|
CHG X-RAY TRUNK SPINE SCOLIOSIS
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
HCPCS 72069
|
| Min. Negotiated Rate |
$23.60 |
| Max. Negotiated Rate |
$41.30 |
| Rate for Payer: BCBS Complete |
$23.60
|
| Rate for Payer: BCBS Complete |
$17.60
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.30
|
| Rate for Payer: UMR Bronson Commercial |
$20.24
|
| Rate for Payer: UMR Bronson Commercial |
$27.14
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
|
IP
|
$561,998.55
|
|
|
Service Code
|
MS-DRG 018
|
| Min. Negotiated Rate |
$170,176.10 |
| Max. Negotiated Rate |
$561,998.55 |
| Rate for Payer: Aetna Medicare |
$295,800.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$355,529.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$355,529.35
|
| Rate for Payer: BCBS MAPPO |
$284,423.48
|
| Rate for Payer: BCBS Trust/PPO |
$170,176.10
|
| Rate for Payer: BCN Medicare Advantage |
$284,423.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$284,423.48
|
| Rate for Payer: Mclaren Medicare |
$284,423.48
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$298,644.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$327,087.00
|
| Rate for Payer: PACE Medicare |
$270,202.31
|
| Rate for Payer: PACE SWMI |
$284,423.48
|
| Rate for Payer: PHP Medicare Advantage |
$284,423.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$528,689.80
|
| Rate for Payer: Priority Health Medicare |
$284,423.48
|
| Rate for Payer: Priority Health Narrow Network |
$422,951.84
|
| Rate for Payer: Railroad Medicare Medicare |
$284,423.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$561,998.55
|
| Rate for Payer: UHC Core |
$460,828.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$284,423.48
|
| Rate for Payer: UHC Exchange |
$366,363.81
|
| Rate for Payer: UHC Medicare Advantage |
$292,956.18
|
| Rate for Payer: VA VA |
$284,423.48
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$435.10
|
|
|
Service Code
|
NDC 51079-375-20
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.44 |
| Max. Negotiated Rate |
$391.59 |
| Rate for Payer: Aetna American Axle |
$282.82
|
| Rate for Payer: Aetna Commercial |
$369.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.82
|
| Rate for Payer: Cash Price |
$348.08
|
| Rate for Payer: Cofinity Commercial |
$304.57
|
| Rate for Payer: Cofinity Commercial |
$374.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.08
|
| Rate for Payer: Healthscope Commercial |
$391.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$369.84
|
| Rate for Payer: PHP Commercial |
$369.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$304.57
|
| Rate for Payer: Priority Health SBD |
$274.11
|
| Rate for Payer: UMR Bronson Commercial |
$191.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.32
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 51079-375-01
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna American Axle |
$2.83
|
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.83
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.05
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.71
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.05
|
| Rate for Payer: Priority Health SBD |
$2.75
|
| Rate for Payer: UMR Bronson Commercial |
$1.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.27
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
NDC 0555-0033-02
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.08 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna American Axle |
$183.30
|
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.30
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.70
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.40
|
| Rate for Payer: Priority Health SBD |
$177.66
|
| Rate for Payer: UMR Bronson Commercial |
$124.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$469.30
|
|
|
Service Code
|
NDC 51079-141-20
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.49 |
| Max. Negotiated Rate |
$422.37 |
| Rate for Payer: Aetna American Axle |
$305.04
|
| Rate for Payer: Aetna Commercial |
$398.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.04
|
| Rate for Payer: Cash Price |
$375.44
|
| Rate for Payer: Cofinity Commercial |
$328.51
|
| Rate for Payer: Cofinity Commercial |
$403.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.44
|
| Rate for Payer: Healthscope Commercial |
$422.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$328.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$351.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$398.90
|
| Rate for Payer: PHP Commercial |
$398.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$328.51
|
| Rate for Payer: Priority Health SBD |
$295.66
|
| Rate for Payer: UMR Bronson Commercial |
$206.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$351.98
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 0555-0159-02
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.00 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna American Axle |
$224.54
|
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.54
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$241.82
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.82
|
| Rate for Payer: Priority Health SBD |
$217.63
|
