|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
NDC 60687031521
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.89 |
| Max. Negotiated Rate |
$177.30 |
| Rate for Payer: Aetna American Axle |
$128.05
|
| Rate for Payer: Aetna Commercial |
$167.45
|
| Rate for Payer: Aetna Medicare |
$98.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.05
|
| Rate for Payer: BCBS Complete |
$78.80
|
| Rate for Payer: Cash Price |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$137.90
|
| Rate for Payer: Cofinity Commercial |
$169.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$137.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.60
|
| Rate for Payer: Healthscope Commercial |
$177.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$137.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.45
|
| Rate for Payer: PHP Commercial |
$167.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.05
|
| Rate for Payer: Priority Health SBD |
$124.11
|
| Rate for Payer: UMR Bronson Commercial |
$72.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.75
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$598.56
|
|
|
Service Code
|
NDC 00904710661
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.47 |
| Max. Negotiated Rate |
$538.70 |
| Rate for Payer: Aetna American Axle |
$389.06
|
| Rate for Payer: Aetna Commercial |
$508.78
|
| Rate for Payer: Aetna Medicare |
$299.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$389.06
|
| Rate for Payer: BCBS Complete |
$239.42
|
| Rate for Payer: Cash Price |
$478.85
|
| Rate for Payer: Cofinity Commercial |
$418.99
|
| Rate for Payer: Cofinity Commercial |
$514.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$418.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$478.85
|
| Rate for Payer: Healthscope Commercial |
$538.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$418.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$448.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$508.78
|
| Rate for Payer: PHP Commercial |
$508.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.06
|
| Rate for Payer: Priority Health SBD |
$377.09
|
| Rate for Payer: UMR Bronson Commercial |
$221.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$448.92
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$595.20
|
|
|
Service Code
|
NDC 51079086420
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.89 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna American Axle |
$386.88
|
| Rate for Payer: Aetna Commercial |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.88
|
| Rate for Payer: Cash Price |
$476.16
|
| Rate for Payer: Cofinity Commercial |
$416.64
|
| Rate for Payer: Cofinity Commercial |
$511.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.16
|
| Rate for Payer: Healthscope Commercial |
$535.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$505.92
|
| Rate for Payer: PHP Commercial |
$505.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$386.88
|
| Rate for Payer: Priority Health SBD |
$374.98
|
| Rate for Payer: UMR Bronson Commercial |
$261.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.40
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$281.28
|
|
|
Service Code
|
NDC 27241016101
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.76 |
| Max. Negotiated Rate |
$253.15 |
| Rate for Payer: Aetna American Axle |
$182.83
|
| Rate for Payer: Aetna Commercial |
$239.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.83
|
| Rate for Payer: Cash Price |
$225.02
|
| Rate for Payer: Cofinity Commercial |
$196.90
|
| Rate for Payer: Cofinity Commercial |
$241.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.02
|
| Rate for Payer: Healthscope Commercial |
$253.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.09
|
| Rate for Payer: PHP Commercial |
$239.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.83
|
| Rate for Payer: Priority Health SBD |
$177.21
|
| Rate for Payer: UMR Bronson Commercial |
$123.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.96
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
OP
|
$595.20
|
|
|
Service Code
|
NDC 51079086420
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.22 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna American Axle |
$386.88
|
| Rate for Payer: Aetna Commercial |
$505.92
|
| Rate for Payer: Aetna Medicare |
$297.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.88
|
| Rate for Payer: BCBS Complete |
$238.08
|
| Rate for Payer: Cash Price |
$476.16
|
| Rate for Payer: Cofinity Commercial |
$416.64
|
| Rate for Payer: Cofinity Commercial |
$511.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.16
|
| Rate for Payer: Healthscope Commercial |
$535.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$505.92
|
| Rate for Payer: PHP Commercial |
$505.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$386.88
|
| Rate for Payer: Priority Health SBD |
$374.98
|
| Rate for Payer: UMR Bronson Commercial |
$220.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.40
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$598.56
|
|
|
Service Code
|
NDC 00904710661
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$263.37 |
| Max. Negotiated Rate |
$538.70 |
| Rate for Payer: Aetna American Axle |
$389.06
|
| Rate for Payer: Aetna Commercial |
$508.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$389.06
|
| Rate for Payer: Cash Price |
$478.85
|
| Rate for Payer: Cofinity Commercial |
$418.99
|
| Rate for Payer: Cofinity Commercial |
$514.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$418.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$478.85
|
| Rate for Payer: Healthscope Commercial |
