|
ZOLPIDEM 5 MG TABLET
|
Facility
|
OP
|
$204.75
|
|
|
Service Code
|
NDC 60687083801
|
| Hospital Charge Code |
11701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.76 |
| Max. Negotiated Rate |
$184.28 |
| Rate for Payer: Aetna American Axle |
$133.09
|
| Rate for Payer: Aetna Commercial |
$174.04
|
| Rate for Payer: Aetna Medicare |
$102.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.09
|
| Rate for Payer: BCBS Complete |
$81.90
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cofinity Commercial |
$143.32
|
| Rate for Payer: Cofinity Commercial |
$176.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.80
|
| Rate for Payer: Healthscope Commercial |
$184.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.04
|
| Rate for Payer: PHP Commercial |
$174.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.09
|
| Rate for Payer: Priority Health SBD |
$128.99
|
| Rate for Payer: UMR Bronson Commercial |
$75.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.56
|
|
|
ZOLPIDEM 5 MG TABLET
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 51079072401
|
| Hospital Charge Code |
11701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna American Axle |
$0.88
|
| Rate for Payer: Aetna Commercial |
$1.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.88
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cofinity Commercial |
$0.95
|
| Rate for Payer: Cofinity Commercial |
$1.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.08
|
| Rate for Payer: Healthscope Commercial |
$1.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.15
|
| Rate for Payer: PHP Commercial |
$1.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.88
|
| Rate for Payer: Priority Health SBD |
$0.85
|
| Rate for Payer: UMR Bronson Commercial |
$0.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.01
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
IP
|
$247.20
|
|
|
Service Code
|
NDC 60687023001
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.77 |
| Max. Negotiated Rate |
$222.48 |
| Rate for Payer: Aetna American Axle |
$160.68
|
| Rate for Payer: Aetna Commercial |
$210.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.68
|
| Rate for Payer: Cash Price |
$197.76
|
| Rate for Payer: Cofinity Commercial |
$173.04
|
| Rate for Payer: Cofinity Commercial |
$212.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.76
|
| Rate for Payer: Healthscope Commercial |
$222.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.12
|
| Rate for Payer: PHP Commercial |
$210.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.68
|
| Rate for Payer: Priority Health SBD |
$155.74
|
| Rate for Payer: UMR Bronson Commercial |
$108.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.40
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
IP
|
$324.90
|
|
|
Service Code
|
NDC 69097086107
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.96 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.18
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$142.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
IP
|
$206.80
|
|
|
Service Code
|
NDC 72578004201
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.99 |
| Max. Negotiated Rate |
$186.12 |
| Rate for Payer: Aetna American Axle |
$134.42
|
| Rate for Payer: Aetna Commercial |
$175.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.42
|
| Rate for Payer: Cash Price |
$165.44
|
| Rate for Payer: Cofinity Commercial |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$177.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.44
|
| Rate for Payer: Healthscope Commercial |
$186.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.78
|
| Rate for Payer: PHP Commercial |
$175.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.42
|
| Rate for Payer: Priority Health SBD |
$130.28
|
| Rate for Payer: UMR Bronson Commercial |
$90.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.10
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
IP
|
$324.90
|
|
|
Service Code
|
NDC 68462013001
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.96 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.18
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$142.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
IP
|
$324.90
|
|
|
Service Code
|
NDC 59651038001
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.96 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.18
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$142.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
OP
|
$247.20
|
|
|
Service Code
|
NDC 60687023001
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.46 |
| Max. Negotiated Rate |
$222.48 |
| Rate for Payer: Aetna American Axle |
$160.68
|
| Rate for Payer: Aetna Commercial |
$210.12
|
| Rate for Payer: Aetna Medicare |
$123.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.68
|
| Rate for Payer: BCBS Complete |
$98.88
|
| Rate for Payer: Cash Price |
$197.76
|
| Rate for Payer: Cofinity Commercial |
$173.04
|
| Rate for Payer: Cofinity Commercial |
$212.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.76
|
| Rate for Payer: Healthscope Commercial |
$222.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.12
|
| Rate for Payer: PHP Commercial |
$210.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.68
|
| Rate for Payer: Priority Health SBD |
$155.74
|
| Rate for Payer: UMR Bronson Commercial |
$91.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.40
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
IP
|
$2.48
|
|
|
Service Code
|
NDC 60687023011
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.74
|
| Rate for Payer: Cofinity Commercial |
$2.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.11
