|
TRAZODONE 25 MG CUSTOM TAB
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 09900000314
|
| Hospital Charge Code |
155125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna American Axle |
$0.60
|
| Rate for Payer: Aetna Commercial |
$0.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.60
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cofinity Commercial |
$0.64
|
| Rate for Payer: Cofinity Commercial |
$0.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.74
|
| Rate for Payer: Healthscope Commercial |
$0.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.78
|
| Rate for Payer: PHP Commercial |
$0.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.60
|
| Rate for Payer: Priority Health SBD |
$0.58
|
| Rate for Payer: UMR Bronson Commercial |
$0.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.69
|
|
|
TRAZODONE 25 MG CUSTOM TAB
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 09900000314
|
| Hospital Charge Code |
155125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna American Axle |
$0.60
|
| Rate for Payer: Aetna Commercial |
$0.78
|
| Rate for Payer: Aetna Medicare |
$0.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.60
|
| Rate for Payer: BCBS Complete |
$0.37
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cofinity Commercial |
$0.64
|
| Rate for Payer: Cofinity Commercial |
$0.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.74
|
| Rate for Payer: Healthscope Commercial |
$0.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.78
|
| Rate for Payer: PHP Commercial |
$0.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.60
|
| Rate for Payer: Priority Health SBD |
$0.58
|
| Rate for Payer: UMR Bronson Commercial |
$0.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.69
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$2.71
|
|
|
Service Code
|
NDC 60687044311
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Aetna American Axle |
$1.76
|
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Aetna Medicare |
$1.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.76
|
| Rate for Payer: BCBS Complete |
$1.08
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.17
|
| Rate for Payer: Healthscope Commercial |
$2.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.76
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UMR Bronson Commercial |
$1.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.03
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$126.90
|
|
|
Service Code
|
NDC 50111056001
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.84 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna American Axle |
$82.48
|
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.48
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Cofinity Commercial |
$88.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$88.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.86
|
| Rate for Payer: PHP Commercial |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.48
|
| Rate for Payer: Priority Health SBD |
$79.95
|
| Rate for Payer: UMR Bronson Commercial |
$55.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.17
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$145.70
|
|
|
Service Code
|
NDC 13668033001
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.91 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna American Axle |
$94.70
|
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Aetna Medicare |
$72.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.70
|
| Rate for Payer: BCBS Complete |
$58.28
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$101.99
|
| Rate for Payer: Cofinity Commercial |
$125.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.99
|
| 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 Commercial |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.70
|
| Rate for Payer: Priority Health SBD |
$91.79
|
| Rate for Payer: UMR Bronson Commercial |
$53.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.28
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$126.90
|
|
|
Service Code
|
NDC 50111056001
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.95 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna American Axle |
$82.48
|
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: Aetna Medicare |
$63.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.48
|
| Rate for Payer: BCBS Complete |
$50.76
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Cofinity Commercial |
$88.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$88.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.86
|
| Rate for Payer: PHP Commercial |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.48
|
| Rate for Payer: Priority Health SBD |
$79.95
|
| Rate for Payer: UMR Bronson Commercial |
$46.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.17
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$270.25
|
|
|
Service Code
|
NDC 60687044301
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.91 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna American Axle |
$175.66
|
| Rate for Payer: Aetna Commercial |
$229.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.66
|
| Rate for Payer: Cash Price |
$216.20
|
| Rate for Payer: Cofinity Commercial |
$189.18
|
| Rate for Payer: Cofinity Commercial |
$232.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$189.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.20
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.71
|
| Rate for Payer: PHP Commercial |
$229.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.66
|
| Rate for Payer: Priority Health SBD |
$170.26
|
| Rate for Payer: UMR Bronson Commercial |
$118.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.69
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$270.25
|
|
|
Service Code
|
NDC 60687044301
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.99 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna American Axle |
$175.66
|
