|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$298.30
|
|
|
Service Code
|
NDC 65862069201
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.37 |
| Max. Negotiated Rate |
$268.47 |
| Rate for Payer: Aetna American Axle |
$193.90
|
| Rate for Payer: Aetna Commercial |
$253.56
|
| Rate for Payer: Aetna Medicare |
$149.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$193.90
|
| Rate for Payer: BCBS Complete |
$119.32
|
| Rate for Payer: Cash Price |
$238.64
|
| Rate for Payer: Cofinity Commercial |
$208.81
|
| Rate for Payer: Cofinity Commercial |
$256.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$208.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.64
|
| Rate for Payer: Healthscope Commercial |
$268.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$208.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$253.56
|
| Rate for Payer: PHP Commercial |
$253.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.90
|
| Rate for Payer: Priority Health SBD |
$187.93
|
| Rate for Payer: UMR Bronson Commercial |
$110.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.72
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE
|
Facility
|
OP
|
$647.52
|
|
|
Service Code
|
NDC 00071374066
|
| Hospital Charge Code |
11019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$239.58 |
| Max. Negotiated Rate |
$582.77 |
| Rate for Payer: Aetna American Axle |
$420.89
|
| Rate for Payer: Aetna Commercial |
$550.39
|
| Rate for Payer: Aetna Medicare |
$323.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$420.89
|
| Rate for Payer: BCBS Complete |
$259.01
|
| Rate for Payer: Cash Price |
$518.02
|
| Rate for Payer: Cofinity Commercial |
$453.26
|
| Rate for Payer: Cofinity Commercial |
$556.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$453.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$518.02
|
| Rate for Payer: Healthscope Commercial |
$582.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$453.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$485.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$550.39
|
| Rate for Payer: PHP Commercial |
$550.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$420.89
|
| Rate for Payer: Priority Health SBD |
$407.94
|
| Rate for Payer: UMR Bronson Commercial |
$239.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$485.64
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE
|
Facility
|
IP
|
$647.52
|
|
|
Service Code
|
NDC 00071374066
|
| Hospital Charge Code |
11019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.91 |
| Max. Negotiated Rate |
$582.77 |
| Rate for Payer: Aetna American Axle |
$420.89
|
| Rate for Payer: Aetna Commercial |
$550.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$420.89
|
| Rate for Payer: Cash Price |
$518.02
|
| Rate for Payer: Cofinity Commercial |
$453.26
|
| Rate for Payer: Cofinity Commercial |
$556.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$453.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$518.02
|
| Rate for Payer: Healthscope Commercial |
$582.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$453.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$485.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$550.39
|
| Rate for Payer: PHP Commercial |
$550.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$420.89
|
| Rate for Payer: Priority Health SBD |
$407.94
|
| Rate for Payer: UMR Bronson Commercial |
$284.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$485.64
|
|
|
PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$396.95
|
|
|
Service Code
|
CPT 99195
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$67.69 |
| Max. Negotiated Rate |
$396.95 |
| Rate for Payer: Aetna Medicare |
$131.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.86
|
| Rate for Payer: BCBS Complete |
$71.08
|
| Rate for Payer: BCBS MAPPO |
$126.29
|
| Rate for Payer: BCBS Trust/PPO |
$396.06
|
| Rate for Payer: BCN Commercial |
$396.06
|
| Rate for Payer: BCN Medicare Advantage |
$126.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$126.29
|
| Rate for Payer: Mclaren Medicaid |
$67.69
|
| Rate for Payer: Mclaren Medicare |
$126.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.60
|
| Rate for Payer: Meridian Medicaid |
$71.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$145.23
|
| Rate for Payer: Nomi Health Commercial |
$378.87
|
| Rate for Payer: PACE Medicare |
$119.98
|
| Rate for Payer: PACE SWMI |
$126.29
|
| Rate for Payer: PHP Medicare Advantage |
$126.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$396.95
|
| Rate for Payer: Priority Health Medicare |
$126.29
|
| Rate for Payer: Priority Health Narrow Network |
$317.56
|
| Rate for Payer: Railroad Medicare Medicare |
$126.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$126.29
|
| Rate for Payer: UHC Exchange |
$86.13
|
| Rate for Payer: UHC Medicare Advantage |
$126.29
|
| Rate for Payer: UHCCP Medicaid |
$67.69
|
| Rate for Payer: VA VA |
$126.29
|
|
|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L
|
Facility
|
OP
|
$440.80
|
|
|
Service Code
|
NDC 24571011706
|
| Hospital Charge Code |
177187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.10 |