$538.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$418.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$448.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$508.78
|
| Rate for Payer: PHP Commercial |
$508.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.06
|
| Rate for Payer: Priority Health SBD |
$377.09
|
| Rate for Payer: UMR Bronson Commercial |
$263.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$448.92
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
NDC 60687031511
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$5.91 |
| Rate for Payer: Aetna American Axle |
$4.27
|
| Rate for Payer: Aetna Commercial |
$5.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.27
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Cofinity Commercial |
$4.60
|
| Rate for Payer: Cofinity Commercial |
$5.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.26
|
| Rate for Payer: Healthscope Commercial |
$5.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.58
|
| Rate for Payer: PHP Commercial |
$5.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.27
|
| Rate for Payer: Priority Health SBD |
$4.14
|
| Rate for Payer: UMR Bronson Commercial |
$2.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.93
|
|
|
CARBACHOL 0.01 % INTRAOCULAR SOLUTION
|
Facility
|
IP
|
$41.89
|
|
|
Service Code
|
NDC 00065002315
|
| Hospital Charge Code |
19704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.43 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna American Axle |
$27.23
|
| Rate for Payer: Aetna Commercial |
$35.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.23
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cofinity Commercial |
$29.32
|
| Rate for Payer: Cofinity Commercial |
$36.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.51
|
| Rate for Payer: Healthscope Commercial |
$37.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.61
|
| Rate for Payer: PHP Commercial |
$35.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.23
|
| Rate for Payer: Priority Health SBD |
$26.39
|
| Rate for Payer: UMR Bronson Commercial |
$18.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.42
|
|
|
CARBACHOL 0.01 % INTRAOCULAR SOLUTION
|
Facility
|
OP
|
$41.89
|
|
|
Service Code
|
NDC 00065002315
|
| Hospital Charge Code |
19704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna American Axle |
$27.23
|
| Rate for Payer: Aetna Commercial |
$35.61
|
| Rate for Payer: Aetna Medicare |
$20.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.23
|
| Rate for Payer: BCBS Complete |
$16.76
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cofinity Commercial |
$29.32
|
| Rate for Payer: Cofinity Commercial |
$36.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.51
|
| Rate for Payer: Healthscope Commercial |
$37.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.61
|
| Rate for Payer: PHP Commercial |
$35.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.23
|
| Rate for Payer: Priority Health SBD |
$26.39
|
| Rate for Payer: UMR Bronson Commercial |
$15.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.42
|
|
|
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,290.15
|
|
|
Service Code
|
NDC 51672404709
|
| Hospital Charge Code |
109663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$477.36 |
| Max. Negotiated Rate |
$1,161.13 |
| Rate for Payer: Aetna American Axle |
$838.60
|
| Rate for Payer: Aetna Commercial |
$1,096.63
|
| Rate for Payer: Aetna Medicare |
$645.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$838.60
|
| Rate for Payer: BCBS Complete |
$516.06
|
| Rate for Payer: Cash Price |
$1,032.12
|
| Rate for Payer: Cofinity Commercial |
$1,109.53
|
| Rate for Payer: Cofinity Commercial |
$903.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$903.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,032.12
|
| Rate for Payer: Healthscope Commercial |
$1,161.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$903.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$967.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,096.63
|
| Rate for Payer: PHP Commercial |
$1,096.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$838.60
|
| Rate for Payer: Priority Health SBD |
$812.79
|
| Rate for Payer: UMR Bronson Commercial |
$477.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$967.61
|
|
|
CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,290.15
|
|
|
Service Code
|
NDC 51672404709
|
| Hospital Charge Code |
109663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$567.67 |
| Max. Negotiated Rate |
$1,161.13 |
| Rate for Payer: Aetna American Axle |
$838.60
|
| Rate for Payer: Aetna Commercial |
$1,096.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$838.60
|
| Rate for Payer: Cash Price |
$1,032.12
|
| Rate for Payer: Cofinity Commercial |
$1,109.53
|
| Rate for Payer: Cofinity Commercial |
$903.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$903.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,032.12
|
| Rate for Payer: Healthscope Commercial |
$1,161.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$903.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$967.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,096.63
|
| Rate for Payer: PHP Commercial |
$1,096.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$838.60
|
| Rate for Payer: Priority Health SBD |
$812.79
|
| Rate for Payer: UMR Bronson Commercial |
$567.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$967.61
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
OP
|
$313.50
|
|
|
Service Code
|
NDC 51079087020
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.00 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna American Axle |
$203.78
|
| Rate for Payer: Aetna Commercial |
$266.48
|
| Rate for Payer: Aetna Medicare |
$156.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.78