| Rate for Payer: UMR Bronson Commercial |
$152.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.09
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$176.25
|
|
|
Service Code
|
NDC 43547-253-10
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.55 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna American Axle |
$114.56
|
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$151.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$158.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.81
|
| Rate for Payer: PHP Commercial |
$149.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.38
|
| Rate for Payer: Priority Health SBD |
$111.04
|
| Rate for Payer: UMR Bronson Commercial |
$77.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.19
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$1,527.50
|
|
|
Service Code
|
NDC 0555-0159-04
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$672.10 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna American Axle |
$992.88
|
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$992.88
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,069.25
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,069.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,145.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,298.38
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,069.25
|
| Rate for Payer: Priority Health SBD |
$962.32
|
| Rate for Payer: UMR Bronson Commercial |
$672.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,145.62
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 51079-141-01
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna American Axle |
$3.06
|
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.06
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Commercial |
$4.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.76
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.00
|
| Rate for Payer: PHP Commercial |
$4.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.29
|
| Rate for Payer: Priority Health SBD |
$2.96
|
| Rate for Payer: UMR Bronson Commercial |
$2.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.52
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
IP
|
$401.85
|
|
|
Service Code
|
NDC 0555-0158-02
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.81 |
| Max. Negotiated Rate |
$361.66 |
| Rate for Payer: Aetna American Axle |
$261.20
|
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$341.57
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.30
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UMR Bronson Commercial |
$176.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 9900-0000-23
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$44.77
|
|
|
Service Code
|
NDC 60687-616-16
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$40.29 |
| Rate for Payer: Aetna American Axle |
$29.10
|
| Rate for Payer: Aetna Commercial |
$38.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.10
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$31.34
|
| Rate for Payer: Cofinity Commercial |
$38.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.05
|
| Rate for Payer: PHP Commercial |
$38.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.34
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UMR Bronson Commercial |
$19.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$44.47
|
|
|
Service Code
|
NDC 0116-2001-16
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.57 |
| Max. Negotiated Rate |
$40.02 |
| Rate for Payer: Aetna American Axle |
$28.91
|
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.91
|
| Rate for Payer: Cash Price |
$35.58
|
| Rate for Payer: Cofinity Commercial |
$31.13
|
| Rate for Payer: Cofinity Commercial |
$38.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.58
|
| Rate for Payer: Healthscope Commercial |
$40.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.80
|
| Rate for Payer: PHP Commercial |
$37.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.13
|
| Rate for Payer: Priority Health SBD |
$28.02
|
| Rate for Payer: UMR Bronson Commercial |
$19.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.35
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$25.74
|
|
|
Service Code
|
NDC 0904-7035-88
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$23.17 |
| Rate for Payer: Aetna American Axle |
$16.73
|
| Rate for Payer: Aetna Commercial |
$21.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.73
|
| Rate for Payer: Cash Price |
$20.59
|
| Rate for Payer: Cofinity Commercial |
$22.14
|
| Rate for Payer: Cofinity Commercial |
$18.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.59
|
| Rate for Payer: Healthscope Commercial |
$23.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.88
|
| Rate for Payer: PHP Commercial |
$21.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.02
|
| Rate for Payer: Priority Health SBD |
$16.22
|
| Rate for Payer: UMR Bronson Commercial |
$11.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.30
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$25.38
|
|
|
Service Code
|
NDC 48878-0620-4
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$22.84 |
| Rate for Payer: Aetna American Axle |
$16.50
|
