|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$4,130.13
|
|
|
Service Code
|
APR-DRG 8122
|
| Min. Negotiated Rate |
$3,933.46 |
| Max. Negotiated Rate |
$4,130.13 |
| Rate for Payer: BCBS Complete |
$4,130.13
|
| Rate for Payer: Mclaren Medicaid |
$3,933.46
|
| Rate for Payer: Meridian Medicaid |
$4,130.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,933.46
|
| Rate for Payer: UHC Medicaid |
$3,933.46
|
| Rate for Payer: UHCCP Medicaid |
$3,933.46
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$5,825.04
|
|
|
Service Code
|
APR-DRG 8123
|
| Min. Negotiated Rate |
$5,547.66 |
| Max. Negotiated Rate |
$5,825.04 |
| Rate for Payer: BCBS Complete |
$5,825.04
|
| Rate for Payer: Mclaren Medicaid |
$5,547.66
|
| Rate for Payer: Meridian Medicaid |
$5,825.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,547.66
|
| Rate for Payer: UHC Medicaid |
$5,547.66
|
| Rate for Payer: UHCCP Medicaid |
$5,547.66
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$11,381.32
|
|
|
Service Code
|
APR-DRG 8124
|
| Min. Negotiated Rate |
$10,839.35 |
| Max. Negotiated Rate |
$11,381.32 |
| Rate for Payer: BCBS Complete |
$11,381.32
|
| Rate for Payer: Mclaren Medicaid |
$10,839.35
|
| Rate for Payer: Meridian Medicaid |
$11,381.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,839.35
|
| Rate for Payer: UHC Medicaid |
$10,839.35
|
| Rate for Payer: UHCCP Medicaid |
$10,839.35
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$88,579.13
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
190691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.77 |
| Max. Negotiated Rate |
$79,721.22 |
| Rate for Payer: Aetna American Axle |
$57,576.43
|
| Rate for Payer: Aetna Commercial |
$75,292.26
|
| Rate for Payer: Aetna Medicare |
$142.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57,576.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$171.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$171.54
|
| Rate for Payer: BCBS Complete |
$75.37
|
| Rate for Payer: BCBS MAPPO |
$137.23
|
| Rate for Payer: BCBS Trust/PPO |
$443.50
|
| Rate for Payer: BCN Commercial |
$443.50
|
| Rate for Payer: BCN Medicare Advantage |
$137.23
|
| Rate for Payer: Cash Price |
$70,863.30
|
| Rate for Payer: Cash Price |
$70,863.30
|
| Rate for Payer: Cofinity Advantage |
$62,005.39
|
| Rate for Payer: Cofinity Commercial |
$76,178.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70,863.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$137.23
|
| Rate for Payer: Healthscope Commercial |
$79,721.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62,005.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66,434.35
|
| Rate for Payer: Mclaren Medicaid |
$137.23
|
| Rate for Payer: Mclaren Medicare |
$137.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$144.09
|
| Rate for Payer: Meridian Medicaid |
$144.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$150.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75,292.26
|
| Rate for Payer: Nomi Health Commercial |
$411.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66,434.35
|
| Rate for Payer: PACE Medicare |
$130.37
|
| Rate for Payer: PACE SWMI |
$137.23
|
| Rate for Payer: PHP Commercial |
$75,292.26
|
| Rate for Payer: PHP Medicare Advantage |
$137.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$71.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$431.04
|
| Rate for Payer: Priority Health Medicare |
$137.23
|
| Rate for Payer: Priority Health SBD |
$55,804.85
|
| Rate for Payer: Priority Health Tiered Network |
$344.83
|
| Rate for Payer: Railroad Medicare Medicare |
$137.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.67
|
| Rate for Payer: UHC Core |
$225.67
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$137.23
|
| Rate for Payer: UHC Exchange |
$225.67
|
| Rate for Payer: UHC Medicaid |
$71.77
|
| Rate for Payer: UHCCP Medicaid |
$71.77
|
| Rate for Payer: UMR Bronson Commercial |
$32,774.28
|
| Rate for Payer: VA VA |
$137.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66,434.35
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$88,579.13
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
190691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38,974.82 |
| Max. Negotiated Rate |
$79,721.22 |
| Rate for Payer: Aetna American Axle |
$57,576.43
|
| Rate for Payer: Aetna Commercial |
$75,292.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57,576.43
|
| Rate for Payer: Cash Price |
$70,863.30
|
| Rate for Payer: Cofinity Advantage |
$62,005.39
|
| Rate for Payer: Cofinity Commercial |
$76,178.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70,863.30
|
| Rate for Payer: Healthscope Commercial |
$79,721.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62,005.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66,434.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75,292.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66,434.35
|
| Rate for Payer: PHP Commercial |
$75,292.26
|
| Rate for Payer: Priority Health SBD |
$55,804.85
|
