|
FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION
|
Facility
|
IP
|
$146.69
|
|
|
Service Code
|
NDC 0173-0695-04
|
| Hospital Charge Code |
26537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.54 |
| Max. Negotiated Rate |
$132.02 |
| Rate for Payer: Aetna American Axle |
$95.35
|
| Rate for Payer: Aetna Commercial |
$124.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.35
|
| Rate for Payer: Cash Price |
$117.35
|
| Rate for Payer: Cofinity Commercial |
$102.68
|
| Rate for Payer: Cofinity Commercial |
$126.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.35
|
| Rate for Payer: Healthscope Commercial |
$132.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.69
|
| Rate for Payer: PHP Commercial |
$124.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.68
|
| Rate for Payer: Priority Health SBD |
$92.41
|
| Rate for Payer: UMR Bronson Commercial |
$64.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.02
|
|
|
FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION
|
Facility
|
IP
|
$146.69
|
|
|
Service Code
|
NDC 0173-0696-04
|
| Hospital Charge Code |
26538
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.54 |
| Max. Negotiated Rate |
$132.02 |
| Rate for Payer: Aetna American Axle |
$95.35
|
| Rate for Payer: Aetna Commercial |
$124.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.35
|
| Rate for Payer: Cash Price |
$117.35
|
| Rate for Payer: Cofinity Commercial |
$102.68
|
| Rate for Payer: Cofinity Commercial |
$126.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.35
|
| Rate for Payer: Healthscope Commercial |
$132.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.69
|
| Rate for Payer: PHP Commercial |
$124.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.68
|
| Rate for Payer: Priority Health SBD |
$92.41
|
| Rate for Payer: UMR Bronson Commercial |
$64.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.02
|
|
|
FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION
|
Facility
|
IP
|
$239.09
|
|
|
Service Code
|
NDC 0173-0697-04
|
| Hospital Charge Code |
104566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.20 |
| Max. Negotiated Rate |
$215.18 |
| Rate for Payer: Aetna American Axle |
$155.41
|
| Rate for Payer: Aetna Commercial |
$203.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.41
|
| Rate for Payer: Cash Price |
$191.27
|
| Rate for Payer: Cofinity Commercial |
$167.36
|
| Rate for Payer: Cofinity Commercial |
$205.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.27
|
| Rate for Payer: Healthscope Commercial |
$215.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$203.23
|
| Rate for Payer: PHP Commercial |
$203.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.36
|
| Rate for Payer: Priority Health SBD |
$150.63
|
| Rate for Payer: UMR Bronson Commercial |
$105.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.32
|
|
|
FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$226.14
|
|
|
Service Code
|
NDC 0173-0874-14
|
| Hospital Charge Code |
173282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.50 |
| Max. Negotiated Rate |
$203.53 |
| Rate for Payer: Aetna American Axle |
$146.99
|
| Rate for Payer: Aetna Commercial |
$192.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.99
|
| Rate for Payer: Cash Price |
$180.91
|
| Rate for Payer: Cofinity Commercial |
$158.30
|
| Rate for Payer: Cofinity Commercial |
$194.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.91
|
| Rate for Payer: Healthscope Commercial |
$203.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$158.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.22
|
| Rate for Payer: PHP Commercial |
$192.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.30
|
| Rate for Payer: Priority Health SBD |
$142.47
|
| Rate for Payer: UMR Bronson Commercial |
$99.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.60
|
|
|
FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$302.75
|
|
|
Service Code
|
NDC 0173-0876-14
|
| Hospital Charge Code |
173283
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.21 |
| Max. Negotiated Rate |
$272.48 |
| Rate for Payer: Aetna American Axle |
$196.79
|
| Rate for Payer: Aetna Commercial |
$257.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.79
|
| Rate for Payer: Cash Price |
$242.20
|
| Rate for Payer: Cofinity Commercial |
$211.92
|
| Rate for Payer: Cofinity Commercial |
$260.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.20
|
| Rate for Payer: Healthscope Commercial |
$272.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$211.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$227.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$257.34
|
| Rate for Payer: PHP Commercial |