| Rate for Payer: Aetna Commercial |
$21.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.50
|
| Rate for Payer: Cash Price |
$20.30
|
| Rate for Payer: Cofinity Commercial |
$17.77
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.30
|
| Rate for Payer: Healthscope Commercial |
$22.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.57
|
| Rate for Payer: PHP Commercial |
$21.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.77
|
| Rate for Payer: Priority Health SBD |
$15.99
|
| Rate for Payer: UMR Bronson Commercial |
$11.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.04
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$44.77
|
|
|
Service Code
|
NDC 60687-616-44
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$40.29 |
| Rate for Payer: Aetna American Axle |
$29.10
|
| Rate for Payer: Aetna Commercial |
$38.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.10
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$31.34
|
| Rate for Payer: Cofinity Commercial |
$38.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.05
|
| Rate for Payer: PHP Commercial |
$38.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.34
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UMR Bronson Commercial |
$19.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$100.04
|
|
|
Service Code
|
NDC 52376-021-02
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.02 |
| Max. Negotiated Rate |
$90.04 |
| Rate for Payer: Aetna American Axle |
$65.03
|
| Rate for Payer: Aetna Commercial |
$85.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.03
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cofinity Commercial |
$70.03
|
| Rate for Payer: Cofinity Commercial |
$86.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.03
|
| Rate for Payer: Healthscope Commercial |
$90.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.03
|
| Rate for Payer: PHP Commercial |
$85.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.03
|
| Rate for Payer: Priority Health SBD |
$63.03
|
| Rate for Payer: UMR Bronson Commercial |
$44.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.03
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 0116-2001-15
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna American Axle |
$0.92
|
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.92
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$0.99
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$1.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.20
|
| Rate for Payer: PHP Commercial |
$1.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.99
|
| Rate for Payer: Priority Health SBD |
$0.89
|
| Rate for Payer: UMR Bronson Commercial |
$0.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.06
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$23.62
|
|
|
Service Code
|
NDC 0904-7035-87
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$21.26 |
| Rate for Payer: Aetna American Axle |
$15.35
|
| Rate for Payer: Aetna Commercial |
$20.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.35
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cofinity Commercial |
$20.31
|
| Rate for Payer: Cofinity Commercial |
$16.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.90
|
| Rate for Payer: Healthscope Commercial |
$21.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.08
|
| Rate for Payer: PHP Commercial |
$20.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.53
|
| Rate for Payer: Priority Health SBD |
$14.88
|
| Rate for Payer: UMR Bronson Commercial |
$10.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.72
|
|
|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$82.86
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
150549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.46 |
| Max. Negotiated Rate |
$74.57 |
| Rate for Payer: Aetna American Axle |
$53.86
|
| Rate for Payer: Aetna Commercial |
$70.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.86
|
| Rate for Payer: Cash Price |
$66.29
|
| Rate for Payer: Cofinity Commercial |
$58.00
|
| Rate for Payer: Cofinity Commercial |
$71.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.29
|
| Rate for Payer: Healthscope Commercial |
$74.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$70.43
|
| Rate for Payer: PHP Commercial |
$70.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.00
|
| Rate for Payer: Priority Health SBD |
$52.20
|
| Rate for Payer: UMR Bronson Commercial |
$36.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.14
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION
|
Facility
|
IP
|
$81.71
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
1635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.95 |
| Max. Negotiated Rate |
$73.54 |
| Rate for Payer: Aetna American Axle |
$53.11
|
| Rate for Payer: Aetna American Axle |
$56.58
|
| Rate for Payer: Aetna Commercial |
$69.45
|
| Rate for Payer: Aetna Commercial |
$73.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.11
|
| Rate for Payer: Cash Price |
$69.64
|
| Rate for Payer: Cash Price |
$65.37
|
| Rate for Payer: Cofinity Commercial |
$60.94
|
| Rate for Payer: Cofinity Commercial |
$74.86
|
| Rate for Payer: Cofinity Commercial |
$70.27
|
| Rate for Payer: Cofinity Commercial |
