|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
OP
|
$26.15
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna American Axle |
$17.00
|
| Rate for Payer: Aetna Commercial |
$22.23
|
| Rate for Payer: Aetna Medicare |
$13.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.00
|
| Rate for Payer: BCBS Complete |
$10.46
|
| Rate for Payer: Cash Price |
$20.92
|
| Rate for Payer: Cofinity Advantage |
$18.30
|
| Rate for Payer: Cofinity Commercial |
$22.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.92
|
| Rate for Payer: Healthscope Commercial |
$23.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.61
|
| Rate for Payer: PHP Commercial |
$22.23
|
| Rate for Payer: Priority Health SBD |
$16.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.00
|
| Rate for Payer: UHC Core |
$13.62
|
| Rate for Payer: UHC Exchange |
$10.28
|
| Rate for Payer: UMR Bronson Commercial |
$9.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.61
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$909.67
|
|
|
Service Code
|
NDC 00093541984
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$400.25 |
| Max. Negotiated Rate |
$818.70 |
| Rate for Payer: Aetna American Axle |
$591.29
|
| Rate for Payer: Aetna Commercial |
$773.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$591.29
|
| Rate for Payer: Cash Price |
$727.74
|
| Rate for Payer: Cofinity Advantage |
$636.77
|
| Rate for Payer: Cofinity Commercial |
$782.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$727.74
|
| Rate for Payer: Healthscope Commercial |
$818.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$636.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$682.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$773.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$682.25
|
| Rate for Payer: PHP Commercial |
$773.22
|
| Rate for Payer: Priority Health SBD |
$573.09
|
| Rate for Payer: UMR Bronson Commercial |
$400.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$682.25
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$2,086.06
|
|
|
Service Code
|
NDC 00093541901
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$771.84 |
| Max. Negotiated Rate |
$1,877.45 |
| Rate for Payer: Aetna American Axle |
$1,355.94
|
| Rate for Payer: Aetna Commercial |
$1,773.15
|
| Rate for Payer: Aetna Medicare |
$1,043.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,355.94
|
| Rate for Payer: BCBS Complete |
$834.42
|
| Rate for Payer: Cash Price |
$1,668.85
|
| Rate for Payer: Cofinity Advantage |
$1,460.24
|
| Rate for Payer: Cofinity Commercial |
$1,794.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,668.85
|
| Rate for Payer: Healthscope Commercial |
$1,877.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,460.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,564.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,668.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,773.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,564.55
|
| Rate for Payer: PHP Commercial |
$1,773.15
|
| Rate for Payer: Priority Health SBD |
$1,314.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,355.94
|
| Rate for Payer: UHC Core |
$1,086.84
|
| Rate for Payer: UHC Exchange |
$819.82
|
| Rate for Payer: UMR Bronson Commercial |
$771.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,564.55
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$1,063.09
|
|
|
Service Code
|
NDC 51079028804
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$393.34 |
| Max. Negotiated Rate |
$956.78 |
| Rate for Payer: Aetna American Axle |
$691.01
|
| Rate for Payer: Aetna Commercial |
$903.63
|
| Rate for Payer: Aetna Medicare |
$531.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$691.01
|
| Rate for Payer: BCBS Complete |
$425.24
|
| Rate for Payer: Cash Price |
$850.47
|
| Rate for Payer: Cofinity Advantage |
$744.16
|
| Rate for Payer: Cofinity Commercial |
$914.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$850.47
|
| Rate for Payer: Healthscope Commercial |
$956.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$744.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$797.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$850.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$903.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$797.32
|
| Rate for Payer: PHP Commercial |
$903.63
|
| Rate for Payer: Priority Health SBD |
$669.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$691.01
|
| Rate for Payer: UHC Core |
$553.87
|
| Rate for Payer: UHC Exchange |
$417.79
|
| Rate for Payer: UMR Bronson Commercial |
$393.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$797.32
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$1,063.09
|
|
|
Service Code
|
NDC 51079028804
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$467.76 |
| Max. Negotiated Rate |
$956.78 |
| Rate for Payer: Aetna American Axle |
$691.01
|
| Rate for Payer: Aetna Commercial |
$903.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$691.01
|
| Rate for Payer: Cash Price |
$850.47
|
| Rate for Payer: Cofinity Advantage |
$744.16
|
| Rate for Payer: Cofinity Commercial |
$914.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$850.47
|
| Rate for Payer: Healthscope Commercial |
$956.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$744.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$797.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$903.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$797.32
|
| Rate for Payer: PHP Commercial |
$903.63
|
| Rate for Payer: Priority Health SBD |
$669.75
|
| Rate for Payer: UMR Bronson Commercial |
$467.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$797.32
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$2,086.06
|
|
|
Service Code
|
NDC 00093541901
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$917.87 |
| Max. Negotiated Rate |
$1,877.45 |
| Rate for Payer: Aetna American Axle |
$1,355.94
|
| Rate for Payer: Aetna Commercial |
$1,773.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,355.94
|
| Rate for Payer: Cash Price |
$1,668.85
|
| Rate for Payer: Cofinity Advantage |
$1,460.24
|
| Rate for Payer: Cofinity Commercial |
$1,794.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,668.85
|
| Rate for Payer: Healthscope Commercial |
$1,877.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,460.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,564.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,773.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,564.55
|
| Rate for Payer: PHP Commercial |
$1,773.15
|
| Rate for Payer: Priority Health SBD |