| Max. Negotiated Rate |
$396.72 |
| Rate for Payer: Aetna American Axle |
$286.52
|
| Rate for Payer: Aetna Commercial |
$374.68
|
| Rate for Payer: Aetna Medicare |
$220.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.52
|
| Rate for Payer: BCBS Complete |
$176.32
|
| Rate for Payer: Cash Price |
$352.64
|
| Rate for Payer: Cofinity Commercial |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$379.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.64
|
| Rate for Payer: Healthscope Commercial |
$396.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.68
|
| Rate for Payer: PHP Commercial |
$374.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.52
|
| Rate for Payer: Priority Health SBD |
$277.70
|
| Rate for Payer: UMR Bronson Commercial |
$163.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.60
|
|
|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L
|
Facility
|
IP
|
$440.80
|
|
|
Service Code
|
NDC 24571011706
|
| Hospital Charge Code |
177187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.95 |
| Max. Negotiated Rate |
$396.72 |
| Rate for Payer: Aetna American Axle |
$286.52
|
| Rate for Payer: Aetna Commercial |
$374.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.52
|
| Rate for Payer: Cash Price |
$352.64
|
| Rate for Payer: Cofinity Commercial |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$379.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.64
|
| Rate for Payer: Healthscope Commercial |
$396.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.68
|
| Rate for Payer: PHP Commercial |
$374.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.52
|
| Rate for Payer: Priority Health SBD |
$277.70
|
| Rate for Payer: UMR Bronson Commercial |
$193.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.60
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$258.47
|
|
|
Service Code
|
NDC 17478051002
|
| Hospital Charge Code |
6270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.63 |
| Max. Negotiated Rate |
$232.62 |
| Rate for Payer: Aetna American Axle |
$168.01
|
| Rate for Payer: Aetna Commercial |
$219.70
|
| Rate for Payer: Aetna Medicare |
$129.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.01
|
| Rate for Payer: BCBS Complete |
$103.39
|
| Rate for Payer: Cash Price |
$206.78
|
| Rate for Payer: Cofinity Commercial |
$180.93
|
| Rate for Payer: Cofinity Commercial |
$222.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.78
|
| Rate for Payer: Healthscope Commercial |
$232.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.70
|
| Rate for Payer: PHP Commercial |
$219.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.01
|
| Rate for Payer: Priority Health SBD |
$162.84
|
| Rate for Payer: UMR Bronson Commercial |
$95.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.85
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$258.47
|
|
|
Service Code
|
NDC 17478051002
|
| Hospital Charge Code |
6270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.73 |
| Max. Negotiated Rate |
$232.62 |
| Rate for Payer: Aetna American Axle |
$168.01
|
| Rate for Payer: Aetna Commercial |
$219.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.01
|
| Rate for Payer: Cash Price |
$206.78
|
| Rate for Payer: Cofinity Commercial |
$180.93
|
| Rate for Payer: Cofinity Commercial |
$222.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.78
|
| Rate for Payer: Healthscope Commercial |
$232.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.70
|
| Rate for Payer: PHP Commercial |
$219.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.01
|
| Rate for Payer: Priority Health SBD |
$162.84
|
| Rate for Payer: UMR Bronson Commercial |
$113.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.85
|
|
|
PHYTONADIONE ORAL SOLUTION 10 MG/ML
|
Facility
|
IP
|
$88.13
|
|
|
Service Code
|
NDC 00409915801
|
| Hospital Charge Code |
150708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.78 |
| Max. Negotiated Rate |
$79.32 |
| Rate for Payer: Aetna American Axle |
$57.28
|
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.28
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cofinity Commercial |
$61.69
|
| Rate for Payer: Cofinity Commercial |
$75.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.50
|
| Rate for Payer: Healthscope Commercial |
$79.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.91
|
| Rate for Payer: PHP Commercial |
$74.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.28
|
| Rate for Payer: Priority Health SBD |
$55.52
|
| Rate for Payer: UMR Bronson Commercial |
$38.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.10
|
|
|
PHYTONADIONE ORAL SOLUTION 10 MG/ML
|
Facility
|
OP
|
$88.13
|
|
|
Service Code
|
NDC 00409915801
|
| Hospital Charge Code |
150708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$79.32 |
| Rate for Payer: Aetna American Axle |
$57.28
|
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: Aetna Medicare |
$44.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.28
|
| Rate for Payer: BCBS Complete |
$35.25
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cofinity Commercial |
$61.69
|
| Rate for Payer: Cofinity Commercial |