$57.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.37
|
| Rate for Payer: Healthscope Commercial |
$78.34
|
| Rate for Payer: Healthscope Commercial |
$73.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.45
|
| Rate for Payer: PHP Commercial |
$73.99
|
| Rate for Payer: PHP Commercial |
$69.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.20
|
| Rate for Payer: Priority Health SBD |
$51.48
|
| Rate for Payer: Priority Health SBD |
$54.84
|
| Rate for Payer: UMR Bronson Commercial |
$38.30
|
| Rate for Payer: UMR Bronson Commercial |
$35.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.29
|
|
|
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$610.16
|
|
|
Service Code
|
NDC 65649-311-12
|
| Hospital Charge Code |
9525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.47 |
| Max. Negotiated Rate |
$549.14 |
| Rate for Payer: Aetna American Axle |
$396.60
|
| Rate for Payer: Aetna Commercial |
$518.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.60
|
| Rate for Payer: Cash Price |
$488.13
|
| Rate for Payer: Cofinity Commercial |
$427.11
|
| Rate for Payer: Cofinity Commercial |
$524.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.13
|
| Rate for Payer: Healthscope Commercial |
$549.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$457.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$518.64
|
| Rate for Payer: PHP Commercial |
$518.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$427.11
|
| Rate for Payer: Priority Health SBD |
$384.40
|
| Rate for Payer: UMR Bronson Commercial |
$268.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$457.62
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$175.38
|
|
|
Service Code
|
HCPCS J1205
|
| Hospital Charge Code |
9526
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.17 |
| Max. Negotiated Rate |
$157.84 |
| Rate for Payer: Aetna American Axle |
$114.00
|
| Rate for Payer: Aetna American Axle |
$85.04
|
| Rate for Payer: Aetna American Axle |
$214.16
|
| Rate for Payer: Aetna American Axle |
$137.20
|
| Rate for Payer: Aetna American Axle |
$114.34
|
| Rate for Payer: Aetna Commercial |
$149.07
|
| Rate for Payer: Aetna Commercial |
$280.06
|
| Rate for Payer: Aetna Commercial |
$179.41
|
| Rate for Payer: Aetna Commercial |
$111.21
|
| Rate for Payer: Aetna Commercial |
$149.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.00
|
| Rate for Payer: Cash Price |
$263.58
|
| Rate for Payer: Cash Price |
$140.73
|
| Rate for Payer: Cash Price |
$104.66
|
| Rate for Payer: Cash Price |
$168.86
|
| Rate for Payer: Cash Price |
$140.30
|
| Rate for Payer: Cofinity Commercial |
$112.51
|
| Rate for Payer: Cofinity Commercial |
$283.35
|
| Rate for Payer: Cofinity Commercial |
$230.64
|
| Rate for Payer: Cofinity Commercial |
$122.77
|
| Rate for Payer: Cofinity Commercial |
$150.83
|
| Rate for Payer: Cofinity Commercial |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$181.52
|
| Rate for Payer: Cofinity Commercial |
$147.75
|
| Rate for Payer: Cofinity Commercial |
$151.28
|
| Rate for Payer: Cofinity Commercial |
$91.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.86
|
| Rate for Payer: Healthscope Commercial |
$157.84
|
| Rate for Payer: Healthscope Commercial |
$117.75
|
| Rate for Payer: Healthscope Commercial |
$158.32
|
| Rate for Payer: Healthscope Commercial |
$189.96
|
| Rate for Payer: Healthscope Commercial |
$296.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$280.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.21
|
| Rate for Payer: PHP Commercial |
$179.41
|
| Rate for Payer: PHP Commercial |
$111.21
|
| Rate for Payer: PHP Commercial |
$280.06
|
| Rate for Payer: PHP Commercial |
$149.07
|
| Rate for Payer: PHP Commercial |
$149.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.14
|
| Rate for Payer: Priority Health SBD |
$110.49
|
| Rate for Payer: Priority Health SBD |
$110.82
|
| Rate for Payer: Priority Health SBD |
$207.57
|
| Rate for Payer: Priority Health SBD |
$132.97
|
| Rate for Payer: Priority Health SBD |
$82.42
|
| Rate for Payer: UMR Bronson Commercial |
$144.97
|
| Rate for Payer: UMR Bronson Commercial |
$57.57
|
| Rate for Payer: UMR Bronson Commercial |
$92.87
|
| Rate for Payer: UMR Bronson Commercial |
$77.40
|
| Rate for Payer: UMR Bronson Commercial |
$77.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.11
|
|
|
CHLORPHENIRAMINE 4 MG TABLET
|
Facility
|
IP
|
$49.35
|
|
|
Service Code
|
NDC 49483-242-01
|
| Hospital Charge Code |
1645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$44.42 |
| Rate for Payer: Aetna American Axle |
$32.08
|
| Rate for Payer: Aetna Commercial |
$41.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.08
|
| Rate for Payer: Cash Price |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$34.54
|
| Rate for Payer: Cofinity Commercial |
$42.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.48
|
| Rate for Payer: Healthscope Commercial |
$44.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.95
|
| Rate for Payer: PHP Commercial |
$41.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.54
|
| Rate for Payer: Priority Health SBD |
$31.09
|
| Rate for Payer: UMR Bronson Commercial |
$21.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.01
|
|
