|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 16729-001-01
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 51079-425-20
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.94
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 51079-425-01
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna American Axle |
$2.63
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.63
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Commercial |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.84
|
| Rate for Payer: Priority Health SBD |
$2.55
|
| Rate for Payer: UMR Bronson Commercial |
$1.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 68084-327-11
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna American Axle |
$1.98
|
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.98
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1.92
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 51079-426-01
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Aetna American Axle |
$2.10
|
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.10
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$2.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.58
|
| Rate for Payer: Healthscope Commercial |
$2.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.75
|
| Rate for Payer: PHP Commercial |
$2.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.26
|
| Rate for Payer: Priority Health SBD |
$2.03
|
| Rate for Payer: UMR Bronson Commercial |
$1.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.42
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$322.05
|
|
|
Service Code
|
NDC 51079-426-20
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.70 |
| Max. Negotiated Rate |
$289.84 |
| Rate for Payer: Aetna American Axle |
$209.33
|
| Rate for Payer: Aetna Commercial |
$273.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.33
|
| Rate for Payer: Cash Price |
$257.64
|
| Rate for Payer: Cofinity Commercial |
$225.44
|
| Rate for Payer: Cofinity Commercial |
$276.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.64
|
| Rate for Payer: Healthscope Commercial |
$289.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$273.74
|
| Rate for Payer: PHP Commercial |
$273.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.44
|
| Rate for Payer: Priority Health SBD |
$202.89
|
| Rate for Payer: UMR Bronson Commercial |
$141.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.54
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$304.32
|
|
|
Service Code
|
NDC 68084-327-01
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.90 |
| Max. Negotiated Rate |
$273.89 |
| Rate for Payer: Aetna American Axle |
$197.81
|
| Rate for Payer: Aetna Commercial |
$258.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.81
|
| Rate for Payer: Cash Price |
$243.46
|
| Rate for Payer: Cofinity Commercial |
$213.02
|
| Rate for Payer: Cofinity Commercial |
$261.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.46
|
| Rate for Payer: Healthscope Commercial |
$273.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.67
|
| Rate for Payer: PHP Commercial |
$258.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.02
|
| Rate for Payer: Priority Health SBD |
$191.72
|
| Rate for Payer: UMR Bronson Commercial |
$133.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.24
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 250 MG TABLET
|
Facility
|
IP
|
$300.20
|
|
|
Service Code
|
NDC 23155-115-01
|
| Hospital Charge Code |
34092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.09 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna American Axle |
$195.13
|
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.13
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$210.14
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.14
|
| Rate for Payer: Priority Health SBD |
$189.13
|
| Rate for Payer: UMR Bronson Commercial |
$132.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 250 MG TABLET
|
Facility
|
IP
|
$277.44
|
|
|
Service Code
|
NDC 0093-7455-01
|
| Hospital Charge Code |
34092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.07 |
| Max. Negotiated Rate |
$249.70 |
| Rate for Payer: Aetna American Axle |
$180.34
|
| Rate for Payer: Aetna Commercial |
$235.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.34
|
| Rate for Payer: Cash Price |
$221.95
|
| Rate for Payer: Cofinity Commercial |
$194.21
|
| Rate for Payer: Cofinity Commercial |
$238.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.95
|
| Rate for Payer: Healthscope Commercial |
$249.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.82
|
| Rate for Payer: PHP Commercial |
$235.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.21
|
| Rate for Payer: Priority Health SBD |
$174.79
|
| Rate for Payer: UMR Bronson Commercial |
$122.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.08
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 500 MG TABLET
|
Facility
|
IP
|
$288.80
|
|
|
Service Code
|
NDC 23155-116-01
|
| Hospital Charge Code |
34093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.07 |
| Max. Negotiated Rate |
$259.92 |
| Rate for Payer: Aetna American Axle |
$187.72
|
| Rate for Payer: Aetna Commercial |
$245.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.72
