|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
IP
|
$26.73
|
|
|
Service Code
|
NDC 61269073063
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$24.06 |
| Rate for Payer: Aetna American Axle |
$17.37
|
| Rate for Payer: Aetna Commercial |
$22.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.37
|
| Rate for Payer: Cash Price |
$21.38
|
| Rate for Payer: Cofinity Commercial |
$18.71
|
| Rate for Payer: Cofinity Commercial |
$22.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$24.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.72
|
| Rate for Payer: PHP Commercial |
$22.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.37
|
| Rate for Payer: Priority Health SBD |
$16.84
|
| Rate for Payer: UMR Bronson Commercial |
$11.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.05
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
IP
|
$15.80
|
|
|
Service Code
|
NDC 61269073041
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$14.22 |
| Rate for Payer: Aetna American Axle |
$10.27
|
| Rate for Payer: Aetna Commercial |
$13.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.27
|
| Rate for Payer: Cash Price |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$11.06
|
| Rate for Payer: Cofinity Commercial |
$13.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.64
|
| Rate for Payer: Healthscope Commercial |
$14.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.43
|
| Rate for Payer: PHP Commercial |
$13.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.27
|
| Rate for Payer: Priority Health SBD |
$9.95
|
| Rate for Payer: UMR Bronson Commercial |
$6.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.85
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
IP
|
$21.47
|
|
|
Service Code
|
NDC 00904773445
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.45 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna American Axle |
$13.96
|
| Rate for Payer: Aetna Commercial |
$18.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.96
|
| Rate for Payer: Cash Price |
$17.18
|
| Rate for Payer: Cofinity Commercial |
$15.03
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.18
|
| Rate for Payer: Healthscope Commercial |
$19.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.25
|
| Rate for Payer: PHP Commercial |
$18.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.96
|
| Rate for Payer: Priority Health SBD |
$13.53
|
| Rate for Payer: UMR Bronson Commercial |
$9.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.10
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
OP
|
$17.42
|
|
|
Service Code
|
NDC 51672203506
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.45 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna American Axle |
$11.32
|
| Rate for Payer: Aetna Commercial |
$14.81
|
| Rate for Payer: Aetna Medicare |
$8.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.32
|
| Rate for Payer: BCBS Complete |
$6.97
|
| Rate for Payer: Cash Price |
$13.94
|
| Rate for Payer: Cofinity Commercial |
$12.19
|
| Rate for Payer: Cofinity Commercial |
$14.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.94
|
| Rate for Payer: Healthscope Commercial |
$15.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.81
|
| Rate for Payer: PHP Commercial |
$14.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.32
|
| Rate for Payer: Priority Health SBD |
$10.97
|
| Rate for Payer: UMR Bronson Commercial |
$6.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.06
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
OP
|
$21.47
|
|
|
Service Code
|
NDC 00904773445
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.94 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna American Axle |
$13.96
|
| Rate for Payer: Aetna Commercial |
$18.25
|
| Rate for Payer: Aetna Medicare |
$10.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.96
|
| Rate for Payer: BCBS Complete |
$8.59
|
| Rate for Payer: Cash Price |
$17.18
|
| Rate for Payer: Cofinity Commercial |
$15.03
|
| Rate for Payer: Cofinity Commercial |
$18.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.18
|
| Rate for Payer: Healthscope Commercial |
$19.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.25
|
| Rate for Payer: PHP Commercial |
$18.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.96
|
| Rate for Payer: Priority Health SBD |
$13.53
|
| Rate for Payer: UMR Bronson Commercial |
$7.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.10
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
OP
|
$15.80
|
|
|
Service Code
|
NDC 61269073041
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$14.22 |
| Rate for Payer: Aetna American Axle |
$10.27
|
| Rate for Payer: Aetna Commercial |
$13.43
|
| Rate for Payer: Aetna Medicare |
$7.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.27
|
| Rate for Payer: BCBS Complete |
$6.32
|
| Rate for Payer: Cash Price |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$11.06
|
| Rate for Payer: Cofinity Commercial |
$13.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.64
|
| Rate for Payer: Healthscope Commercial |
$14.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.43
|
| Rate for Payer: PHP Commercial |
$13.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.27
|
| Rate for Payer: Priority Health SBD |
$9.95
|
| Rate for Payer: UMR Bronson Commercial |
$5.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.85
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
IP
|
$17.42
|
|
|
Service Code