| Rate for Payer: UMR Bronson Commercial |
$38,974.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66,434.35
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18,981.30
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.77 |
| Max. Negotiated Rate |
$17,083.17 |
| Rate for Payer: Aetna American Axle |
$12,337.84
|
| Rate for Payer: Aetna Commercial |
$16,134.10
|
| Rate for Payer: Aetna Medicare |
$142.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,337.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$171.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$171.54
|
| Rate for Payer: BCBS Complete |
$75.37
|
| Rate for Payer: BCBS MAPPO |
$137.23
|
| Rate for Payer: BCBS Trust/PPO |
$443.50
|
| Rate for Payer: BCN Commercial |
$443.50
|
| Rate for Payer: BCN Medicare Advantage |
$137.23
|
| Rate for Payer: Cash Price |
$15,185.04
|
| Rate for Payer: Cash Price |
$15,185.04
|
| Rate for Payer: Cofinity Advantage |
$13,286.91
|
| Rate for Payer: Cofinity Commercial |
$16,323.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,185.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$137.23
|
| Rate for Payer: Healthscope Commercial |
$17,083.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,286.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,235.98
|
| Rate for Payer: Mclaren Medicaid |
$137.23
|
| Rate for Payer: Mclaren Medicare |
$137.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$144.09
|
| Rate for Payer: Meridian Medicaid |
$144.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$150.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,134.10
|
| Rate for Payer: Nomi Health Commercial |
$411.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,235.98
|
| Rate for Payer: PACE Medicare |
$130.37
|
| Rate for Payer: PACE SWMI |
$137.23
|
| Rate for Payer: PHP Commercial |
$16,134.10
|
| Rate for Payer: PHP Medicare Advantage |
$137.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$71.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$431.04
|
| Rate for Payer: Priority Health Medicare |
$137.23
|
| Rate for Payer: Priority Health SBD |
$11,958.22
|
| Rate for Payer: Priority Health Tiered Network |
$344.83
|
| Rate for Payer: Railroad Medicare Medicare |
$137.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.67
|
| Rate for Payer: UHC Core |
$225.67
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$137.23
|
| Rate for Payer: UHC Exchange |
$225.67
|
| Rate for Payer: UHC Medicaid |
$71.77
|
| Rate for Payer: UHCCP Medicaid |
$71.77
|
| Rate for Payer: UMR Bronson Commercial |
$7,023.08
|
| Rate for Payer: VA VA |
$137.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,235.98
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18,981.30
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,351.77 |
| Max. Negotiated Rate |
$17,083.17 |
| Rate for Payer: Aetna American Axle |
$12,337.84
|
| Rate for Payer: Aetna Commercial |
$16,134.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,337.84
|
| Rate for Payer: Cash Price |
$15,185.04
|
| Rate for Payer: Cofinity Advantage |
$13,286.91
|
| Rate for Payer: Cofinity Commercial |
$16,323.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,185.04
|
| Rate for Payer: Healthscope Commercial |
$17,083.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,286.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,235.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,134.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,235.98
|
| Rate for Payer: PHP Commercial |
$16,134.10
|
| Rate for Payer: Priority Health SBD |
$11,958.22
|
| Rate for Payer: UMR Bronson Commercial |
$8,351.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,235.98
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$81.54
|
|
|
Service Code
|
NDC 67850014000
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Advantage |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.16
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$35.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$81.54
|
|
|
Service Code
|
NDC 67850014005
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Advantage |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.16
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$35.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$81.54
|
|
|
Service Code
|
NDC 67850014005
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: BCBS Complete |
$32.62
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Advantage |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.16
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.00
|
| Rate for Payer: UHC Core |
$42.48
|
| Rate for Payer: UHC Exchange |
$32.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$81.54
|
|
|
Service Code
|
NDC 67850014000
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: BCBS Complete |
$32.62
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Advantage |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.16
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.00
|
| Rate for Payer: UHC Core |