| Rate for Payer: Aetna Commercial |
$229.71
|
| Rate for Payer: Aetna Medicare |
$135.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.66
|
| Rate for Payer: BCBS Complete |
$108.10
|
| Rate for Payer: Cash Price |
$216.20
|
| Rate for Payer: Cofinity Commercial |
$189.18
|
| Rate for Payer: Cofinity Commercial |
$232.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$189.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.20
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.71
|
| Rate for Payer: PHP Commercial |
$229.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.66
|
| Rate for Payer: Priority Health SBD |
$170.26
|
| Rate for Payer: UMR Bronson Commercial |
$99.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.69
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$2.71
|
|
|
Service Code
|
NDC 60687044311
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Aetna American Axle |
$1.76
|
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.76
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.17
|
| Rate for Payer: Healthscope Commercial |
$2.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.76
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UMR Bronson Commercial |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.03
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 68382080501
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.56 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.27
|
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.27
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$47.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$145.70
|
|
|
Service Code
|
NDC 13107007901
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.91 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna American Axle |
$94.70
|
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Aetna Medicare |
$72.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.70
|
| Rate for Payer: BCBS Complete |
$58.28
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$101.99
|
| Rate for Payer: Cofinity Commercial |
$125.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.99
|
| 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 Commercial |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.70
|
| Rate for Payer: Priority Health SBD |
$91.79
|
| Rate for Payer: UMR Bronson Commercial |
$53.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.28
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$244.40
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna American Axle |
$158.86
|
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna Medicare |
$122.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: BCBS Complete |
$97.76
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health SBD |
$153.97
|
| Rate for Payer: UMR Bronson Commercial |
$90.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
OP
|
$108.10
|
|
|
Service Code
|
NDC 68382080501
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.27
|
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna Medicare |
$54.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: BCBS Complete |
$43.24
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.27
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$40.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 00904686861
|
| Hospital Charge Code |
8085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.54 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna American Axle |
$158.86
|
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health SBD |
$153.97
|
| Rate for Payer: UMR Bronson Commercial |
$107.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$145.70
|
|
|
Service Code
|
NDC 13668033001
|
| Hospital Charge Code |
8085
|
|
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: Cofinity Medicare Advantage |
$101.99
|
| 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 Commercial |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.70
|
| 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
|
|
|
TRAZODONE 50 MG TABLET
|
Facility
|
IP
|
$145.70
|
|
|
Service Code
|
NDC 13107007901
|
| Hospital Charge Code |
8085
|
|
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: Cofinity Medicare Advantage |
$101.99
|
| 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 Commercial |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.70
|
| 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
|
|
|
TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 24605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Exchange |
$2,982.94
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$836.62
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS
|
Facility
|
OP
|
$35,323.48
|
|
|
Service Code
|
CPT 24516
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,726.13 |
| Max. Negotiated Rate |
$35,323.48 |
| Rate for Payer: Aetna Medicare |
$13,050.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,685.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,685.94
|
| Rate for Payer: BCBS Complete |
$7,062.44
|
| Rate for Payer: BCBS MAPPO |
$12,548.75
|
| Rate for Payer: BCN Medicare Advantage |
$12,548.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,548.75
|
| Rate for Payer: Mclaren Medicaid |
$6,726.13
|
| Rate for Payer: Mclaren Medicare |
$12,548.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,176.19
|
| Rate for Payer: Meridian Medicaid |
$7,062.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,431.06
|
| Rate for Payer: PACE Medicare |
$11,921.31
|
| Rate for Payer: PACE SWMI |
$12,548.75
|
| Rate for Payer: PHP Medicare Advantage |
$12,548.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,726.13
|
| Rate for Payer: Priority Health Medicare |
$12,548.75
|
| Rate for Payer: Railroad Medicare Medicare |
$12,548.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35,323.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,548.75
|
| Rate for Payer: UHC Exchange |
$23,981.92
|
| Rate for Payer: UHC Medicare Advantage |