|
NDC 51672203506
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.66 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna American Axle |
$11.32
|
| Rate for Payer: Aetna Commercial |
$14.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.32
|
| Rate for Payer: Cash Price |
$13.94
|
| Rate for Payer: Cofinity Commercial |
$12.19
|
| Rate for Payer: Cofinity Commercial |
$14.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.94
|
| Rate for Payer: Healthscope Commercial |
$15.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.81
|
| Rate for Payer: PHP Commercial |
$14.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.32
|
| Rate for Payer: Priority Health SBD |
$10.97
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.06
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM
|
Facility
|
OP
|
$26.73
|
|
|
Service Code
|
NDC 61269073063
|
| Hospital Charge Code |
5040
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$24.06 |
| Rate for Payer: Aetna American Axle |
$17.37
|
| Rate for Payer: Aetna Commercial |
$22.72
|
| Rate for Payer: Aetna Medicare |
$13.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.37
|
| Rate for Payer: BCBS Complete |
$10.69
|
| Rate for Payer: Cash Price |
$21.38
|
| Rate for Payer: Cofinity Commercial |
$18.71
|
| Rate for Payer: Cofinity Commercial |
$22.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$24.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.72
|
| Rate for Payer: PHP Commercial |
$22.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.37
|
| Rate for Payer: Priority Health SBD |
$16.84
|
| Rate for Payer: UMR Bronson Commercial |
$9.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.05
|
|
|
MICRODERMABRASION
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS 00173
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$66.30 |
| Rate for Payer: Aetna Medicare |
$51.00
|
| Rate for Payer: BCBS Complete |
$40.80
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.30
|
| Rate for Payer: UMR Bronson Commercial |
$46.92
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT POWDER
|
Facility
|
OP
|
$1,025.98
|
|
|
Service Code
|
NDC 53276101002
|
| Hospital Charge Code |
10606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$379.61 |
| Max. Negotiated Rate |
$923.38 |
| Rate for Payer: Aetna American Axle |
$666.89
|
| Rate for Payer: Aetna Commercial |
$872.08
|
| Rate for Payer: Aetna Medicare |
$512.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$666.89
|
| Rate for Payer: BCBS Complete |
$410.39
|
| Rate for Payer: Cash Price |
$820.78
|
| Rate for Payer: Cofinity Commercial |
$718.19
|
| Rate for Payer: Cofinity Commercial |
$882.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$718.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$820.78
|
| Rate for Payer: Healthscope Commercial |
$923.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$718.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$769.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$872.08
|
| Rate for Payer: PHP Commercial |
$872.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$666.89
|
| Rate for Payer: Priority Health SBD |
$646.37
|
| Rate for Payer: UMR Bronson Commercial |
$379.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$769.48
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT POWDER
|
Facility
|
IP
|
$1,025.98
|
|
|
Service Code
|
NDC 53276101002
|
| Hospital Charge Code |
10606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$451.43 |
| Max. Negotiated Rate |
$923.38 |
| Rate for Payer: Aetna American Axle |
$666.89
|
| Rate for Payer: Aetna Commercial |
$872.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$666.89
|
| Rate for Payer: Cash Price |
$820.78
|
| Rate for Payer: Cofinity Commercial |
$718.19
|
| Rate for Payer: Cofinity Commercial |
$882.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$718.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$820.78
|
| Rate for Payer: Healthscope Commercial |
$923.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$718.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$769.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$872.08
|
| Rate for Payer: PHP Commercial |
$872.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$666.89
|
| Rate for Payer: Priority Health SBD |
$646.37
|
| Rate for Payer: UMR Bronson Commercial |
$451.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$769.48
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT TOPICAL POWDER IN PACKET
|
Facility
|
OP
|
$496.76
|
|
|
Service Code
|
NDC 53276101001
|
| Hospital Charge Code |
159416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$183.80 |
| Max. Negotiated Rate |
$447.08 |
| Rate for Payer: Aetna American Axle |
$322.89
|
| Rate for Payer: Aetna Commercial |
$422.25
|
| Rate for Payer: Aetna Medicare |
$248.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$322.89
|
| Rate for Payer: BCBS Complete |
$198.70
|
| Rate for Payer: Cash Price |
$397.41
|
| Rate for Payer: Cofinity Commercial |
$347.73
|
| Rate for Payer: Cofinity Commercial |
$427.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$347.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$397.41
|
| Rate for Payer: Healthscope Commercial |
$447.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$347.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$372.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$422.25
|
| Rate for Payer: PHP Commercial |