|
| Rate for Payer: PHP Commercial |
$2.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.86
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
OP
|
$2.48
|
|
|
Service Code
|
NDC 60687023011
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.11
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.74
|
| Rate for Payer: Cofinity Commercial |
$2.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.11
|
| Rate for Payer: PHP Commercial |
$2.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$0.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.86
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
OP
|
$324.90
|
|
|
Service Code
|
NDC 69097086107
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.21 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna Medicare |
$162.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: BCBS Complete |
$129.96
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.18
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$120.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
OP
|
$324.90
|
|
|
Service Code
|
NDC 68462013001
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.21 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna Medicare |
$162.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: BCBS Complete |
$129.96
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.18
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$120.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
OP
|
$206.80
|
|
|
Service Code
|
NDC 72578004201
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$186.12 |
| Rate for Payer: Aetna American Axle |
$134.42
|
| Rate for Payer: Aetna Commercial |
$175.78
|
| Rate for Payer: Aetna Medicare |
$103.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.42
|
| Rate for Payer: BCBS Complete |
$82.72
|
| Rate for Payer: Cash Price |
$165.44
|
| Rate for Payer: Cofinity Commercial |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$177.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.44
|
| Rate for Payer: Healthscope Commercial |
$186.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.78
|
| Rate for Payer: PHP Commercial |
$175.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.42
|
| Rate for Payer: Priority Health SBD |
$130.28
|
| Rate for Payer: UMR Bronson Commercial |
$76.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.10
|
|
|
ZONISAMIDE 100 MG CAPSULE
|
Facility
|
OP
|
$324.90
|
|
|
Service Code
|
NDC 59651038001
|
| Hospital Charge Code |
27780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.21 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna Medicare |
$162.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: BCBS Complete |
$129.96
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.18
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$120.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
ZONISAMIDE 25 MG CAPSULE
|
Facility
|
IP
|
$169.20
|
|
|
Service Code
|
NDC 72578004001
|
| Hospital Charge Code |
36987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.45 |
| Max. Negotiated Rate |
$152.28 |
| Rate for Payer: Aetna American Axle |
$109.98
|
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.98
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$145.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$152.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: PHP Commercial |
$143.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.98
|
| Rate for Payer: Priority Health SBD |
$106.60
|
| Rate for Payer: UMR Bronson Commercial |
$74.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.90
|
|
|
ZONISAMIDE 25 MG CAPSULE
|
Facility
|
IP
|
$343.10
|
|
|
Service Code
|
NDC 59651037801
|
| Hospital Charge Code |
36987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.96 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna American Axle |
$223.02
|
| Rate for Payer: Aetna Commercial |
$291.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.02
|
| Rate for Payer: Cash Price |
$274.48
|
| Rate for Payer: Cofinity Commercial |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$295.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$240.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.48
|
| Rate for Payer: Healthscope Commercial |
$308.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$240.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$257.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.64
|
| Rate for Payer: PHP Commercial |
$291.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.02
|
| Rate for Payer: Priority Health SBD |
$216.15
|
| Rate for Payer: UMR Bronson Commercial |
$150.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$257.32
|
|
|
ZONISAMIDE 25 MG CAPSULE
|
Facility
|
IP
|
$343.10
|
|
|
Service Code
|
NDC 68462012801
|
| Hospital Charge Code |
36987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.96 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna American Axle |
$223.02
|
| Rate for Payer: Aetna Commercial |
$291.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.02
|
| Rate for Payer: Cash Price |
$274.48
|
| Rate for Payer: Cofinity Commercial |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$295.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$240.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.48
|
| Rate for Payer: Healthscope Commercial |
$308.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$240.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$257.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.64
|
| Rate for Payer: PHP Commercial |
$291.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.02
|
| Rate for Payer: Priority Health SBD |
$216.15