$12,548.75
|
| Rate for Payer: UHCCP Medicaid |
$6,726.13
|
| Rate for Payer: VA VA |
$12,548.75
|
|
|
TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 59812
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 59820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 59821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE
|
Facility
|
OP
|
$1,680.50
|
|
|
Service Code
|
CPT 12020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$319.99 |
| Max. Negotiated Rate |
$1,680.50 |
| Rate for Payer: Aetna Medicare |
$620.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$746.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$746.25
|
| Rate for Payer: BCBS Complete |
$335.99
|
| Rate for Payer: BCBS MAPPO |
$597.00
|
| Rate for Payer: BCN Medicare Advantage |
$597.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$597.00
|
| Rate for Payer: Mclaren Medicaid |
$319.99
|
| Rate for Payer: Mclaren Medicare |
$597.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$626.85
|
| Rate for Payer: Meridian Medicaid |
$335.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$686.55
|
| Rate for Payer: PACE Medicare |
$567.15
|
| Rate for Payer: PACE SWMI |
$597.00
|
| Rate for Payer: PHP Medicare Advantage |
$597.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$319.99
|
| Rate for Payer: Priority Health Medicare |
$597.00
|
| Rate for Payer: Railroad Medicare Medicare |
$597.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,680.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$597.00
|
| Rate for Payer: UHC Exchange |
$1,140.93
|
| Rate for Payer: UHC Medicare Advantage |
$597.00
|
| Rate for Payer: UHCCP Medicaid |
$319.99
|
| Rate for Payer: VA VA |
$597.00
|
|
|
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE
|
Facility
|
OP
|
$1,680.50
|
|
|
Service Code
|
CPT 12020
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$319.99 |
| Max. Negotiated Rate |
$1,680.50 |
| Rate for Payer: Aetna Medicare |
$620.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$746.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$746.25
|
| Rate for Payer: BCBS Complete |
$335.99
|
| Rate for Payer: BCBS MAPPO |
$597.00
|
| Rate for Payer: BCN Medicare Advantage |
$597.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$597.00
|
| Rate for Payer: Mclaren Medicaid |
$319.99
|
| Rate for Payer: Mclaren Medicare |
$597.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$626.85
|
| Rate for Payer: Meridian Medicaid |
$335.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$686.55
|
| Rate for Payer: PACE Medicare |
$567.15
|
| Rate for Payer: PACE SWMI |
$597.00
|
| Rate for Payer: PHP Medicare Advantage |
$597.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$319.99
|
| Rate for Payer: Priority Health Medicare |
$597.00
|
| Rate for Payer: Railroad Medicare Medicare |
$597.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,680.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$597.00
|
| Rate for Payer: UHC Exchange |
$1,140.93
|
| Rate for Payer: UHC Medicare Advantage |
$597.00
|
| Rate for Payer: UHCCP Medicaid |
$319.99
|
| Rate for Payer: VA VA |
$597.00
|
|
|
TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS); WITHOUT MANIPULATION, EACH
|
Facility
|
OP
|
$658.55
|
|
|
Service Code
|
CPT 28450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$658.55 |
| Rate for Payer: Aetna Medicare |
$243.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$292.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$292.44
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: BCBS MAPPO |
$233.95
|
| Rate for Payer: BCN Medicare Advantage |
$233.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$233.95
|
| Rate for Payer: Mclaren Medicaid |
$125.40
|
| Rate for Payer: Mclaren Medicare |
$233.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$245.65
|
| Rate for Payer: Meridian Medicaid |
$131.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: PACE Medicare |
$222.25
|
| Rate for Payer: PACE SWMI |
$233.95
|
| Rate for Payer: PHP Medicare Advantage |
$233.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$125.40
|
| Rate for Payer: Priority Health Medicare |
$233.95
|
| Rate for Payer: Railroad Medicare Medicare |
$233.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$658.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$233.95
|
| Rate for Payer: UHC Exchange |
$447.10
|
| Rate for Payer: UHC Medicare Advantage |
$233.95
|
| Rate for Payer: UHCCP Medicaid |
$125.40
|
| Rate for Payer: VA VA |
$233.95
|
|
|
TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE
|
Facility
|
OP
|
$35,323.48
|
|
|
Service Code
|
CPT 27759
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,726.13 |
| Max. Negotiated Rate |
$35,323.48 |
| Rate for Payer: Aetna Medicare |
$13,050.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,685.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,685.94
|
| Rate for Payer: BCBS Complete |
$7,062.44
|
| Rate for Payer: BCBS MAPPO |
$12,548.75
|
| Rate for Payer: BCN Medicare Advantage |
$12,548.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,548.75
|
| Rate for Payer: Mclaren Medicaid |
$6,726.13
|
| Rate for Payer: Mclaren Medicare |
$12,548.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,176.19
|
| Rate for Payer: Meridian Medicaid |
$7,062.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,431.06
|
| Rate for Payer: PACE Medicare |
$11,921.31
|
| Rate for Payer: PACE SWMI |
$12,548.75
|
| Rate for Payer: PHP Medicare Advantage |
$12,548.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,726.13
|
| Rate for Payer: Priority Health Medicare |
$12,548.75
|
| Rate for Payer: Railroad Medicare Medicare |
$12,548.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35,323.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,548.75
|
| Rate for Payer: UHC Exchange |
$23,981.92
|
| Rate for Payer: UHC Medicare Advantage |
$12,548.75
|
| Rate for Payer: UHCCP Medicaid |
$6,726.13
|
| Rate for Payer: VA VA |
$12,548.75
|
|
