|
BUSPIRONE 30 MG TABLET
|
Facility
|
OP
|
$132.81
|
|
|
Service Code
|
NDC 24689093306
|
| Hospital Charge Code |
27046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$119.53 |
| Rate for Payer: Aetna American Axle |
$86.33
|
| Rate for Payer: Aetna Commercial |
$112.89
|
| Rate for Payer: Aetna Medicare |
$66.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.33
|
| Rate for Payer: BCBS Complete |
$53.12
|
| Rate for Payer: Cash Price |
$106.25
|
| Rate for Payer: Cofinity Commercial |
$114.22
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.25
|
| Rate for Payer: Healthscope Commercial |
$119.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.89
|
| Rate for Payer: PHP Commercial |
$112.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.33
|
| Rate for Payer: Priority Health SBD |
$83.67
|
| Rate for Payer: UMR Bronson Commercial |
$49.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.61
|
|
|
BUSPIRONE 30 MG TABLET
|
Facility
|
OP
|
$176.13
|
|
|
Service Code
|
NDC 68382018314
|
| Hospital Charge Code |
27046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.17 |
| Max. Negotiated Rate |
$158.52 |
| Rate for Payer: Aetna American Axle |
$114.48
|
| Rate for Payer: Aetna Commercial |
$149.71
|
| Rate for Payer: Aetna Medicare |
$88.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.48
|
| Rate for Payer: BCBS Complete |
$70.45
|
| Rate for Payer: Cash Price |
$140.90
|
| Rate for Payer: Cofinity Commercial |
$123.29
|
| Rate for Payer: Cofinity Commercial |
$151.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.90
|
| Rate for Payer: Healthscope Commercial |
$158.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.71
|
| Rate for Payer: PHP Commercial |
$149.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.48
|
| Rate for Payer: Priority Health SBD |
$110.96
|
| Rate for Payer: UMR Bronson Commercial |
$65.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.10
|
|
|
BUSPIRONE 30 MG TABLET
|
Facility
|
IP
|
$176.13
|
|
|
Service Code
|
NDC 68382018314
|
| Hospital Charge Code |
27046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.50 |
| Max. Negotiated Rate |
$158.52 |
| Rate for Payer: Aetna American Axle |
$114.48
|
| Rate for Payer: Aetna Commercial |
$149.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.48
|
| Rate for Payer: Cash Price |
$140.90
|
| Rate for Payer: Cofinity Commercial |
$123.29
|
| Rate for Payer: Cofinity Commercial |
$151.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.90
|
| Rate for Payer: Healthscope Commercial |
$158.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.71
|
| Rate for Payer: PHP Commercial |
$149.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.48
|
| Rate for Payer: Priority Health SBD |
$110.96
|
| Rate for Payer: UMR Bronson Commercial |
$77.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.10
|
|
|
BUSPIRONE 30 MG TABLET
|
Facility
|
IP
|
$253.16
|
|
|
Service Code
|
NDC 00093520006
|
| Hospital Charge Code |
27046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.39 |
| Max. Negotiated Rate |
$227.84 |
| Rate for Payer: Aetna American Axle |
$164.55
|
| Rate for Payer: Aetna Commercial |
$215.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.55
|
| Rate for Payer: Cash Price |
$202.53
|
| Rate for Payer: Cofinity Commercial |
$177.21
|
| Rate for Payer: Cofinity Commercial |
$217.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.53
|
| Rate for Payer: Healthscope Commercial |
$227.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$189.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.19
|
| Rate for Payer: PHP Commercial |
$215.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.55
|
| Rate for Payer: Priority Health SBD |
$159.49
|
| Rate for Payer: UMR Bronson Commercial |
$111.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$189.87
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$119.85
|
|
|
Service Code
|
NDC 00093005301
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.73 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Cofinity Commercial |
$83.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.90
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UMR Bronson Commercial |
$52.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$65.80
|
|
|
Service Code
|
NDC 16729020001
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna American Axle |
$42.77
|
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna Medicare |
$32.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: BCBS Complete |
$26.32
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.77
|
| Rate for Payer: Priority Health SBD |
$41.45
|
| Rate for Payer: UMR Bronson Commercial |
$24.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.35
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 59651038901
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$105.75
|
|
|
Service Code
|
NDC 59651038901
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Medicare |
$52.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: BCBS Complete |
$42.30
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$65.80
|
|
|
Service Code
|
NDC 16729020001
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.95 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna American Axle |
$42.77
|
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.77
|
| Rate for Payer: Priority Health SBD |
$41.45
|
| Rate for Payer: UMR Bronson Commercial |
$28.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.35
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$119.85
|
|
|
Service Code
|
NDC 00093005301
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna Medicare |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: BCBS Complete |
$47.94
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Cofinity Commercial |
$83.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.90
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UMR Bronson Commercial |
$44.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
BUSPIRONE 7.5 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 16729020101
|
| Hospital Charge Code |
29967
|
|
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: Cofinity Medicare Advantage |
$157.60
|
| 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 Commercial |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.35