|
| Rate for Payer: BCBS Complete |
$125.40
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$219.45
|
| Rate for Payer: Cofinity Commercial |
$269.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$219.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$219.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: PHP Commercial |
$266.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: Priority Health SBD |
$197.50
|
| Rate for Payer: UMR Bronson Commercial |
$116.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.12
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
NDC 51079087001
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna American Axle |
$2.04
|
| Rate for Payer: Aetna Commercial |
$2.67
|
| Rate for Payer: Aetna Medicare |
$1.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.04
|
| Rate for Payer: BCBS Complete |
$1.26
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Commercial |
$2.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.51
|
| Rate for Payer: Healthscope Commercial |
$2.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.67
|
| Rate for Payer: PHP Commercial |
$2.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.04
|
| Rate for Payer: Priority Health SBD |
$1.98
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
OP
|
$224.20
|
|
|
Service Code
|
NDC 51672404101
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.95 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna Medicare |
$112.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: BCBS Complete |
$89.68
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$82.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
IP
|
$313.50
|
|
|
Service Code
|
NDC 51079087020
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.94 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna American Axle |
$203.78
|
| Rate for Payer: Aetna Commercial |
$266.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.78
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$219.45
|
| Rate for Payer: Cofinity Commercial |
$269.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$219.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$219.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: PHP Commercial |
$266.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: Priority Health SBD |
$197.50
|
| Rate for Payer: UMR Bronson Commercial |
$137.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.12
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
OP
|
$1,130.50
|
|
|
Service Code
|
NDC 51672404102
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$418.29 |
| Max. Negotiated Rate |
$1,017.45 |
| Rate for Payer: Aetna American Axle |
$734.83
|
| Rate for Payer: Aetna Commercial |
$960.92
|
| Rate for Payer: Aetna Medicare |
$565.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$734.83
|
| Rate for Payer: BCBS Complete |
$452.20
|
| Rate for Payer: Cash Price |
$904.40
|
| Rate for Payer: Cofinity Commercial |
$791.35
|
| Rate for Payer: Cofinity Commercial |
$972.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$791.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$904.40
|
| Rate for Payer: Healthscope Commercial |
$1,017.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$791.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$847.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$960.92
|
| Rate for Payer: PHP Commercial |
$960.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$734.83
|
| Rate for Payer: Priority Health SBD |
$712.22
|
| Rate for Payer: UMR Bronson Commercial |
$418.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$847.88
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
IP
|
$224.20
|
|
|
Service Code
|
NDC 51672404101
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.65 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$98.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
IP
|
$1,130.50
|
|
|
Service Code
|
NDC 51672404102
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$497.42 |
| Max. Negotiated Rate |
$1,017.45 |
| Rate for Payer: Aetna American Axle |
$734.83
|
| Rate for Payer: Aetna Commercial |
$960.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$734.83
|
| Rate for Payer: Cash Price |
$904.40
|
| Rate for Payer: Cofinity Commercial |
$791.35
|
| Rate for Payer: Cofinity Commercial |
$972.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$791.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$904.40
|
| Rate for Payer: Healthscope Commercial |
$1,017.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$791.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$847.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$960.92
|
| Rate for Payer: PHP Commercial |
$960.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$734.83
|
| Rate for Payer: Priority Health SBD |
$712.22
|
| Rate for Payer: UMR Bronson Commercial |
$497.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$847.88
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
IP
|
$320.15
|
|
|
Service Code
|
NDC 00904385461
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.87 |
| Max. Negotiated Rate |
$288.13 |
| Rate for Payer: Aetna American Axle |
$208.10
|
| Rate for Payer: Aetna Commercial |
$272.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.10
|
| Rate for Payer: Cash Price |
$256.12
|
| Rate for Payer: Cofinity Commercial |
$224.10
|
| Rate for Payer: Cofinity Commercial |
$275.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$224.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.12
|
| Rate for Payer: Healthscope Commercial |
$288.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$224.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$240.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$272.13