$1,314.22
|
| Rate for Payer: UMR Bronson Commercial |
$917.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,564.55
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$18.96
|
|
|
Service Code
|
NDC 00093541919
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: Aetna American Axle |
$12.32
|
| Rate for Payer: Aetna Commercial |
$16.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.32
|
| Rate for Payer: Cash Price |
$15.17
|
| Rate for Payer: Cofinity Advantage |
$13.27
|
| Rate for Payer: Cofinity Commercial |
$16.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.17
|
| Rate for Payer: Healthscope Commercial |
$17.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.22
|
| Rate for Payer: PHP Commercial |
$16.12
|
| Rate for Payer: Priority Health SBD |
$11.94
|
| Rate for Payer: UMR Bronson Commercial |
$8.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.22
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$909.67
|
|
|
Service Code
|
NDC 00093541984
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$336.58 |
| Max. Negotiated Rate |
$818.70 |
| Rate for Payer: Aetna American Axle |
$591.29
|
| Rate for Payer: Aetna Commercial |
$773.22
|
| Rate for Payer: Aetna Medicare |
$454.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$591.29
|
| Rate for Payer: BCBS Complete |
$363.87
|
| Rate for Payer: Cash Price |
$727.74
|
| Rate for Payer: Cofinity Advantage |
$636.77
|
| Rate for Payer: Cofinity Commercial |
$782.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$727.74
|
| Rate for Payer: Healthscope Commercial |
$818.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$636.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$682.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$727.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$773.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$682.25
|
| Rate for Payer: PHP Commercial |
$773.22
|
| Rate for Payer: Priority Health SBD |
$573.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$591.29
|
| Rate for Payer: UHC Core |
$473.94
|
| Rate for Payer: UHC Exchange |
$357.50
|
| Rate for Payer: UMR Bronson Commercial |
$336.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$682.25
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$26.58
|
|
|
Service Code
|
NDC 51079028801
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna American Axle |
$17.28
|
| Rate for Payer: Aetna Commercial |
$22.59
|
| Rate for Payer: Aetna Medicare |
$13.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.28
|
| Rate for Payer: BCBS Complete |
$10.63
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cofinity Advantage |
$18.61
|
| Rate for Payer: Cofinity Commercial |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.26
|
| Rate for Payer: Healthscope Commercial |
$23.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.93
|
| Rate for Payer: PHP Commercial |
$22.59
|
| Rate for Payer: Priority Health SBD |
$16.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.28
|
| Rate for Payer: UHC Core |
$13.85
|
| Rate for Payer: UHC Exchange |
$10.45
|
| Rate for Payer: UMR Bronson Commercial |
$9.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.93
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$18.96
|
|
|
Service Code
|
NDC 00093541919
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: Aetna American Axle |
$12.32
|
| Rate for Payer: Aetna Commercial |
$16.12
|
| Rate for Payer: Aetna Medicare |
$9.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.32
|
| Rate for Payer: BCBS Complete |
$7.58
|
| Rate for Payer: Cash Price |
$15.17
|
| Rate for Payer: Cofinity Advantage |
$13.27
|
| Rate for Payer: Cofinity Commercial |
$16.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.17
|
| Rate for Payer: Healthscope Commercial |
$17.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.22
|
| Rate for Payer: PHP Commercial |
$16.12
|
| Rate for Payer: Priority Health SBD |
$11.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.32
|
| Rate for Payer: UHC Core |
$9.88
|
| Rate for Payer: UHC Exchange |
$7.45
|
| Rate for Payer: UMR Bronson Commercial |
$7.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.22
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$26.58
|
|
|
Service Code
|
NDC 51079028801
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna American Axle |
$17.28
|
| Rate for Payer: Aetna Commercial |
$22.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.28
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cofinity Advantage |
$18.61
|
| Rate for Payer: Cofinity Commercial |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.26
|
| Rate for Payer: Healthscope Commercial |
$23.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.93
|
| Rate for Payer: PHP Commercial |
$22.59
|
| Rate for Payer: Priority Health SBD |
$16.75
|
| Rate for Payer: UMR Bronson Commercial |
$11.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.93
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.19 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna American Axle |
$248.04
|
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna Medicare |
$190.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: BCBS Complete |
$152.64
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Advantage |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$267.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$286.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$305.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.20
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health SBD |
$240.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.04
|
| Rate for Payer: UHC Core |
$198.81
|
| Rate for Payer: UHC Exchange |
$149.97
|
| Rate for Payer: UMR Bronson Commercial |
$141.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.20
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Advantage |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.87
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Core |
$1.99
|
| Rate for Payer: UHC Exchange |
$1.50
|
| Rate for Payer: UMR Bronson Commercial |
$1.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.57
|
|
|
Service Code
|
NDC 60687041511
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna American Axle |
$2.32
|
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Advantage |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UMR Bronson Commercial |
$1.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.90 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna American Axle |
$248.04
|