$75.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.50
|
| Rate for Payer: Healthscope Commercial |
$79.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.91
|
| Rate for Payer: PHP Commercial |
$74.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.28
|
| Rate for Payer: Priority Health SBD |
$55.52
|
| Rate for Payer: UMR Bronson Commercial |
$32.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.10
|
|
|
PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE
|
Facility
|
OP
|
$340.75
|
|
|
Service Code
|
NDC 05105010500
|
| Hospital Charge Code |
196288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.08 |
| Max. Negotiated Rate |
$306.68 |
| Rate for Payer: Aetna American Axle |
$221.49
|
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna Medicare |
$170.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: BCBS Complete |
$136.30
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cofinity Commercial |
$238.52
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.64
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.49
|
| Rate for Payer: Priority Health SBD |
$214.67
|
| Rate for Payer: UMR Bronson Commercial |
$126.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.56
|
|
|
PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE
|
Facility
|
IP
|
$340.75
|
|
|
Service Code
|
NDC 05105010500
|
| Hospital Charge Code |
196288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.93 |
| Max. Negotiated Rate |
$306.68 |
| Rate for Payer: Aetna American Axle |
$221.49
|
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cofinity Commercial |
$238.52
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.64
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.49
|
| Rate for Payer: Priority Health SBD |
$214.67
|
| Rate for Payer: UMR Bronson Commercial |
$149.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.56
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$105.99
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.64 |
| Max. Negotiated Rate |
$95.39 |
| Rate for Payer: Aetna American Axle |
$68.89
|
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.89
|
| Rate for Payer: Cash Price |
$84.79
|
| Rate for Payer: Cofinity Commercial |
$74.19
|
| Rate for Payer: Cofinity Commercial |
$91.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.79
|
| Rate for Payer: Healthscope Commercial |
$95.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.09
|
| Rate for Payer: PHP Commercial |
$90.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.89
|
| Rate for Payer: Priority Health SBD |
$66.77
|
| Rate for Payer: UMR Bronson Commercial |
$46.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.49
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$105.99
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$95.39 |
| Rate for Payer: Aetna American Axle |
$68.89
|
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Aetna Medicare |
$53.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.89
|
| Rate for Payer: BCBS Complete |
$42.40
|
| Rate for Payer: BCBS Trust/PPO |
$6.75
|
| Rate for Payer: BCN Commercial |
$6.75
|
| Rate for Payer: Cash Price |
$84.79
|
| Rate for Payer: Cash Price |
$84.79
|
| Rate for Payer: Cofinity Commercial |
$74.19
|
| Rate for Payer: Cofinity Commercial |
$91.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.79
|
| Rate for Payer: Healthscope Commercial |
$95.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.09
|
| Rate for Payer: PHP Commercial |
$90.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.89
|
| Rate for Payer: Priority Health SBD |
$66.77
|
| Rate for Payer: UMR Bronson Commercial |
$39.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.49
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.09
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
108266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$21.68 |
| Rate for Payer: Aetna American Axle |
$15.66
|
| Rate for Payer: Aetna American Axle |
$18.12
|
| Rate for Payer: Aetna Commercial |
$23.70
|
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: Aetna Medicare |
$12.04
|
| Rate for Payer: Aetna Medicare |
$13.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.12
|
| Rate for Payer: BCBS Complete |
$11.15
|
| Rate for Payer: BCBS Complete |
$9.64
|
| Rate for Payer: BCBS Trust/PPO |
$6.75
|
| Rate for Payer: BCBS Trust/PPO |
$6.75
|
| Rate for Payer: BCN Commercial |
$6.75
|
| Rate for Payer: BCN Commercial |
$6.75
|
| Rate for Payer: Cash Price |
$22.30
|
| Rate for Payer: Cash Price |
$22.30
|
| Rate for Payer: Cash Price |
$19.27
|
| Rate for Payer: Cash Price |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$23.98
|
| Rate for Payer: Cofinity Commercial |
$16.86
|
| Rate for Payer: Cofinity Commercial |
$19.52
|
| Rate for Payer: Cofinity Commercial |
$20.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.27
|
| Rate for Payer: Healthscope Commercial |
$25.09
|
| Rate for Payer: Healthscope Commercial |
$21.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.70
|
| Rate for Payer: PHP Commercial |
$20.48
|
| Rate for Payer: PHP Commercial |
$23.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.12
|