$42.48
|
| Rate for Payer: UHC Exchange |
$32.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$46.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: BCBS Complete |
$37.42
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.80
|
| Rate for Payer: UHC Core |
$48.73
|
| Rate for Payer: UHC Exchange |
$36.76
|
| Rate for Payer: UMR Bronson Commercial |
$34.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$41.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014105
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$41.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$93.54
|
|
|
Service Code
|
NDC 67850014105
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$46.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: BCBS Complete |
$37.42
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.80
|
| Rate for Payer: UHC Core |
$48.73
|
| Rate for Payer: UHC Exchange |
$36.76
|
| Rate for Payer: UMR Bronson Commercial |
$34.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION
|
Facility
|
IP
|
$1,057.66
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
108802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.37 |
| Max. Negotiated Rate |
$951.89 |
| Rate for Payer: Aetna American Axle |
$687.48
|
| Rate for Payer: Aetna Commercial |
$899.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$687.48
|
| Rate for Payer: Cash Price |
$846.13
|
| Rate for Payer: Cofinity Advantage |
$740.36
|
| Rate for Payer: Cofinity Commercial |
$909.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$846.13
|
| Rate for Payer: Healthscope Commercial |
$951.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$740.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$793.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$899.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$793.25
|
| Rate for Payer: PHP Commercial |
$899.01
|
| Rate for Payer: Priority Health SBD |
$666.33
|
| Rate for Payer: UMR Bronson Commercial |
$465.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$793.25
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION
|
Facility
|
OP
|
$1,057.66
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
108802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.41 |
| Max. Negotiated Rate |
$951.89 |
| Rate for Payer: Aetna American Axle |
$687.48
|
| Rate for Payer: Aetna Commercial |
$899.01
|
| Rate for Payer: Aetna Medicare |
$528.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$687.48
|
| Rate for Payer: BCBS Complete |
$423.06
|
| Rate for Payer: BCBS Trust/PPO |
$152.16
|
| Rate for Payer: BCN Commercial |
$152.16
|
| Rate for Payer: Cash Price |
$846.13
|
| Rate for Payer: Cash Price |
$846.13
|
| Rate for Payer: Cofinity Advantage |
$740.36
|
| Rate for Payer: Cofinity Commercial |
$909.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$846.13
|
| Rate for Payer: Healthscope Commercial |
$951.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$740.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$793.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$846.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$899.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$793.25
|
| Rate for Payer: PHP Commercial |
$899.01
|
| Rate for Payer: Priority Health SBD |
$666.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94.41
|
| Rate for Payer: UHC Core |
$94.41
|
| Rate for Payer: UHC Exchange |
$94.41
|
| Rate for Payer: UMR Bronson Commercial |
$391.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$793.25
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$16.61
|
|
|
Service Code
|
NDC 45802086801
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna American Axle |
$10.80
|
| Rate for Payer: Aetna Commercial |
$14.12
|
| Rate for Payer: Aetna Medicare |
$8.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.80
|
| Rate for Payer: BCBS Complete |
$6.64
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cofinity Advantage |
$11.63
|
| Rate for Payer: Cofinity Commercial |
$14.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.29
|
| Rate for Payer: Healthscope Commercial |
$14.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.46
|
| Rate for Payer: PHP Commercial |
$14.12
|
| Rate for Payer: Priority Health SBD |
$10.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.80
|
| Rate for Payer: UHC Core |
$8.65
|
| Rate for Payer: UHC Exchange |
$6.53
|
| Rate for Payer: UMR Bronson Commercial |
$6.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.46
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 70000041501
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna American Axle |
$9.75
|
| Rate for Payer: Aetna Commercial |
$12.75
|
| Rate for Payer: Aetna Medicare |
$7.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.75
|
| Rate for Payer: BCBS Complete |
$6.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Advantage |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.25
|
| Rate for Payer: PHP Commercial |
$12.75
|
| Rate for Payer: Priority Health SBD |