|
| Rate for Payer: UMR Bronson Commercial |
$150.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$257.32
|
|
|
ZONISAMIDE 25 MG CAPSULE
|
Facility
|
OP
|
$343.10
|
|
|
Service Code
|
NDC 68462012801
|
| Hospital Charge Code |
36987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.95 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna American Axle |
$223.02
|
| Rate for Payer: Aetna Commercial |
$291.64
|
| Rate for Payer: Aetna Medicare |
$171.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.02
|
| Rate for Payer: BCBS Complete |
$137.24
|
| Rate for Payer: Cash Price |
$274.48
|
| Rate for Payer: Cofinity Commercial |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$295.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$240.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.48
|
| Rate for Payer: Healthscope Commercial |
$308.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$240.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$257.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.64
|
| Rate for Payer: PHP Commercial |
$291.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.02
|
| Rate for Payer: Priority Health SBD |
$216.15
|
| Rate for Payer: UMR Bronson Commercial |
$126.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$257.32
|
|
|
ZONISAMIDE 25 MG CAPSULE
|
Facility
|
OP
|
$169.20
|
|
|
Service Code
|
NDC 72578004001
|
| Hospital Charge Code |
36987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.60 |
| Max. Negotiated Rate |
$152.28 |
| Rate for Payer: Aetna American Axle |
$109.98
|
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna Medicare |
$84.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.98
|
| Rate for Payer: BCBS Complete |
$67.68
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$145.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$152.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: PHP Commercial |
$143.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.98
|
| Rate for Payer: Priority Health SBD |
$106.60
|
| Rate for Payer: UMR Bronson Commercial |
$62.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.90
|
|
|
ZONISAMIDE 25 MG CAPSULE
|
Facility
|
OP
|
$343.10
|
|
|
Service Code
|
NDC 59651037801
|
| Hospital Charge Code |
36987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.95 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna American Axle |
$223.02
|
| Rate for Payer: Aetna Commercial |
$291.64
|
| Rate for Payer: Aetna Medicare |
$171.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.02
|
| Rate for Payer: BCBS Complete |
$137.24
|
| Rate for Payer: Cash Price |
$274.48
|
| Rate for Payer: Cofinity Commercial |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$295.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$240.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.48
|
| Rate for Payer: Healthscope Commercial |
$308.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$240.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$257.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.64
|
| Rate for Payer: PHP Commercial |
$291.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.02
|
| Rate for Payer: Priority Health SBD |
$216.15
|
| Rate for Payer: UMR Bronson Commercial |
$126.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$257.32
|
|
|
ZONISAMIDE 50 MG CAPSULE
|
Facility
|
IP
|
$401.85
|
|
|
Service Code
|
NDC 59651037901
|
| Hospital Charge Code |
36988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.81 |
| Max. Negotiated Rate |
$361.66 |
| Rate for Payer: Aetna American Axle |
$261.20
|
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$281.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.20
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UMR Bronson Commercial |
$176.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
|
ZONISAMIDE 50 MG CAPSULE
|
Facility
|
IP
|
$401.85
|
|
|
Service Code
|
NDC 68462012901
|
| Hospital Charge Code |
36988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.81 |
| Max. Negotiated Rate |
$361.66 |
| Rate for Payer: Aetna American Axle |
$261.20
|
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$281.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.20
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UMR Bronson Commercial |
$176.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
|
ZONISAMIDE 50 MG CAPSULE
|
Facility
|
OP
|
$401.85
|
|
|
Service Code
|
NDC 59651037901
|
| Hospital Charge Code |
36988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.68 |
| Max. Negotiated Rate |
$361.66 |
| Rate for Payer: Aetna American Axle |
$261.20
|
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna Medicare |
$200.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: BCBS Complete |
$160.74
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$281.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.20
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UMR Bronson Commercial |
$148.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
|
ZONISAMIDE 50 MG CAPSULE
|
Facility
|
OP
|
$401.85
|
|
|
Service Code
|
NDC 68462012901
|
| Hospital Charge Code |
36988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.68 |
| Max. Negotiated Rate |
$361.66 |
| Rate for Payer: Aetna American Axle |
$261.20
|
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna Medicare |
$200.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: BCBS Complete |
$160.74
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$281.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.20
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UMR Bronson Commercial |
$148.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
