Cash Price |
$119.50
|
| Rate for Payer: Cofinity Commercial |
$104.56
|
| Rate for Payer: Cofinity Commercial |
$128.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.50
|
| Rate for Payer: Healthscope Commercial |
$134.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.96
|
| Rate for Payer: PHP Commercial |
$126.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.56
|
| Rate for Payer: Priority Health SBD |
$94.10
|
| Rate for Payer: UMR Bronson Commercial |
$65.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.03
|
|
|
PILOCARPINE 4 % EYE DROPS
|
Facility
|
IP
|
$325.45
|
|
|
Service Code
|
NDC 0998-0206-15
|
| Hospital Charge Code |
6282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.20 |
| Max. Negotiated Rate |
$292.90 |
| Rate for Payer: Aetna American Axle |
$211.54
|
| Rate for Payer: Aetna Commercial |
$276.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.54
|
| Rate for Payer: Cash Price |
$260.36
|
| Rate for Payer: Cofinity Commercial |
$227.82
|
| Rate for Payer: Cofinity Commercial |
$279.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.36
|
| Rate for Payer: Healthscope Commercial |
$292.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.63
|
| Rate for Payer: PHP Commercial |
$276.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.82
|
| Rate for Payer: Priority Health SBD |
$205.03
|
| Rate for Payer: UMR Bronson Commercial |
$143.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.09
|
|
|
PILOCARPINE 5 MG TABLET
|
Facility
|
IP
|
$460.60
|
|
|
Service Code
|
NDC 0574-0792-01
|
| Hospital Charge Code |
12803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.66 |
| Max. Negotiated Rate |
$414.54 |
| Rate for Payer: Aetna American Axle |
$299.39
|
| Rate for Payer: Aetna Commercial |
$391.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$299.39
|
| Rate for Payer: Cash Price |
$368.48
|
| Rate for Payer: Cofinity Commercial |
$322.42
|
| Rate for Payer: Cofinity Commercial |
$396.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.48
|
| Rate for Payer: Healthscope Commercial |
$414.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$322.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$345.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$391.51
|
| Rate for Payer: PHP Commercial |
$391.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$322.42
|
| Rate for Payer: Priority Health SBD |
$290.18
|
| Rate for Payer: UMR Bronson Commercial |
$202.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$345.45
|
|
|
PILOCARPINE 5 MG TABLET
|
Facility
|
IP
|
$267.36
|
|
|
Service Code
|
NDC 0115-5922-01
|
| Hospital Charge Code |
12803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.64 |
| Max. Negotiated Rate |
$240.62 |
| Rate for Payer: Aetna American Axle |
$173.78
|
| Rate for Payer: Aetna Commercial |
$227.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.78
|
| Rate for Payer: Cash Price |
$213.89
|
| Rate for Payer: Cofinity Commercial |
$187.15
|
| Rate for Payer: Cofinity Commercial |
$229.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.89
|
| Rate for Payer: Healthscope Commercial |
$240.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.26
|
| Rate for Payer: PHP Commercial |
$227.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.15
|
| Rate for Payer: Priority Health SBD |
$168.44
|
| Rate for Payer: UMR Bronson Commercial |
$117.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.52
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
IP
|
$264.38
|
|
|
Service Code
|
NDC 16729-020-15
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.33 |
| Max. Negotiated Rate |
$237.94 |
| Rate for Payer: Aetna American Axle |
$171.85
|
| Rate for Payer: Aetna Commercial |
$224.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.85
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cofinity Commercial |
$185.07
|
| Rate for Payer: Cofinity Commercial |
$227.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.50
|
| Rate for Payer: Healthscope Commercial |
$237.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.72
|
| Rate for Payer: PHP Commercial |
$224.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.07
|
| Rate for Payer: Priority Health SBD |
$166.56
|
| Rate for Payer: UMR Bronson Commercial |
$116.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.28
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
IP
|
$459.84
|
|
|
Service Code
|
NDC 60687-391-01
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.33 |
| Max. Negotiated Rate |
$413.86 |
| Rate for Payer: Aetna American Axle |
$298.90
|
| Rate for Payer: Aetna Commercial |
$390.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.90
|
| Rate for Payer: Cash Price |
$367.87
|
| Rate for Payer: Cofinity Commercial |
$321.89
|
| Rate for Payer: Cofinity Commercial |
$395.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.87
|
| Rate for Payer: Healthscope Commercial |
$413.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$321.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$344.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$390.86
|
| Rate for Payer: PHP Commercial |
$390.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.89
|
| Rate for Payer: Priority Health SBD |
$289.70
|
| Rate for Payer: UMR Bronson Commercial |
$202.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$344.88
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
IP
|
$251.69
|
|
|
Service Code
|
NDC 57237-219-90
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.74 |
| Max. Negotiated Rate |
$226.52 |
| Rate for Payer: Aetna American Axle |
$163.60
|
| Rate for Payer: Aetna Commercial |
$213.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.60
|
| Rate for Payer: Cash Price |
$201.35
|
| Rate for Payer: Cofinity Commercial |
$176.18
|
| Rate for Payer: Cofinity Commercial |
$216.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.35
|
| Rate for Payer: Healthscope Commercial |
$226.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.94
|
| Rate for Payer: PHP Commercial |
$213.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.18
|
| Rate for Payer: Priority Health SBD |
$158.56
|
| Rate for Payer: UMR Bronson Commercial |
$110.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.77
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
IP
|
$74.39
|
|
|
Service Code
|
NDC 0093-7271-56
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.73 |
| Max. Negotiated Rate |
$66.95 |
| Rate for Payer: Aetna American Axle |
$48.35
|
| Rate for Payer: Aetna Commercial |
$63.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.35
|
| Rate for Payer: Cash Price |
$59.51
|
| Rate for Payer: Cofinity Commercial |
$52.07
|
| Rate for Payer: Cofinity Commercial |
$63.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.51
|
| Rate for Payer: Healthscope Commercial |
$66.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.23
|
| Rate for Payer: PHP Commercial |
$63.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.07
|
| Rate for Payer: Priority Health SBD |
$46.87
|
| Rate for Payer: UMR Bronson Commercial |
$32.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.79
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
IP
|
$58.52
|
|
|
Service Code
|
NDC 16729-020-10
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.75 |
| Max. Negotiated Rate |
$52.67 |
| Rate for Payer: Aetna American Axle |
$38.04
|
| Rate for Payer: Aetna Commercial |
$49.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.04
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Cofinity Commercial |
$40.96
|
| Rate for Payer: Cofinity Commercial |
$50.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.82
|
| Rate for Payer: Healthscope Commercial |
$52.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.74
|
| Rate for Payer: PHP Commercial |
$49.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.96
|
| Rate for Payer: Priority Health SBD |
$36.87
|
| Rate for Payer: UMR Bronson Commercial |
$25.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.89
|
|