$9.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.75
|
| Rate for Payer: UHC Core |
$7.82
|
| Rate for Payer: UHC Exchange |
$5.89
|
| Rate for Payer: UMR Bronson Commercial |
$5.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.25
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$24.16
|
|
|
Service Code
|
NDC 57896048914
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna American Axle |
$15.70
|
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.70
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cofinity Advantage |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$20.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.33
|
| Rate for Payer: Healthscope Commercial |
$21.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.12
|
| Rate for Payer: PHP Commercial |
$20.54
|
| Rate for Payer: Priority Health SBD |
$15.22
|
| Rate for Payer: UMR Bronson Commercial |
$10.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.12
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$39.99
|
|
|
Service Code
|
NDC 41100082073
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$35.99 |
| Rate for Payer: Aetna American Axle |
$25.99
|
| Rate for Payer: Aetna Commercial |
$33.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.99
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cofinity Advantage |
$27.99
|
| Rate for Payer: Cofinity Commercial |
$34.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.99
|
| Rate for Payer: Healthscope Commercial |
$35.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.99
|
| Rate for Payer: PHP Commercial |
$33.99
|
| Rate for Payer: Priority Health SBD |
$25.19
|
| Rate for Payer: UMR Bronson Commercial |
$17.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.99
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$39.99
|
|
|
Service Code
|
NDC 41100082073
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$35.99 |
| Rate for Payer: Aetna American Axle |
$25.99
|
| Rate for Payer: Aetna Commercial |
$33.99
|
| Rate for Payer: Aetna Medicare |
$20.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.99
|
| Rate for Payer: BCBS Complete |
$16.00
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cofinity Advantage |
$27.99
|
| Rate for Payer: Cofinity Commercial |
$34.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.99
|
| Rate for Payer: Healthscope Commercial |
$35.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.99
|
| Rate for Payer: PHP Commercial |
$33.99
|
| Rate for Payer: Priority Health SBD |
$25.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.99
|
| Rate for Payer: UHC Core |
$20.83
|
| Rate for Payer: UHC Exchange |
$15.72
|
| Rate for Payer: UMR Bronson Commercial |
$14.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.99
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 70000041501
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna American Axle |
$9.75
|
| Rate for Payer: Aetna Commercial |
$12.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.75
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Advantage |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.25
|
| Rate for Payer: PHP Commercial |
$12.75
|
| Rate for Payer: Priority Health SBD |
$9.45
|
| Rate for Payer: UMR Bronson Commercial |
$6.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.25
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$24.16
|
|
|
Service Code
|
NDC 57896048914
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna American Axle |
$15.70
|
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna Medicare |
$12.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.70
|
| Rate for Payer: BCBS Complete |
$9.66
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cofinity Advantage |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$20.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.33
|
| Rate for Payer: Healthscope Commercial |
$21.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.12
|
| Rate for Payer: PHP Commercial |
$20.54
|
| Rate for Payer: Priority Health SBD |
$15.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.70
|
| Rate for Payer: UHC Core |
$12.59
|
| Rate for Payer: UHC Exchange |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$8.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.12
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$16.61
|
|
|
Service Code
|
NDC 45802086801
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna American Axle |
$10.80
|
| Rate for Payer: Aetna Commercial |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.80
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cofinity Advantage |
$11.63
|
| Rate for Payer: Cofinity Commercial |
$14.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.29
|
| Rate for Payer: Healthscope Commercial |
$14.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.46
|
| Rate for Payer: PHP Commercial |
$14.12
|
| Rate for Payer: Priority Health SBD |
$10.46
|
| Rate for Payer: UMR Bronson Commercial |
$7.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.46
|
|