$257.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.92
|
| Rate for Payer: Priority Health SBD |
$190.73
|
| Rate for Payer: UMR Bronson Commercial |
$133.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$227.06
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER
|
Facility
|
IP
|
$1,103.04
|
|
|
Service Code
|
NDC 0173-0719-20
|
| Hospital Charge Code |
40698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$485.34 |
| Max. Negotiated Rate |
$992.74 |
| Rate for Payer: Aetna American Axle |
$716.98
|
| Rate for Payer: Aetna Commercial |
$937.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$716.98
|
| Rate for Payer: Cash Price |
$882.43
|
| Rate for Payer: Cofinity Commercial |
$772.13
|
| Rate for Payer: Cofinity Commercial |
$948.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$882.43
|
| Rate for Payer: Healthscope Commercial |
$992.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$772.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$827.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$937.58
|
| Rate for Payer: PHP Commercial |
$937.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$772.13
|
| Rate for Payer: Priority Health SBD |
$694.92
|
| Rate for Payer: UMR Bronson Commercial |
$485.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$827.28
|
|
|
FLUTICASONE PROPIONATE 115 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER
|
Facility
|
IP
|
$504.26
|
|
|
Service Code
|
NDC 0173-0716-22
|
| Hospital Charge Code |
77174
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.87 |
| Max. Negotiated Rate |
$453.83 |
| Rate for Payer: Aetna American Axle |
$327.77
|
| Rate for Payer: Aetna Commercial |
$428.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$327.77
|
| Rate for Payer: Cash Price |
$403.41
|
| Rate for Payer: Cofinity Commercial |
$352.98
|
| Rate for Payer: Cofinity Commercial |
$433.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$403.41
|
| Rate for Payer: Healthscope Commercial |
$453.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$352.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$378.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$428.62
|
| Rate for Payer: PHP Commercial |
$428.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.98
|
| Rate for Payer: Priority Health SBD |
$317.68
|
| Rate for Payer: UMR Bronson Commercial |
$221.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$378.20
|
|
|
FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER
|
Facility
|
IP
|
$1,463.43
|
|
|
Service Code
|
NDC 0173-0720-20
|
| Hospital Charge Code |
40699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$643.91 |
| Max. Negotiated Rate |
$1,317.09 |
| Rate for Payer: Aetna American Axle |
$951.23
|
| Rate for Payer: Aetna Commercial |
$1,243.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$951.23
|
| Rate for Payer: Cash Price |
$1,170.74
|
| Rate for Payer: Cofinity Commercial |
$1,024.40
|
| Rate for Payer: Cofinity Commercial |
$1,258.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,170.74
|
| Rate for Payer: Healthscope Commercial |
$1,317.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,024.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,097.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,243.92
|
| Rate for Payer: PHP Commercial |
$1,243.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,024.40
|
| Rate for Payer: Priority Health SBD |
$921.96
|
| Rate for Payer: UMR Bronson Commercial |
$643.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,097.57
|
|
|
FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER
|
Facility
|
IP
|
$824.16
|
|
|
Service Code
|
NDC 0173-0717-22
|
| Hospital Charge Code |
77175
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$362.63 |
| Max. Negotiated Rate |
$741.74 |
| Rate for Payer: Aetna American Axle |
$535.70
|
| Rate for Payer: Aetna Commercial |
$700.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$535.70
|
| Rate for Payer: Cash Price |
$659.33
|
| Rate for Payer: Cofinity Commercial |
$576.91
|
| Rate for Payer: Cofinity Commercial |
$708.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$659.33
|
| Rate for Payer: Healthscope Commercial |
$741.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$576.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$618.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$700.54
|
| Rate for Payer: PHP Commercial |
$700.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$576.91
|
| Rate for Payer: Priority Health SBD |
$519.22
|
| Rate for Payer: UMR Bronson Commercial |
$362.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$618.12
|
|
|
FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER
|
Facility
|
IP
|
$635.21
|
|
|
Service Code
|
NDC 0173-0718-20
