|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$716.95
|
|
|
Service Code
|
NDC 55253080230
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.46 |
| Max. Negotiated Rate |
$645.25 |
| Rate for Payer: Aetna American Axle |
$466.02
|
| Rate for Payer: Aetna Commercial |
$609.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$466.02
|
| Rate for Payer: Cash Price |
$573.56
|
| Rate for Payer: Cofinity Advantage |
$501.87
|
| Rate for Payer: Cofinity Commercial |
$616.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$573.56
|
| Rate for Payer: Healthscope Commercial |
$645.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$609.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.71
|
| Rate for Payer: PHP Commercial |
$609.41
|
| Rate for Payer: Priority Health SBD |
$451.68
|
| Rate for Payer: UMR Bronson Commercial |
$315.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.71
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
OP
|
$8,704.07
|
|
|
Service Code
|
NDC 63459020130
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,220.51 |
| Max. Negotiated Rate |
$7,833.66 |
| Rate for Payer: Aetna American Axle |
$5,657.65
|
| Rate for Payer: Aetna Commercial |
$7,398.46
|
| Rate for Payer: Aetna Medicare |
$4,352.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,657.65
|
| Rate for Payer: BCBS Complete |
$3,481.63
|
| Rate for Payer: Cash Price |
$6,963.26
|
| Rate for Payer: Cofinity Advantage |
$6,092.85
|
| Rate for Payer: Cofinity Commercial |
$7,485.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,963.26
|
| Rate for Payer: Healthscope Commercial |
$7,833.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,092.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,528.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,963.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,398.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,528.05
|
| Rate for Payer: PHP Commercial |
$7,398.46
|
| Rate for Payer: Priority Health SBD |
$5,483.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,657.65
|
| Rate for Payer: UHC Core |
$4,534.82
|
| Rate for Payer: UHC Exchange |
$3,420.70
|
| Rate for Payer: UMR Bronson Commercial |
$3,220.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,528.05
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
OP
|
$716.95
|
|
|
Service Code
|
NDC 55253080230
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.27 |
| Max. Negotiated Rate |
$645.25 |
| Rate for Payer: Aetna American Axle |
$466.02
|
| Rate for Payer: Aetna Commercial |
$609.41
|
| Rate for Payer: Aetna Medicare |
$358.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$466.02
|
| Rate for Payer: BCBS Complete |
$286.78
|
| Rate for Payer: Cash Price |
$573.56
|
| Rate for Payer: Cofinity Advantage |
$501.87
|
| Rate for Payer: Cofinity Commercial |
$616.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$573.56
|
| Rate for Payer: Healthscope Commercial |
$645.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$573.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$609.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.71
|
| Rate for Payer: PHP Commercial |
$609.41
|
| Rate for Payer: Priority Health SBD |
$451.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$466.02
|
| Rate for Payer: UHC Core |
$373.53
|
| Rate for Payer: UHC Exchange |
$281.76
|
| Rate for Payer: UMR Bronson Commercial |
$265.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.71
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$8,704.07
|
|
|
Service Code
|
NDC 63459020130
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,829.79 |
| Max. Negotiated Rate |
$7,833.66 |
| Rate for Payer: Aetna American Axle |
$5,657.65
|
| Rate for Payer: Aetna Commercial |
$7,398.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,657.65
|
| Rate for Payer: Cash Price |
$6,963.26
|
| Rate for Payer: Cofinity Advantage |
$6,092.85
|
| Rate for Payer: Cofinity Commercial |
$7,485.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,963.26
|
| Rate for Payer: Healthscope Commercial |
$7,833.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,092.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,528.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,398.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,528.05
|
| Rate for Payer: PHP Commercial |
$7,398.46
|
| Rate for Payer: Priority Health SBD |
$5,483.56
|
| Rate for Payer: UMR Bronson Commercial |
$3,829.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,528.05
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$107.28
|
|
|
Service Code
|
NDC 62332038630
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.20 |
| Max. Negotiated Rate |
$96.55 |
| Rate for Payer: Aetna American Axle |
$69.73
|
| Rate for Payer: Aetna Commercial |
$91.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.73
|
| Rate for Payer: Cash Price |
$85.82
|
| Rate for Payer: Cofinity Advantage |
$75.10
|