$422.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$322.89
|
| Rate for Payer: Priority Health SBD |
$312.96
|
| Rate for Payer: UMR Bronson Commercial |
$183.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$372.57
|
|
|
MICROFIBRILLAR COLLAGEN HEMOSTAT TOPICAL POWDER IN PACKET
|
Facility
|
IP
|
$496.76
|
|
|
Service Code
|
NDC 53276101001
|
| Hospital Charge Code |
159416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$218.57 |
| Max. Negotiated Rate |
$447.08 |
| Rate for Payer: Aetna American Axle |
$322.89
|
| Rate for Payer: Aetna Commercial |
$422.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$322.89
|
| Rate for Payer: Cash Price |
$397.41
|
| Rate for Payer: Cofinity Commercial |
$347.73
|
| Rate for Payer: Cofinity Commercial |
$427.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$347.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$397.41
|
| Rate for Payer: Healthscope Commercial |
$447.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$347.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$372.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$422.25
|
| Rate for Payer: PHP Commercial |
$422.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$322.89
|
| Rate for Payer: Priority Health SBD |
$312.96
|
| Rate for Payer: UMR Bronson Commercial |
$218.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$372.57
|
|
|
MICRO NEEDLING
|
Professional
|
Both
|
$204.00
|
|
|
Service Code
|
HCPCS 00171
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Aetna Medicare |
$102.00
|
| Rate for Payer: BCBS Complete |
$81.60
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.60
|
| Rate for Payer: UMR Bronson Commercial |
$93.84
|
|
|
MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$812.41
|
|
|
Service Code
|
CPT 69990
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$216.59 |
| Max. Negotiated Rate |
$812.41 |
| Rate for Payer: BCBS Trust/PPO |
$812.41
|
| Rate for Payer: BCN Commercial |
$812.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.25
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$216.59
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
IP
|
$48.22
|
|
|
Service Code
|
NDC 09900000015
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: Aetna American Axle |
$31.34
|
| Rate for Payer: Aetna Commercial |
$40.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.34
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cofinity Commercial |
$33.75
|
| Rate for Payer: Cofinity Commercial |
$41.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$33.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.58
|
| Rate for Payer: Healthscope Commercial |
$43.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.99
|
| Rate for Payer: PHP Commercial |
$40.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.34
|
| Rate for Payer: Priority Health SBD |
$30.38
|
| Rate for Payer: UMR Bronson Commercial |
$21.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.16
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
IP
|
$35.25
|
|
|
Service Code
|
NDC 00904711341
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.51 |
| Max. Negotiated Rate |
$31.72 |
| Rate for Payer: Aetna American Axle |
$22.91
|
| Rate for Payer: Aetna Commercial |
$29.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.91
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Cofinity Commercial |
$30.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.20
|
| Rate for Payer: Healthscope Commercial |
$31.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.96
|
| Rate for Payer: PHP Commercial |
$29.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.91
|
| Rate for Payer: Priority Health SBD |
$22.21
|
| Rate for Payer: UMR Bronson Commercial |
$15.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.44
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
IP
|
$38.71
|
|
|
Service Code
|
NDC 60687057640
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$34.84 |
| Rate for Payer: Aetna American Axle |
$25.16
|
| Rate for Payer: Aetna Commercial |
$32.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.16
|
| Rate for Payer: Cash Price |
$30.97
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$33.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.97
|
| Rate for Payer: Healthscope Commercial |
$34.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.90
|
| Rate for Payer: PHP Commercial |
$32.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.16
|
| Rate for Payer: Priority Health SBD |
$24.39
|
| Rate for Payer: UMR Bronson Commercial |
$17.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.03
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
IP
|
$38.71
|
|
|
Service Code
|
NDC 60687057686
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$34.84 |
| Rate for Payer: Aetna American Axle |
$25.16
|
| Rate for Payer: Aetna Commercial |
$32.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.16
|
| Rate for Payer: Cash Price |
$30.97
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$33.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.97
|
| Rate for Payer: Healthscope Commercial |
$34.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.90
|
| Rate for Payer: PHP Commercial |
$32.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.16
|
| Rate for Payer: Priority Health SBD |
$24.39
|
| Rate for Payer: UMR Bronson Commercial |
$17.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.03
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