|
| Hospital Charge Code |
40697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$279.49 |
| Max. Negotiated Rate |
$571.69 |
| Rate for Payer: Aetna American Axle |
$412.89
|
| Rate for Payer: Aetna Commercial |
$539.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$412.89
|
| Rate for Payer: Cash Price |
$508.17
|
| Rate for Payer: Cofinity Commercial |
$444.65
|
| Rate for Payer: Cofinity Commercial |
$546.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$508.17
|
| Rate for Payer: Healthscope Commercial |
$571.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$444.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$476.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$539.93
|
| Rate for Payer: PHP Commercial |
$539.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$444.65
|
| Rate for Payer: Priority Health SBD |
$400.18
|
| Rate for Payer: UMR Bronson Commercial |
$279.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$476.41
|
|
|
FLUTICASONE PROPIONATE 44 MCG/ACTUATION HFA AEROSOL INHALER
|
Facility
|
IP
|
$449.51
|
|
|
Service Code
|
NDC 66993-078-96
|
| Hospital Charge Code |
40697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.78 |
| Max. Negotiated Rate |
$404.56 |
| Rate for Payer: Aetna American Axle |
$292.18
|
| Rate for Payer: Aetna Commercial |
$382.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.18
|
| Rate for Payer: Cash Price |
$359.61
|
| Rate for Payer: Cofinity Commercial |
$314.66
|
| Rate for Payer: Cofinity Commercial |
$386.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.61
|
| Rate for Payer: Healthscope Commercial |
$404.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$382.08
|
| Rate for Payer: PHP Commercial |
$382.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.66
|
| Rate for Payer: Priority Health SBD |
$283.19
|
| Rate for Payer: UMR Bronson Commercial |
$197.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.13
|
|
|
FLUTICASONE PROPIONATE 45 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER
|
Facility
|
IP
|
$543.01
|
|
|
Service Code
|
NDC 0173-0715-22
|
| Hospital Charge Code |
77173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.92 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna American Axle |
$352.96
|
| Rate for Payer: Aetna Commercial |
$461.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$352.96
|
| Rate for Payer: Cash Price |
$434.41
|
| Rate for Payer: Cofinity Commercial |
$380.11
|
| Rate for Payer: Cofinity Commercial |
$466.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$434.41
|
| Rate for Payer: Healthscope Commercial |
$488.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$380.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$407.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$461.56
|
| Rate for Payer: PHP Commercial |
$461.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$380.11
|
| Rate for Payer: Priority Health SBD |
$342.10
|
| Rate for Payer: UMR Bronson Commercial |
$238.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$407.26
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION
|
Facility
|
IP
|
$14.55
|
|
|
Service Code
|
NDC 60432-264-15
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$13.10 |
| Rate for Payer: Aetna American Axle |
$9.46
|
| Rate for Payer: Aetna Commercial |
$12.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.46
|
| Rate for Payer: Cash Price |
$11.64
|
| Rate for Payer: Cofinity Commercial |
$10.18
|
| Rate for Payer: Cofinity Commercial |
$12.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.64
|
| Rate for Payer: Healthscope Commercial |
$13.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.37
|
| Rate for Payer: PHP Commercial |
$12.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.18
|
| Rate for Payer: Priority Health SBD |
$9.17
|
| Rate for Payer: UMR Bronson Commercial |
$6.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.91
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION
|
Facility
|
IP
|
$19.66
|
|
|
Service Code
|
NDC 50383-700-16
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$17.69 |
| Rate for Payer: Aetna American Axle |
$12.78
|
| Rate for Payer: Aetna Commercial |
$16.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.78
|
| Rate for Payer: Cash Price |
$15.73
|
| Rate for Payer: Cofinity Commercial |
$13.76
|
| Rate for Payer: Cofinity Commercial |
$16.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.73
|
| Rate for Payer: Healthscope Commercial |
$17.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.71
|
| Rate for Payer: PHP Commercial |
$16.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.76
|
| Rate for Payer: Priority Health SBD |
$12.39
|
| Rate for Payer: UMR Bronson Commercial |
