|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$2.19
|
|
|
Service Code
|
NDC 51079-131-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna American Axle |
$1.42
|
| Rate for Payer: Aetna Commercial |
$1.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.42
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.75
|
| Rate for Payer: Healthscope Commercial |
$1.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.86
|
| Rate for Payer: PHP Commercial |
$1.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.53
|
| Rate for Payer: Priority Health SBD |
$1.38
|
| Rate for Payer: UMR Bronson Commercial |
$0.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.64
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$3.46
|
|
|
Service Code
|
NDC 50268-037-11
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna American Axle |
$2.25
|
| Rate for Payer: Aetna Commercial |
$2.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.25
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.94
|
| Rate for Payer: PHP Commercial |
$2.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: Priority Health SBD |
$2.18
|
| Rate for Payer: UMR Bronson Commercial |
$1.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.60
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$218.55
|
|
|
Service Code
|
NDC 51079-131-20
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.16 |
| Max. Negotiated Rate |
$196.70 |
| Rate for Payer: Aetna American Axle |
$142.06
|
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$152.98
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
| Rate for Payer: Priority Health SBD |
$137.69
|
| Rate for Payer: UMR Bronson Commercial |
$96.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$172.90
|
|
|
Service Code
|
NDC 50268-037-15
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.08 |
| Max. Negotiated Rate |
$155.61 |
| Rate for Payer: Aetna American Axle |
$112.38
|
| Rate for Payer: Aetna Commercial |
$146.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.38
|
| Rate for Payer: Cash Price |
$138.32
|
| Rate for Payer: Cofinity Commercial |
$121.03
|
| Rate for Payer: Cofinity Commercial |
$148.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.32
|
| Rate for Payer: Healthscope Commercial |
$155.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$121.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$129.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$146.96
|
| Rate for Payer: PHP Commercial |
$146.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.03
|
| Rate for Payer: Priority Health SBD |
$108.93
|
| Rate for Payer: UMR Bronson Commercial |
$76.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$129.68
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$211.50
|
|
|
Service Code
|
NDC 29300-419-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.06 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna American Axle |
$137.48
|
| Rate for Payer: Aetna Commercial |
$179.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.48
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cofinity Commercial |
$148.05
|
| Rate for Payer: Cofinity Commercial |
$181.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.20
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.78
|
| Rate for Payer: PHP Commercial |
$179.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.05
|
| Rate for Payer: Priority Health SBD |
$133.24
|
| Rate for Payer: UMR Bronson Commercial |
$93.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.62
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$136.30
|
|
|
Service Code
|
NDC 16729-171-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.97 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.60
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$59.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$141.00
|
|
|
Service Code
|
NDC 70756-201-11
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$225.15
|
|
|
Service Code
|
NDC 0904-7184-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.07 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.60
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$99.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$2.83
|
|
|
Service Code
|
NDC 60687-433-11
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna American Axle |
$1.84
|
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.84
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Commercial |
$1.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.41
|
| Rate for Payer: PHP Commercial |
$2.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$282.15
|
|
|
Service Code
|
NDC 60687-433-01
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.15 |
| Max. Negotiated Rate |
$253.94 |
| Rate for Payer: Aetna American Axle |
$183.40
|
| Rate for Payer: Aetna Commercial |
$239.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.40
|
| Rate for Payer: Cash Price |
$225.72
|
| Rate for Payer: Cofinity Commercial |
$197.50
|
| Rate for Payer: Cofinity Commercial |
$242.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.72
|
| Rate for Payer: Healthscope Commercial |
$253.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.83
|
| Rate for Payer: PHP Commercial |
$239.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.50
|
| Rate for Payer: Priority Health SBD |
$177.75
|
| Rate for Payer: UMR Bronson Commercial |
$124.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.61
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$240.35
|
|
|
Service Code
|
NDC 0904-0201-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.75 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.24
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$105.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$3.32
|
|
|
Service Code
|
NDC 51079-133-01
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna American Axle |
$2.16
|
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.66
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.49
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$336.30
|
|
|
Service Code
|
NDC 0904-7185-61
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.97 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna American Axle |
$218.60
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.60
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.41
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UMR Bronson Commercial |
$147.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$331.55
|
|
|
Service Code
|
NDC 51079-133-20
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.88 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.08
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.08