| Rate for Payer: Priority Health SBD |
$17.56
|
| Rate for Payer: Priority Health SBD |
$15.18
|
| Rate for Payer: UMR Bronson Commercial |
$8.91
|
| Rate for Payer: UMR Bronson Commercial |
$10.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.07
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.09
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
108266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$21.68 |
| Rate for Payer: Aetna American Axle |
$15.66
|
| Rate for Payer: Aetna American Axle |
$18.12
|
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: Aetna Commercial |
$23.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.12
|
| Rate for Payer: Cash Price |
$19.27
|
| Rate for Payer: Cash Price |
$22.30
|
| Rate for Payer: Cofinity Commercial |
$23.98
|
| Rate for Payer: Cofinity Commercial |
$19.52
|
| Rate for Payer: Cofinity Commercial |
$16.86
|
| Rate for Payer: Cofinity Commercial |
$20.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.30
|
| Rate for Payer: Healthscope Commercial |
$21.68
|
| Rate for Payer: Healthscope Commercial |
$25.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: PHP Commercial |
$23.70
|
| Rate for Payer: PHP Commercial |
$20.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.12
|
| Rate for Payer: Priority Health SBD |
$15.18
|
| Rate for Payer: Priority Health SBD |
$17.56
|
| Rate for Payer: UMR Bronson Commercial |
$10.60
|
| Rate for Payer: UMR Bronson Commercial |
$12.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.91
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
IP
|
$4,114.66
|
|
|
Service Code
|
NDC 69238105103
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,810.45 |
| Max. Negotiated Rate |
$3,703.19 |
| Rate for Payer: Aetna American Axle |
$2,674.53
|
| Rate for Payer: Aetna Commercial |
$3,497.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,674.53
|
| Rate for Payer: Cash Price |
$3,291.73
|
| Rate for Payer: Cofinity Commercial |
$2,880.26
|
| Rate for Payer: Cofinity Commercial |
$3,538.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,880.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,291.73
|
| Rate for Payer: Healthscope Commercial |
$3,703.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,880.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,086.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,497.46
|
| Rate for Payer: PHP Commercial |
$3,497.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,674.53
|
| Rate for Payer: Priority Health SBD |
$2,592.24
|
| Rate for Payer: UMR Bronson Commercial |
$1,810.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,086.00
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
OP
|
$4,114.66
|
|
|
Service Code
|
NDC 69238105103
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,522.42 |
| Max. Negotiated Rate |
$3,703.19 |
| Rate for Payer: Aetna American Axle |
$2,674.53
|
| Rate for Payer: Aetna Commercial |
$3,497.46
|
| Rate for Payer: Aetna Medicare |
$2,057.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,674.53
|
| Rate for Payer: BCBS Complete |
$1,645.86
|
| Rate for Payer: Cash Price |
$3,291.73
|
| Rate for Payer: Cofinity Commercial |
$2,880.26
|
| Rate for Payer: Cofinity Commercial |
$3,538.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,880.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,291.73
|
| Rate for Payer: Healthscope Commercial |
$3,703.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,880.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,086.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,497.46
|
| Rate for Payer: PHP Commercial |
$3,497.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,674.53
|
| Rate for Payer: Priority Health SBD |
$2,592.24
|
| Rate for Payer: UMR Bronson Commercial |
$1,522.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,086.00
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
OP
|
$136.98
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$123.28 |
| Rate for Payer: Aetna American Axle |
$89.04
|
| Rate for Payer: Aetna Commercial |
$116.43
|
| Rate for Payer: Aetna Medicare |
$68.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.04
|
| Rate for Payer: BCBS Complete |
$54.79
|
| Rate for Payer: Cash Price |
$109.58
|
| Rate for Payer: Cofinity Commercial |
$117.80
|
| Rate for Payer: Cofinity Commercial |
$95.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.58
|
| Rate for Payer: Healthscope Commercial |
$123.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.43
|
| Rate for Payer: PHP Commercial |
$116.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.04
|
| Rate for Payer: Priority Health SBD |
$86.30
|
| Rate for Payer: UMR Bronson Commercial |
$50.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.74
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
OP
|
$156.93
|
|
|
Service Code
|
NDC 17478022312
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.06 |
| Max. Negotiated Rate |
$141.24 |
| Rate for Payer: Aetna American Axle |
$102.00
|
| Rate for Payer: Aetna Commercial |
$133.39
|
| Rate for Payer: Aetna Medicare |
$78.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.00
|