$8.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.74
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION
|
Facility
|
IP
|
$36.57
|
|
|
Service Code
|
NDC 0054-3270-99
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.09 |
| Max. Negotiated Rate |
$32.91 |
| Rate for Payer: Aetna American Axle |
$23.77
|
| Rate for Payer: Aetna Commercial |
$31.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.77
|
| Rate for Payer: Cash Price |
$29.26
|
| Rate for Payer: Cofinity Commercial |
$25.60
|
| Rate for Payer: Cofinity Commercial |
$31.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.26
|
| Rate for Payer: Healthscope Commercial |
$32.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.08
|
| Rate for Payer: PHP Commercial |
$31.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.60
|
| Rate for Payer: Priority Health SBD |
$23.04
|
| Rate for Payer: UMR Bronson Commercial |
$16.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.43
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
NDC 60505-0829-1
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Aetna American Axle |
$12.87
|
| Rate for Payer: Aetna Commercial |
$16.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.87
|
| Rate for Payer: Cash Price |
$15.84
|
| Rate for Payer: Cofinity Commercial |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$17.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.84
|
| Rate for Payer: Healthscope Commercial |
$17.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.83
|
| Rate for Payer: PHP Commercial |
$16.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.86
|
| Rate for Payer: Priority Health SBD |
$12.47
|
| Rate for Payer: UMR Bronson Commercial |
$8.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.85
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION
|
Facility
|
IP
|
$43.74
|
|
|
Service Code
|
NDC 9629512745
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$39.37 |
| Rate for Payer: Aetna American Axle |
$28.43
|
| Rate for Payer: Aetna Commercial |
$37.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.43
|
| Rate for Payer: Cash Price |
$34.99
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Cofinity Commercial |
$37.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.99
|
| Rate for Payer: Healthscope Commercial |
$39.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.18
|
| Rate for Payer: PHP Commercial |
$37.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.62
|
| Rate for Payer: Priority Health SBD |
$27.56
|
| Rate for Payer: UMR Bronson Commercial |
$19.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.80
|
|
|
FLU VACCINE QS2023-24(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$222.09
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
204599
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.72 |
| Max. Negotiated Rate |
$199.88 |
| Rate for Payer: Aetna American Axle |
$144.36
|
| Rate for Payer: Aetna Commercial |
$188.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.36
|
| Rate for Payer: Cash Price |
$177.67
|
| Rate for Payer: Cofinity Commercial |
$155.46
|
| Rate for Payer: Cofinity Commercial |
$191.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.67
|
| Rate for Payer: Healthscope Commercial |
$199.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$155.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$188.78
|
| Rate for Payer: PHP Commercial |
$188.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.46
|
| Rate for Payer: Priority Health SBD |
$139.92
|
| Rate for Payer: UMR Bronson Commercial |
$97.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.57
|
|
|
FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE
|
Facility
|
IP
|
$83.74
|
|
|
Service Code
|
HCPCS 90686
|
| Hospital Charge Code |
204598
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.85 |
| Max. Negotiated Rate |
$75.37 |
| Rate for Payer: Aetna American Axle |
$54.43
|
| Rate for Payer: Aetna Commercial |
$71.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.43
|
| Rate for Payer: Cash Price |
$66.99
|
| Rate for Payer: Cofinity Commercial |
$58.62
|
| Rate for Payer: Cofinity Commercial |
$72.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.99
|
| Rate for Payer: Healthscope Commercial |
$75.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.18
|
| Rate for Payer: PHP Commercial |
$71.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.62
|
| Rate for Payer: Priority Health SBD |
$52.76
|
| Rate for Payer: UMR Bronson Commercial |
$36.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.80
|
|
|
FLUVOXAMINE 100 MG TABLET
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
NDC 62559-160-01
|
| Hospital Charge Code |