|
| 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
|
|
|
BUSPIRONE 7.5 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 64380078706
|
| Hospital Charge Code |
29967
|
|
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: Cofinity Medicare Advantage |
$157.60
|
| 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 Commercial |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.35
|
| 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
|
|
|
BUSPIRONE 7.5 MG TABLET
|
Facility
|
OP
|
$225.15
|
|
|
Service Code
|
NDC 64380078706
|
| Hospital Charge Code |
29967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna Medicare |
$112.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: BCBS Complete |
$90.06
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.60
|
| 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 Commercial |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.35
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$83.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
BUSPIRONE 7.5 MG TABLET
|
Facility
|
IP
|
$368.95
|
|
|
Service Code
|
NDC 72888006301
|
| Hospital Charge Code |
29967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.34 |
| Max. Negotiated Rate |
$332.06 |
| Rate for Payer: Aetna American Axle |
$239.82
|
| Rate for Payer: Aetna Commercial |
$313.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$239.82
|
| Rate for Payer: Cash Price |
$295.16
|
| Rate for Payer: Cofinity Commercial |
$258.26
|
| Rate for Payer: Cofinity Commercial |
$317.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$258.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.16
|
| Rate for Payer: Healthscope Commercial |
$332.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$258.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$276.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$313.61
|
| Rate for Payer: PHP Commercial |
$313.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$239.82
|
| Rate for Payer: Priority Health SBD |
$232.44
|
| Rate for Payer: UMR Bronson Commercial |
$162.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$276.71
|
|
|
BUSPIRONE 7.5 MG TABLET
|
Facility
|
OP
|
$368.95
|
|
|
Service Code
|
NDC 72888006301
|
| Hospital Charge Code |
29967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.51 |
| Max. Negotiated Rate |
$332.06 |
| Rate for Payer: Aetna American Axle |
$239.82
|
| Rate for Payer: Aetna Commercial |
$313.61
|
| Rate for Payer: Aetna Medicare |
$184.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$239.82
|
| Rate for Payer: BCBS Complete |
$147.58
|
| Rate for Payer: Cash Price |
$295.16
|
| Rate for Payer: Cofinity Commercial |
$258.26
|
| Rate for Payer: Cofinity Commercial |
$317.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$258.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.16
|
| Rate for Payer: Healthscope Commercial |
$332.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$258.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$276.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$313.61
|
| Rate for Payer: PHP Commercial |
$313.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$239.82
|
| Rate for Payer: Priority Health SBD |
$232.44
|
| Rate for Payer: UMR Bronson Commercial |
$136.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$276.71
|
|
|
BUSPIRONE 7.5 MG TABLET
|
Facility
|
OP
|
$225.15
|
|
|
Service Code
|
NDC 16729020101
|
| Hospital Charge Code |
29967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna Medicare |
$112.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: BCBS Complete |
$90.06
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.60
|
| 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 Commercial |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.35
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$83.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$3,472.00
|
|
|
Service Code
|
NDC 00603254428
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,284.64 |
| Max. Negotiated Rate |
$3,124.80 |
| Rate for Payer: Aetna American Axle |
$2,256.80
|
| Rate for Payer: Aetna Commercial |
$2,951.20
|
| Rate for Payer: Aetna Medicare |
$1,736.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,256.80
|
| Rate for Payer: BCBS Complete |
$1,388.80
|
| Rate for Payer: Cash Price |
$2,777.60
|
| Rate for Payer: Cofinity Commercial |
$2,430.40
|
| Rate for Payer: Cofinity Commercial |
$2,985.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,430.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,777.60
|
| Rate for Payer: Healthscope Commercial |
$3,124.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,430.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,604.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,951.20
|
| Rate for Payer: PHP Commercial |
$2,951.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,256.80
|
| Rate for Payer: Priority Health SBD |
$2,187.36
|
| Rate for Payer: UMR Bronson Commercial |
$1,284.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,604.00
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$10.65
|
|
|
Service Code
|
NDC 68084039611
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna American Axle |
$6.92
|
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna Medicare |
$5.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.92
|
| Rate for Payer: BCBS Complete |
$4.26
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cofinity Commercial |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$9.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.52
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.05
|
| Rate for Payer: PHP Commercial |
$9.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.92
|
| Rate for Payer: Priority Health SBD |
$6.71
|
| Rate for Payer: UMR Bronson Commercial |
$3.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.99
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$302.75
|
|
|
Service Code
|
NDC 00527169501
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.21 |
| Max. Negotiated Rate |
$272.48 |
| Rate for Payer: Aetna American Axle |
$196.79
|
| Rate for Payer: Aetna Commercial |
$257.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.79
|
| Rate for Payer: Cash Price |
$242.20
|
| Rate for Payer: Cofinity Commercial |
$211.92
|