| Rate for Payer: BCBS Complete |
$62.77
|
| Rate for Payer: Cash Price |
$125.54
|
| Rate for Payer: Cofinity Commercial |
$109.85
|
| Rate for Payer: Cofinity Commercial |
$134.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.54
|
| Rate for Payer: Healthscope Commercial |
$141.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.39
|
| Rate for Payer: PHP Commercial |
$133.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.00
|
| Rate for Payer: Priority Health SBD |
$98.87
|
| Rate for Payer: UMR Bronson Commercial |
$58.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.70
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
IP
|
$156.93
|
|
|
Service Code
|
NDC 17478022312
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.05 |
| Max. Negotiated Rate |
$141.24 |
| Rate for Payer: Aetna American Axle |
$102.00
|
| Rate for Payer: Aetna Commercial |
$133.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.00
|
| Rate for Payer: Cash Price |
$125.54
|
| Rate for Payer: Cofinity Commercial |
$109.85
|
| Rate for Payer: Cofinity Commercial |
$134.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.54
|
| Rate for Payer: Healthscope Commercial |
$141.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.39
|
| Rate for Payer: PHP Commercial |
$133.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.00
|
| Rate for Payer: Priority Health SBD |
$98.87
|
| Rate for Payer: UMR Bronson Commercial |
$69.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.70
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
OP
|
$304.61
|
|
|
Service Code
|
NDC 00998020315
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.71 |
| Max. Negotiated Rate |
$274.15 |
| Rate for Payer: Aetna American Axle |
$198.00
|
| Rate for Payer: Aetna Commercial |
$258.92
|
| Rate for Payer: Aetna Medicare |
$152.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.00
|
| Rate for Payer: BCBS Complete |
$121.84
|
| Rate for Payer: Cash Price |
$243.69
|
| Rate for Payer: Cofinity Commercial |
$213.23
|
| Rate for Payer: Cofinity Commercial |
$261.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.69
|
| Rate for Payer: Healthscope Commercial |
$274.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.92
|
| Rate for Payer: PHP Commercial |
$258.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.00
|
| Rate for Payer: Priority Health SBD |
$191.90
|
| Rate for Payer: UMR Bronson Commercial |
$112.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.46
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
IP
|
$304.61
|
|
|
Service Code
|
NDC 00998020315
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.03 |
| Max. Negotiated Rate |
$274.15 |
| Rate for Payer: Aetna American Axle |
$198.00
|
| Rate for Payer: Aetna Commercial |
$258.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.00
|
| Rate for Payer: Cash Price |
$243.69
|
| Rate for Payer: Cofinity Commercial |
$213.23
|
| Rate for Payer: Cofinity Commercial |
$261.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.69
|
| Rate for Payer: Healthscope Commercial |
$274.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.92
|
| Rate for Payer: PHP Commercial |
$258.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.00
|
| Rate for Payer: Priority Health SBD |
$191.90
|
| Rate for Payer: UMR Bronson Commercial |
$134.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.46
|
|
|
PILOCARPINE 1 % EYE DROPS
|
Facility
|
IP
|
$136.98
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
6279
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$123.28 |
| Rate for Payer: Aetna American Axle |
$89.04
|
| Rate for Payer: Aetna Commercial |
$116.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.04
|
| Rate for Payer: Cash Price |
$109.58
|
| Rate for Payer: Cofinity Commercial |
$117.80
|
| Rate for Payer: Cofinity Commercial |
$95.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.58
|
| Rate for Payer: Healthscope Commercial |
$123.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.43
|
| Rate for Payer: PHP Commercial |
$116.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.04
|
| Rate for Payer: Priority Health SBD |
$86.30
|
| Rate for Payer: UMR Bronson Commercial |
$60.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.74
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
IP
|
$132.62
|
|
|
Service Code
|
NDC 70069019101
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.35 |
| Max. Negotiated Rate |
$119.36 |
| Rate for Payer: Aetna American Axle |
$86.20
|
| Rate for Payer: Aetna Commercial |
$112.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.20
|
| Rate for Payer: Cash Price |
$106.10
|
| Rate for Payer: Cofinity Commercial |
$114.05
|
| Rate for Payer: Cofinity Commercial |
$92.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.10
|
| Rate for Payer: Healthscope Commercial |
$119.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.73
|
| Rate for Payer: PHP Commercial |
$112.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.20
|
| Rate for Payer: Priority Health SBD |
$83.55
|
| Rate for Payer: UMR Bronson Commercial |
$58.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.46
|
|