| Rate for Payer: Cofinity Commercial |
$92.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.82
|
| Rate for Payer: Healthscope Commercial |
$96.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.46
|
| Rate for Payer: PHP Commercial |
$91.19
|
| Rate for Payer: Priority Health SBD |
$67.59
|
| Rate for Payer: UMR Bronson Commercial |
$47.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.46
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
OP
|
$107.28
|
|
|
Service Code
|
NDC 62332038630
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$96.55 |
| Rate for Payer: Aetna American Axle |
$69.73
|
| Rate for Payer: Aetna Commercial |
$91.19
|
| Rate for Payer: Aetna Medicare |
$53.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.73
|
| Rate for Payer: BCBS Complete |
$42.91
|
| Rate for Payer: Cash Price |
$85.82
|
| Rate for Payer: Cofinity Advantage |
$75.10
|
| Rate for Payer: Cofinity Commercial |
$92.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.82
|
| Rate for Payer: Healthscope Commercial |
$96.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$85.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.46
|
| Rate for Payer: PHP Commercial |
$91.19
|
| Rate for Payer: Priority Health SBD |
$67.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.73
|
| Rate for Payer: UHC Core |
$55.89
|
| Rate for Payer: UHC Exchange |
$42.16
|
| Rate for Payer: UMR Bronson Commercial |
$39.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.46
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$24,914.57
|
|
|
Service Code
|
APR-DRG 7934
|
| Min. Negotiated Rate |
$23,728.16 |
| Max. Negotiated Rate |
$24,914.57 |
| Rate for Payer: BCBS Complete |
$24,914.57
|
| Rate for Payer: Mclaren Medicaid |
$23,728.16
|
| Rate for Payer: Meridian Medicaid |
$24,914.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$23,728.16
|
| Rate for Payer: UHC Medicaid |
$23,728.16
|
| Rate for Payer: UHCCP Medicaid |
$23,728.16
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$14,283.25
|
|
|
Service Code
|
APR-DRG 7933
|
| Min. Negotiated Rate |
$13,603.09 |
| Max. Negotiated Rate |
$14,283.25 |
| Rate for Payer: BCBS Complete |
$14,283.25
|
| Rate for Payer: Mclaren Medicaid |
$13,603.09
|
| Rate for Payer: Meridian Medicaid |
$14,283.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,603.09
|
| Rate for Payer: UHC Medicaid |
$13,603.09
|
| Rate for Payer: UHCCP Medicaid |
$13,603.09
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$7,486.66
|
|
|
Service Code
|
APR-DRG 7931
|
| Min. Negotiated Rate |
$7,130.15 |
| Max. Negotiated Rate |
$7,486.66 |
| Rate for Payer: BCBS Complete |
$7,486.66
|
| Rate for Payer: Mclaren Medicaid |
$7,130.15
|
| Rate for Payer: Meridian Medicaid |
$7,486.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$7,130.15
|
| Rate for Payer: UHC Medicaid |
$7,130.15
|
| Rate for Payer: UHCCP Medicaid |
$7,130.15
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$9,869.22
|
|
|
Service Code
|
APR-DRG 7932
|
| Min. Negotiated Rate |
$9,399.26 |
| Max. Negotiated Rate |
$9,869.22 |
| Rate for Payer: BCBS Complete |
$9,869.22
|
| Rate for Payer: Mclaren Medicaid |
$9,399.26
|
| Rate for Payer: Meridian Medicaid |
$9,869.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,399.26
|
| Rate for Payer: UHC Medicaid |
$9,399.26
|
| Rate for Payer: UHCCP Medicaid |
$9,399.26
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$8,018.74
|
|
|
Service Code
|
APR-DRG 9511
|
| Min. Negotiated Rate |
$7,636.90 |
| Max. Negotiated Rate |
$8,018.74 |
| Rate for Payer: BCBS Complete |
$8,018.74
|
| Rate for Payer: Mclaren Medicaid |
$7,636.90
|
| Rate for Payer: Meridian Medicaid |
$8,018.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$7,636.90
|
| Rate for Payer: UHC Medicaid |
$7,636.90
|
| Rate for Payer: UHCCP Medicaid |
$7,636.90
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$10,621.03
|
|
|
Service Code
|
APR-DRG 9512
|
| Min. Negotiated Rate |
$10,115.27 |
| Max. Negotiated Rate |
$10,621.03 |
| Rate for Payer: BCBS Complete |
$10,621.03
|
| Rate for Payer: Mclaren Medicaid |
$10,115.27
|
| Rate for Payer: Meridian Medicaid |
$10,621.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,115.27
|
| Rate for Payer: UHC Medicaid |
$10,115.27
|
| Rate for Payer: UHCCP Medicaid |
$10,115.27
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$23,927.89
|
|
|
Service Code
|
APR-DRG 9514
|
| Min. Negotiated Rate |
$22,788.47 |
| Max. Negotiated Rate |
$23,927.89 |
| Rate for Payer: BCBS Complete |
$23,927.89
|
| Rate for Payer: Mclaren Medicaid |
$22,788.47
|
| Rate for Payer: Meridian Medicaid |
$23,927.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$22,788.47
|
| Rate for Payer: UHC Medicaid |
$22,788.47
|
| Rate for Payer: UHCCP Medicaid |
$22,788.47
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$14,668.24
|
|
|
Service Code
|
APR-DRG 9513
|
| Min. Negotiated Rate |
$13,969.75 |
| Max. Negotiated Rate |
$14,668.24 |