|
| Rate for Payer: PHP Commercial |
$272.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.10
|
| Rate for Payer: Priority Health SBD |
$201.69
|
| Rate for Payer: UMR Bronson Commercial |
$140.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$240.11
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 51079087001
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna American Axle |
$2.04
|
| Rate for Payer: Aetna Commercial |
$2.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.04
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Commercial |
$2.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.51
|
| Rate for Payer: Healthscope Commercial |
$2.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.67
|
| Rate for Payer: PHP Commercial |
$2.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.04
|
| Rate for Payer: Priority Health SBD |
$1.98
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
|
OP
|
$320.15
|
|
|
Service Code
|
NDC 00904385461
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.46 |
| Max. Negotiated Rate |
$288.13 |
| Rate for Payer: Aetna American Axle |
$208.10
|
| Rate for Payer: Aetna Commercial |
$272.13
|
| Rate for Payer: Aetna Medicare |
$160.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.10
|
| Rate for Payer: BCBS Complete |
$128.06
|
| Rate for Payer: Cash Price |
$256.12
|
| Rate for Payer: Cofinity Commercial |
$224.10
|
| Rate for Payer: Cofinity Commercial |
$275.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$224.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.12
|
| Rate for Payer: Healthscope Commercial |
$288.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$224.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$240.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$272.13
|
| Rate for Payer: PHP Commercial |
$272.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.10
|
| Rate for Payer: Priority Health SBD |
$201.69
|
| Rate for Payer: UMR Bronson Commercial |
$118.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$240.11
|
|
|
CARBAMAZEPINE 200 MG/10 ML ORAL SUSPENSION
|
Facility
|
OP
|
$9.48
|
|
|
Service Code
|
NDC 00121189410
|
| Hospital Charge Code |
1356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$8.53 |
| Rate for Payer: Aetna American Axle |
$6.16
|
| Rate for Payer: Aetna Commercial |
$8.06
|
| Rate for Payer: Aetna Medicare |
$4.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.16
|
| Rate for Payer: BCBS Complete |
$3.79
|
| Rate for Payer: Cash Price |
$7.58
|
| Rate for Payer: Cofinity Commercial |
$6.64
|
| Rate for Payer: Cofinity Commercial |
$8.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.58
|
| Rate for Payer: Healthscope Commercial |
$8.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.06
|
| Rate for Payer: PHP Commercial |
$8.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.16
|
| Rate for Payer: Priority Health SBD |
$5.97
|
| Rate for Payer: UMR Bronson Commercial |
$3.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.11
|
|
|
CARBAMAZEPINE 200 MG/10 ML ORAL SUSPENSION
|
Facility
|
IP
|
$9.29
|
|
|
Service Code
|
NDC 00121172410
|
| Hospital Charge Code |
1356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Aetna American Axle |
$6.04
|
| Rate for Payer: Aetna Commercial |
$7.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.04
|
| Rate for Payer: Cash Price |
$7.43
|
| Rate for Payer: Cofinity Commercial |
$6.50
|
| Rate for Payer: Cofinity Commercial |
$7.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.43
|
| Rate for Payer: Healthscope Commercial |
$8.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.90
|
| Rate for Payer: PHP Commercial |
$7.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.04
|
| Rate for Payer: Priority Health SBD |
$5.85
|
| Rate for Payer: UMR Bronson Commercial |
$4.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.97
|
|
|
CARBAMAZEPINE 200 MG/10 ML ORAL SUSPENSION
|
Facility
|
OP
|
$9.29
|
|
|
Service Code
|
NDC 00121172410
|
| Hospital Charge Code |
1356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Aetna American Axle |
$6.04
|
| Rate for Payer: Aetna Commercial |
$7.90
|
| Rate for Payer: Aetna Medicare |
$4.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.04
|
| Rate for Payer: BCBS Complete |
$3.72
|
| Rate for Payer: Cash Price |
$7.43
|
| Rate for Payer: Cofinity Commercial |
$6.50
|
| Rate for Payer: Cofinity Commercial |
$7.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.43
|
| Rate for Payer: Healthscope Commercial |
$8.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.90
|
| Rate for Payer: PHP Commercial |
$7.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.04
|
| Rate for Payer: Priority Health SBD |
$5.85
|
| Rate for Payer: UMR Bronson Commercial |
$3.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.97
|
|
|
CARBAMAZEPINE 200 MG/10 ML ORAL SUSPENSION
|
Facility
|
IP
|
$9.48
|
|
|
Service Code
|
NDC 00121189410
|
| Hospital Charge Code |
1356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$8.53 |
| Rate for Payer: Aetna American Axle |
$6.16
|
| Rate for Payer: Aetna Commercial |
$8.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.16
|
| Rate for Payer: Cash Price |
$7.58
|
| Rate for Payer: Cofinity Commercial |
$6.64
|
| Rate for Payer: Cofinity Commercial |
$8.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.58
|
| Rate for Payer: Healthscope Commercial |
$8.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.06
|
| Rate for Payer: PHP Commercial |
$8.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.16
|
| Rate for Payer: Priority Health SBD |
$5.97
|
| Rate for Payer: UMR Bronson Commercial |
$4.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.11
|
|