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Advantage |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$267.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$286.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.20
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health SBD |
$240.41
|
| Rate for Payer: UMR Bronson Commercial |
$167.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.20
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$356.16
|
|
|
Service Code
|
NDC 60687041501
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.71 |
| Max. Negotiated Rate |
$320.54 |
| Rate for Payer: Aetna American Axle |
$231.50
|
| Rate for Payer: Aetna Commercial |
$302.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.50
|
| Rate for Payer: Cash Price |
$284.93
|
| Rate for Payer: Cofinity Advantage |
$249.31
|
| Rate for Payer: Cofinity Commercial |
$306.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.93
|
| Rate for Payer: Healthscope Commercial |
$320.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.12
|
| Rate for Payer: PHP Commercial |
$302.74
|
| Rate for Payer: Priority Health SBD |
$224.38
|
| Rate for Payer: UMR Bronson Commercial |
$156.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.12
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Advantage |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.87
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 60687041511
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna American Axle |
$2.32
|
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$1.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: BCBS Complete |
$1.43
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Advantage |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.32
|
| Rate for Payer: UHC Core |
$1.86
|
| Rate for Payer: UHC Exchange |
$1.40
|
| Rate for Payer: UMR Bronson Commercial |
$1.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$356.16
|
|
|
Service Code
|
NDC 60687041501
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.78 |
| Max. Negotiated Rate |
$320.54 |
| Rate for Payer: Aetna American Axle |
$231.50
|
| Rate for Payer: Aetna Commercial |
$302.74
|
| Rate for Payer: Aetna Medicare |
$178.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.50
|
| Rate for Payer: BCBS Complete |
$142.46
|
| Rate for Payer: Cash Price |
$284.93
|
| Rate for Payer: Cofinity Advantage |
$249.31
|
| Rate for Payer: Cofinity Commercial |
$306.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.93
|
| Rate for Payer: Healthscope Commercial |
$320.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$284.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.12
|
| Rate for Payer: PHP Commercial |
$302.74
|
| Rate for Payer: Priority Health SBD |
$224.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.50
|
| Rate for Payer: UHC Core |
$185.56
|
| Rate for Payer: UHC Exchange |
$139.97
|
| Rate for Payer: UMR Bronson Commercial |
$131.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.12
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$2.72
|
|
|
Service Code
|
NDC 51079092101
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna American Axle |
$1.77
|
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UMR Bronson Commercial |
$1.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.04
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$243.20
|
|
|
Service Code
|
NDC 00904708961
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.01 |
| Max. Negotiated Rate |
$218.88 |
| Rate for Payer: Aetna American Axle |
$158.08
|
| Rate for Payer: Aetna Commercial |
$206.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.08
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Advantage |
$170.24
|
| Rate for Payer: Cofinity Commercial |
$209.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$218.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.40
|
| Rate for Payer: PHP Commercial |
$206.72
|
| Rate for Payer: Priority Health SBD |
$153.22
|
| Rate for Payer: UMR Bronson Commercial |
$107.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.40
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
OP
|
$2.72
|
|
|
Service Code
|
NDC 51079092101
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna American Axle |
$1.77
|
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna Medicare |
$1.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: BCBS Complete |
$1.09
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.77
|
| Rate for Payer: UHC Core |
$1.42
|
| Rate for Payer: UHC Exchange |
$1.07
|
| Rate for Payer: UMR Bronson Commercial |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.04
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$271.70
|
|
|
Service Code
|
NDC 51079092120
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.55 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna American Axle |
$176.60
|
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UMR Bronson Commercial |
$119.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.78
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 65862084401
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.64 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna American Axle |
$180.31
|
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Advantage |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$221.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.05
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$180.31
|
| Rate for Payer: UHC Core |
$144.53
|
| Rate for Payer: UHC Exchange |
$109.02
|
| Rate for Payer: UMR Bronson Commercial |
$102.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
OP
|
$243.20
|
|
|
Service Code
|
NDC 00904708961
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.98 |
| Max. Negotiated Rate |
$218.88 |
| Rate for Payer: Aetna American Axle |
$158.08
|
| Rate for Payer: Aetna Commercial |
$206.72
|
| Rate for Payer: Aetna Medicare |
$121.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.08
|
| Rate for Payer: BCBS Complete |
$97.28
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Advantage |
$170.24
|
| Rate for Payer: Cofinity Commercial |
$209.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$218.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$194.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.40
|
| Rate for Payer: PHP Commercial |
$206.72
|
| Rate for Payer: Priority Health SBD |
$153.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$158.08
|
| Rate for Payer: UHC Core |
$126.71
|
| Rate for Payer: UHC Exchange |
$95.58
|
| Rate for Payer: UMR Bronson Commercial |
$89.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.40
|
|