| Rate for Payer: BCBS Complete |
$14,668.24
|
| Rate for Payer: Mclaren Medicaid |
$13,969.75
|
| Rate for Payer: Meridian Medicaid |
$14,668.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,969.75
|
| Rate for Payer: UHC Medicaid |
$13,969.75
|
| Rate for Payer: UHCCP Medicaid |
$13,969.75
|
|
|
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18,468.60
|
|
|
Service Code
|
HCPCS J9204
|
| Hospital Charge Code |
188111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,126.18 |
| Max. Negotiated Rate |
$16,621.74 |
| Rate for Payer: Aetna American Axle |
$12,004.59
|
| Rate for Payer: Aetna Commercial |
$15,698.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,004.59
|
| Rate for Payer: Cash Price |
$14,774.88
|
| Rate for Payer: Cofinity Advantage |
$12,928.02
|
| Rate for Payer: Cofinity Commercial |
$15,883.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,774.88
|
| Rate for Payer: Healthscope Commercial |
$16,621.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,928.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,851.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,698.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,851.45
|
| Rate for Payer: PHP Commercial |
$15,698.31
|
| Rate for Payer: Priority Health SBD |
$11,635.22
|
| Rate for Payer: UMR Bronson Commercial |
$8,126.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,851.45
|
|
|
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18,468.60
|
|
|
Service Code
|
HCPCS J9204
|
| Hospital Charge Code |
188111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.56 |
| Max. Negotiated Rate |
$16,621.74 |
| Rate for Payer: Aetna American Axle |
$12,004.59
|
| Rate for Payer: Aetna Commercial |
$15,698.31
|
| Rate for Payer: Aetna Medicare |
$263.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,004.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$316.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$316.84
|
| Rate for Payer: BCBS Complete |
$139.21
|
| Rate for Payer: BCBS MAPPO |
$253.47
|
| Rate for Payer: BCBS Trust/PPO |
$821.87
|
| Rate for Payer: BCN Commercial |
$821.87
|
| Rate for Payer: BCN Medicare Advantage |
$253.47
|
| Rate for Payer: Cash Price |
$14,774.88
|
| Rate for Payer: Cash Price |
$14,774.88
|
| Rate for Payer: Cofinity Advantage |
$12,928.02
|
| Rate for Payer: Cofinity Commercial |
$15,883.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,774.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$253.47
|
| Rate for Payer: Healthscope Commercial |
$16,621.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,928.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,851.45
|
| Rate for Payer: Mclaren Medicaid |
$253.47
|
| Rate for Payer: Mclaren Medicare |
$253.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$266.14
|
| Rate for Payer: Meridian Medicaid |
$266.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$291.49
|
| Rate for Payer: Molina Medicare/Medicaid |
$278.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,698.31
|
| Rate for Payer: Nomi Health Commercial |
$760.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,851.45
|
| Rate for Payer: PACE Medicare |
$240.80
|
| Rate for Payer: PACE SWMI |
$253.47
|
| Rate for Payer: PHP Commercial |
$15,698.31
|
| Rate for Payer: PHP Medicare Advantage |
$253.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$132.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$783.74
|
| Rate for Payer: Priority Health Medicare |
$253.47
|
| Rate for Payer: Priority Health SBD |
$11,635.22
|
| Rate for Payer: Priority Health Tiered Network |
$626.99
|
| Rate for Payer: Railroad Medicare Medicare |
$253.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.23
|
| Rate for Payer: UHC Core |
$418.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$253.47
|
| Rate for Payer: UHC Exchange |
$418.23
|
| Rate for Payer: UHC Medicaid |
$132.56
|
| Rate for Payer: UHCCP Medicaid |
$132.56
|
| Rate for Payer: UMR Bronson Commercial |
$6,833.38
|
| Rate for Payer: VA VA |
$253.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,851.45
|
|
|
MOLASSES
|
Facility
|
IP
|
$23.94
|
|
|
Service Code
|
NDC 00990000075
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna American Axle |
$15.56
|
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.56
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cofinity Advantage |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.15
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.95
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.95
|
|
|
MOLASSES
|
Facility
|
OP
|
$23.94
|
|
|
Service Code
|
NDC 00990000075
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna American Axle |
$15.56
|
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: Aetna Medicare |
$11.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.56
|
| Rate for Payer: BCBS Complete |
$9.58
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cofinity Advantage |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.15