| Rate for Payer: Cofinity Commercial |
$260.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$211.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.20
|
| Rate for Payer: Healthscope Commercial |
$272.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$211.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$227.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.34
|
| Rate for Payer: PHP Commercial |
$257.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.79
|
| Rate for Payer: Priority Health SBD |
$190.73
|
| Rate for Payer: UMR Bronson Commercial |
$133.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$227.06
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$434.70
|
|
|
Service Code
|
NDC 00591336901
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.84 |
| Max. Negotiated Rate |
$391.23 |
| Rate for Payer: Aetna American Axle |
$282.56
|
| Rate for Payer: Aetna Commercial |
$369.50
|
| Rate for Payer: Aetna Medicare |
$217.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.56
|
| Rate for Payer: BCBS Complete |
$173.88
|
| Rate for Payer: Cash Price |
$347.76
|
| Rate for Payer: Cofinity Commercial |
$304.29
|
| Rate for Payer: Cofinity Commercial |
$373.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$347.76
|
| Rate for Payer: Healthscope Commercial |
$391.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.50
|
| Rate for Payer: PHP Commercial |
$369.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.56
|
| Rate for Payer: Priority Health SBD |
$273.86
|
| Rate for Payer: UMR Bronson Commercial |
$160.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.02
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$434.70
|
|
|
Service Code
|
NDC 00591336901
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.27 |
| Max. Negotiated Rate |
$391.23 |
| Rate for Payer: Aetna American Axle |
$282.56
|
| Rate for Payer: Aetna Commercial |
$369.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.56
|
| Rate for Payer: Cash Price |
$347.76
|
| Rate for Payer: Cofinity Commercial |
$304.29
|
| Rate for Payer: Cofinity Commercial |
$373.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$304.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$347.76
|
| Rate for Payer: Healthscope Commercial |
$391.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$304.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$326.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$369.50
|
| Rate for Payer: PHP Commercial |
$369.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.56
|
| Rate for Payer: Priority Health SBD |
$273.86
|
| Rate for Payer: UMR Bronson Commercial |
$191.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$326.02
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$3,472.00
|
|
|
Service Code
|
NDC 00603254428
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,527.68 |
| Max. Negotiated Rate |
$3,124.80 |
| Rate for Payer: Aetna American Axle |
$2,256.80
|
| Rate for Payer: Aetna Commercial |
$2,951.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,256.80
|
| Rate for Payer: Cash Price |
$2,777.60
|
| Rate for Payer: Cofinity Commercial |
$2,430.40
|
| Rate for Payer: Cofinity Commercial |
$2,985.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,430.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,777.60
|
| Rate for Payer: Healthscope Commercial |
$3,124.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,430.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,604.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,951.20
|
| Rate for Payer: PHP Commercial |
$2,951.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,256.80
|
| Rate for Payer: Priority Health SBD |
$2,187.36
|
| Rate for Payer: UMR Bronson Commercial |
$1,527.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,604.00
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$10.65
|
|
|
Service Code
|
NDC 68084039611
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna American Axle |
$6.92
|
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.92
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cofinity Commercial |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$9.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.52
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.05
|
| Rate for Payer: PHP Commercial |
$9.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.92
|
| Rate for Payer: Priority Health SBD |
$6.71
|
| Rate for Payer: UMR Bronson Commercial |
$4.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.99
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
NDC 46672005310
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna American Axle |
$95.55
|
| Rate for Payer: Aetna Commercial |
$124.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.55
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cofinity Commercial |
$102.90
|
| Rate for Payer: Cofinity Commercial |
$126.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$102.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.60
|
| Rate for Payer: Healthscope Commercial |
$132.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.95
|
| Rate for Payer: PHP Commercial |
$124.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.55
|
| Rate for Payer: Priority Health SBD |
$92.61
|
| Rate for Payer: UMR Bronson Commercial |
$64.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.25
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
NDC 46672005310
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna American Axle |
$95.55
|
| Rate for Payer: Aetna Commercial |
$124.95
|
| Rate for Payer: Aetna Medicare |
$73.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.55
|
| Rate for Payer: BCBS Complete |
$58.80
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cofinity Commercial |
$102.90
|
| Rate for Payer: Cofinity Commercial |
$126.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$102.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.60
|
| Rate for Payer: Healthscope Commercial |
$132.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.95
|
| Rate for Payer: PHP Commercial |
$124.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.55
|
| Rate for Payer: Priority Health SBD |
$92.61
|
| Rate for Payer: UMR Bronson Commercial |
$54.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.25
|
|