NDC 09900000014
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Aetna American Axle |
$6.27
|
| Rate for Payer: Aetna Commercial |
$8.20
|
| Rate for Payer: Aetna Medicare |
$4.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.27
|
| Rate for Payer: BCBS Complete |
$3.86
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Cofinity Commercial |
$6.76
|
| Rate for Payer: Cofinity Commercial |
$8.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.72
|
| Rate for Payer: Healthscope Commercial |
$8.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.20
|
| Rate for Payer: PHP Commercial |
$8.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.27
|
| Rate for Payer: Priority Health SBD |
$6.08
|
| Rate for Payer: UMR Bronson Commercial |
$3.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.24
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
NDC 09900000014
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$8.68 |
| Rate for Payer: Aetna American Axle |
$6.27
|
| Rate for Payer: Aetna Commercial |
$8.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.27
|
| Rate for Payer: Cash Price |
$7.72
|
| Rate for Payer: Cofinity Commercial |
$6.76
|
| Rate for Payer: Cofinity Commercial |
$8.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.72
|
| Rate for Payer: Healthscope Commercial |
$8.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.20
|
| Rate for Payer: PHP Commercial |
$8.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.27
|
| Rate for Payer: Priority Health SBD |
$6.08
|
| Rate for Payer: UMR Bronson Commercial |
$4.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.24
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
OP
|
$38.71
|
|
|
Service Code
|
NDC 60687057686
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$34.84 |
| Rate for Payer: Aetna American Axle |
$25.16
|
| Rate for Payer: Aetna Commercial |
$32.90
|
| Rate for Payer: Aetna Medicare |
$19.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.16
|
| Rate for Payer: BCBS Complete |
$15.48
|
| Rate for Payer: Cash Price |
$30.97
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$33.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.97
|
| Rate for Payer: Healthscope Commercial |
$34.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.90
|
| Rate for Payer: PHP Commercial |
$32.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.16
|
| Rate for Payer: Priority Health SBD |
$24.39
|
| Rate for Payer: UMR Bronson Commercial |
$14.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.03
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
OP
|
$38.71
|
|
|
Service Code
|
NDC 60687057640
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$34.84 |
| Rate for Payer: Aetna American Axle |
$25.16
|
| Rate for Payer: Aetna Commercial |
$32.90
|
| Rate for Payer: Aetna Medicare |
$19.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.16
|
| Rate for Payer: BCBS Complete |
$15.48
|
| Rate for Payer: Cash Price |
$30.97
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$33.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.97
|
| Rate for Payer: Healthscope Commercial |
$34.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.90
|
| Rate for Payer: PHP Commercial |
$32.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.16
|
| Rate for Payer: Priority Health SBD |
$24.39
|
| Rate for Payer: UMR Bronson Commercial |
$14.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.03
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
OP
|
$35.25
|
|
|
Service Code
|
NDC 00904711341
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.04 |
| Max. Negotiated Rate |
$31.72 |
| Rate for Payer: Aetna American Axle |
$22.91
|
| Rate for Payer: Aetna Commercial |
$29.96
|
| Rate for Payer: Aetna Medicare |
$17.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.91
|
| Rate for Payer: BCBS Complete |
$14.10
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Cofinity Commercial |
$30.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.20
|
| Rate for Payer: Healthscope Commercial |
$31.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.96
|
| Rate for Payer: PHP Commercial |
$29.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.91
|
| Rate for Payer: Priority Health SBD |
$22.21
|
| Rate for Payer: UMR Bronson Commercial |
$13.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.44
|
|
|
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRUP
|
Facility
|
OP
|
$48.22
|
|
|
Service Code
|
NDC 09900000015
|
| Hospital Charge Code |
120031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.84 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: Aetna American Axle |
$31.34
|
| Rate for Payer: Aetna Commercial |
$40.99
|
| Rate for Payer: Aetna Medicare |
$24.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.34
|
| Rate for Payer: BCBS Complete |
$19.29
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cofinity Commercial |
$33.75
|
| Rate for Payer: Cofinity Commercial |
$41.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$33.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.58
|
| Rate for Payer: Healthscope Commercial |
$43.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.99
|
| Rate for Payer: PHP Commercial |
$40.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.34
|
| Rate for Payer: Priority Health SBD |
$30.38
|
| Rate for Payer: UMR Bronson Commercial |
$17.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.16
|
|