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.95
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.56
|
| Rate for Payer: UHC Core |
$12.47
|
| Rate for Payer: UHC Exchange |
$9.41
|
| Rate for Payer: UMR Bronson Commercial |
$8.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.95
|
|
|
MONALISA TOUCH, SERIES, UP TO 3 VISITS
|
Professional
|
Both
|
$1,891.00
|
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$756.40 |
| Max. Negotiated Rate |
$1,418.25 |
| Rate for Payer: Aetna Medicare |
$945.50
|
| Rate for Payer: BCBS Complete |
$756.40
|
| Rate for Payer: Cash Price |
$1,512.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,418.25
|
| Rate for Payer: UMR Bronson Commercial |
$869.86
|
|
|
MONALISA TOUCH, SINGLE TREATMENT FOLLOWING A SERIES
|
Professional
|
Both
|
$630.00
|
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$252.00 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: BCBS Complete |
$252.00
|
| Rate for Payer: Cash Price |
$504.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$472.50
|
| Rate for Payer: UMR Bronson Commercial |
$289.80
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 68084087511
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Aetna American Axle |
$1.80
|
| Rate for Payer: Aetna Commercial |
$2.35
|
| Rate for Payer: Aetna Medicare |
$1.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.80
|
| Rate for Payer: BCBS Complete |
$1.11
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cofinity Advantage |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.22
|
| Rate for Payer: Healthscope Commercial |
$2.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.08
|
| Rate for Payer: PHP Commercial |
$2.35
|
| Rate for Payer: Priority Health SBD |
$1.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.80
|
| Rate for Payer: UHC Core |
$1.44
|
| Rate for Payer: UHC Exchange |
$1.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.08
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$3.13
|
|
|
Service Code
|
NDC 50268055611
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Advantage |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.35
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 68084087511
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Aetna American Axle |
$1.80
|
| Rate for Payer: Aetna Commercial |
$2.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.80
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cofinity Advantage |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.22
|
| Rate for Payer: Healthscope Commercial |
$2.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.08
|
| Rate for Payer: PHP Commercial |
$2.35
|
| Rate for Payer: Priority Health SBD |
$1.75
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.08
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$64.16
|
|
|
Service Code
|
NDC 29300022013
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.74 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Aetna American Axle |
$41.70
|
| Rate for Payer: Aetna Commercial |
$54.54
|
| Rate for Payer: Aetna Medicare |
$32.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.70
|
| Rate for Payer: BCBS Complete |
$25.66
|
| Rate for Payer: Cash Price |
$51.33
|
| Rate for Payer: Cofinity Advantage |
$44.91
|
| Rate for Payer: Cofinity Commercial |
$55.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.33
|
| Rate for Payer: Healthscope Commercial |
$57.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.12
|
| Rate for Payer: PHP Commercial |
$54.54
|
| Rate for Payer: Priority Health SBD |
$40.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.70
|
| Rate for Payer: UHC Core |
$33.43
|
| Rate for Payer: UHC Exchange |
$25.21
|
| Rate for Payer: UMR Bronson Commercial |
$23.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.12
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$156.28
|
|
|
Service Code
|
NDC 50268055615
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna American Axle |
$101.58
|
| Rate for Payer: Aetna Commercial |
$132.84
|
| Rate for Payer: Aetna Medicare |
$78.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.58
|
| Rate for Payer: BCBS Complete |
$62.51
|
| Rate for Payer: Cash Price |
$125.02
|
| Rate for Payer: Cofinity Advantage |
$109.40
|
| Rate for Payer: Cofinity Commercial |
$134.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.02
|
| Rate for Payer: Healthscope Commercial |
$140.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$125.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.21
|
| Rate for Payer: PHP Commercial |
$132.84
|
| Rate for Payer: Priority Health SBD |
$98.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.58
|
| Rate for Payer: UHC Core |
$81.42
|
| Rate for Payer: UHC Exchange |
$61.42
|
| Rate for Payer: UMR Bronson Commercial |
$57.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.21
|
|