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$145.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$162.15
|
|
|
Service Code
|
NDC 16729-173-01
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.35 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.50
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UMR Bronson Commercial |
$71.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$409.45
|
|
|
Service Code
|
NDC 0904-0202-61
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.16 |
| Max. Negotiated Rate |
$368.50 |
| Rate for Payer: Aetna American Axle |
$266.14
|
| Rate for Payer: Aetna Commercial |
$348.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.14
|
| Rate for Payer: Cash Price |
$327.56
|
| Rate for Payer: Cofinity Commercial |
$286.62
|
| Rate for Payer: Cofinity Commercial |
$352.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.56
|
| Rate for Payer: Healthscope Commercial |
$368.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$348.03
|
| Rate for Payer: PHP Commercial |
$348.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.62
|
| Rate for Payer: Priority Health SBD |
$257.95
|
| Rate for Payer: UMR Bronson Commercial |
$180.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.09
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$422.75
|
|
|
Service Code
|
NDC 60687-444-01
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.01 |
| Max. Negotiated Rate |
$380.48 |
| Rate for Payer: Aetna American Axle |
$274.79
|
| Rate for Payer: Aetna Commercial |
$359.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.79
|
| Rate for Payer: Cash Price |
$338.20
|
| Rate for Payer: Cofinity Commercial |
$295.92
|
| Rate for Payer: Cofinity Commercial |
$363.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.20
|
| Rate for Payer: Healthscope Commercial |
$380.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$295.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.34
|
| Rate for Payer: PHP Commercial |
$359.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.92
|
| Rate for Payer: Priority Health SBD |
$266.33
|
| Rate for Payer: UMR Bronson Commercial |
$186.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.06
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$4.23
|
|
|
Service Code
|
NDC 60687-444-11
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna American Axle |
$2.75
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.96
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.17
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$326.65
|
|
|
Service Code
|
NDC 70756-203-11
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.73 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna American Axle |
$212.32
|
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: Priority Health SBD |
$205.79
|
| Rate for Payer: UMR Bronson Commercial |
$143.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$326.65
|
|
|
Service Code
|
NDC 60687-496-01
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.73 |
| Max. Negotiated Rate |
$293.98 |
| Rate for Payer: Aetna American Axle |
$212.32
|
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: Priority Health SBD |
$205.79
|
| Rate for Payer: UMR Bronson Commercial |
$143.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.99
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$3.27
|
|
|
Service Code
|
NDC 60687-496-11
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna American Axle |
$2.13
|
| Rate for Payer: Aetna Commercial |
$2.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.13
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$2.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.78
|
| Rate for Payer: PHP Commercial |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.29
|
| Rate for Payer: Priority Health SBD |
$2.06
|
| Rate for Payer: UMR Bronson Commercial |
$1.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.45
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$71.91
|
|
|
Service Code
|
NDC 67877-199-90
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.64 |
| Max. Negotiated Rate |
$64.72 |
| Rate for Payer: Aetna American Axle |
$46.74
|
| Rate for Payer: Aetna Commercial |
$61.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.74
|
| Rate for Payer: Cash Price |
$57.53
|
| Rate for Payer: Cofinity Commercial |
$50.34
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.53
|
| Rate for Payer: Healthscope Commercial |
$64.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$61.12
|
| Rate for Payer: PHP Commercial |
$61.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.34
|
| Rate for Payer: Priority Health SBD |
$45.30
|
| Rate for Payer: UMR Bronson Commercial |
$31.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.93
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$145.70
|
|
|
Service Code
|
NDC 63739-631-10
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.11 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna American Axle |
$94.70
|
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.70
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$101.99
|
| Rate for Payer: Cofinity Commercial |
$125.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.56
|
| Rate for Payer: Healthscope Commercial |
$131.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.99
|
| Rate for Payer: Priority Health SBD |
$91.79
|
| Rate for Payer: UMR Bronson Commercial |
$64.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.28
|
|
|
AMLODIPINE 2.5 MG TABLET
|
Facility
IP
|
$406.08
|
|
|
Service Code
|
NDC 59762-1520-1
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.68 |
| Max. Negotiated Rate |
$365.47 |
| Rate for Payer: Aetna American Axle |
$263.95
|
| Rate for Payer: Aetna Commercial |
$345.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.95
|
| Rate for Payer: Cash Price |
$324.86
|
| Rate for Payer: Cofinity Commercial |
$284.26
|
| Rate for Payer: Cofinity Commercial |
$349.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$324.86
|
| Rate for Payer: Healthscope Commercial |
$365.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$345.17
|
| Rate for Payer: PHP Commercial |
$345.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.26
|
| Rate for Payer: Priority Health SBD |
$255.83
|
| Rate for Payer: UMR Bronson Commercial |
$178.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.56
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$183.30
|
|
|
Service Code
|
NDC 51079-451-20
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.65 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna American Axle |
$119.14
|
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$115.48
|
| Rate for Payer: UMR Bronson Commercial |
$80.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.48
|
|