10084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna American Axle |
$135.85
|
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.85
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cofinity Commercial |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$179.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.20
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.30
|
| Rate for Payer: Priority Health SBD |
$131.67
|
| Rate for Payer: UMR Bronson Commercial |
$91.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.75
|
|
|
FLUVOXAMINE 100 MG TABLET
|
Facility
|
IP
|
$4.15
|
|
|
Service Code
|
NDC 51079-993-01
|
| Hospital Charge Code |
10084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Aetna American Axle |
$2.70
|
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.70
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.32
|
| Rate for Payer: Healthscope Commercial |
$3.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.53
|
| Rate for Payer: PHP Commercial |
$3.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.90
|
| Rate for Payer: Priority Health SBD |
$2.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.11
|
|
|
FLUVOXAMINE 100 MG TABLET
|
Facility
|
IP
|
$332.50
|
|
|
Service Code
|
NDC 0185-0157-01
|
| Hospital Charge Code |
10084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.30 |
| Max. Negotiated Rate |
$299.25 |
| Rate for Payer: Aetna American Axle |
$216.12
|
| Rate for Payer: Aetna Commercial |
$282.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.12
|
| Rate for Payer: Cash Price |
$266.00
|
| Rate for Payer: Cofinity Commercial |
$232.75
|
| Rate for Payer: Cofinity Commercial |
$285.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.00
|
| Rate for Payer: Healthscope Commercial |
$299.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$249.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$282.62
|
| Rate for Payer: PHP Commercial |
$282.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.75
|
| Rate for Payer: Priority Health SBD |
$209.48
|
| Rate for Payer: UMR Bronson Commercial |
$146.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$249.38
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
NDC 63739-537-10
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.96 |
| Max. Negotiated Rate |
$255.60 |
| Rate for Payer: Aetna American Axle |
$184.60
|
| Rate for Payer: Aetna Commercial |
$241.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.60
|
| Rate for Payer: Cash Price |
$227.20
|
| Rate for Payer: Cofinity Commercial |
$198.80
|
| Rate for Payer: Cofinity Commercial |
$244.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.20
|
| Rate for Payer: Healthscope Commercial |
$255.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.40
|
| Rate for Payer: PHP Commercial |
$241.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.80
|
| Rate for Payer: Priority Health SBD |
$178.92
|
| Rate for Payer: UMR Bronson Commercial |
$124.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$135.30
|
|
|
Service Code
|
NDC 0904-7224-61
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.53 |
| Max. Negotiated Rate |
$121.77 |
| Rate for Payer: Aetna American Axle |
$87.94
|
| Rate for Payer: Aetna Commercial |
$115.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.94
|
| Rate for Payer: Cash Price |
$108.24
|
| Rate for Payer: Cofinity Commercial |
$116.36
|
| Rate for Payer: Cofinity Commercial |
$94.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.24
|
| Rate for Payer: Healthscope Commercial |
$121.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.00
|
| Rate for Payer: PHP Commercial |
$115.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.71
|
| Rate for Payer: Priority Health SBD |
$85.24
|
| Rate for Payer: UMR Bronson Commercial |
$59.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.48
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
NDC 69315-127-01
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna American Axle |
$104.00
|
| Rate for Payer: Aetna Commercial |
$136.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cofinity Commercial |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$137.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$128.00
|
| Rate for Payer: Healthscope Commercial |
$144.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$112.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$120.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$136.00
|
| Rate for Payer: PHP Commercial |
$136.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.00
|
| Rate for Payer: Priority Health SBD |
$100.80
|
| Rate for Payer: UMR Bronson Commercial |
$70.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$120.00
|
|