|
| Rate for Payer: Cash Price |
$231.04
|
| Rate for Payer: Cofinity Commercial |
$202.16
|
| Rate for Payer: Cofinity Commercial |
$248.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.04
|
| Rate for Payer: Healthscope Commercial |
$259.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$245.48
|
| Rate for Payer: PHP Commercial |
$245.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.16
|
| Rate for Payer: Priority Health SBD |
$181.94
|
| Rate for Payer: UMR Bronson Commercial |
$127.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.60
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 500 MG TABLET
|
Facility
|
IP
|
$331.20
|
|
|
Service Code
|
NDC 0093-7456-01
|
| Hospital Charge Code |
34093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.73 |
| Max. Negotiated Rate |
$298.08 |
| Rate for Payer: Aetna American Axle |
$215.28
|
| Rate for Payer: Aetna Commercial |
$281.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.28
|
| Rate for Payer: Cash Price |
$264.96
|
| Rate for Payer: Cofinity Commercial |
$231.84
|
| Rate for Payer: Cofinity Commercial |
$284.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.96
|
| Rate for Payer: Healthscope Commercial |
$298.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.52
|
| Rate for Payer: PHP Commercial |
$281.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.84
|
| Rate for Payer: Priority Health SBD |
$208.66
|
| Rate for Payer: UMR Bronson Commercial |
$145.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.40
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$206.15
|
|
|
Service Code
|
NDC 51079-810-20
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$185.54 |
| Rate for Payer: Aetna American Axle |
$134.00
|
| Rate for Payer: Aetna Commercial |
$175.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.00
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$144.30
|
| Rate for Payer: Cofinity Commercial |
$177.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.92
|
| Rate for Payer: Healthscope Commercial |
$185.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.23
|
| Rate for Payer: PHP Commercial |
$175.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.30
|
| Rate for Payer: Priority Health SBD |
$129.87
|
| Rate for Payer: UMR Bronson Commercial |
$90.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.61
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$2.07
|
|
|
Service Code
|
NDC 51079-810-01
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna American Axle |
$1.35
|
| Rate for Payer: Aetna Commercial |
$1.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.35
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.66
|
| Rate for Payer: Healthscope Commercial |
$1.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.76
|
| Rate for Payer: PHP Commercial |
$1.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.45
|
| Rate for Payer: Priority Health SBD |
$1.30
|
| Rate for Payer: UMR Bronson Commercial |
$0.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.55
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$228.95
|
|
|
Service Code
|
NDC 64980-281-01
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.74 |
| Max. Negotiated Rate |
$206.06 |
| Rate for Payer: Aetna American Axle |
$148.82
|
| Rate for Payer: Aetna Commercial |
$194.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.82
|
| Rate for Payer: Cash Price |
$183.16
|
| Rate for Payer: Cofinity Commercial |
$160.26
|
| Rate for Payer: Cofinity Commercial |
$196.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.16
|
| Rate for Payer: Healthscope Commercial |
$206.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$160.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$171.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$194.61
|
| Rate for Payer: PHP Commercial |
$194.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.26
|
| Rate for Payer: Priority Health SBD |
$144.24
|
| Rate for Payer: UMR Bronson Commercial |
$100.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$171.71
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$361.95
|
|
|
Service Code
|
NDC 10370-746-01
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.26 |
| Max. Negotiated Rate |
$325.76 |
| Rate for Payer: Aetna American Axle |
$235.27
|
| Rate for Payer: Aetna Commercial |
$307.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.27
|
| Rate for Payer: Cash Price |
$289.56
|
| Rate for Payer: Cofinity Commercial |
$253.36
|
| Rate for Payer: Cofinity Commercial |
$311.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.56
|
| Rate for Payer: Healthscope Commercial |
$325.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.66
|
| Rate for Payer: PHP Commercial |
$307.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.36
|
| Rate for Payer: Priority Health SBD |
$228.03
|
| Rate for Payer: UMR Bronson Commercial |
$159.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.46
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$389.76
|
|
|
Service Code
|
NDC 68084-112-01
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.49 |
| Max. Negotiated Rate |
$350.78 |
| Rate for Payer: Aetna American Axle |
$253.34
|
| Rate for Payer: Aetna Commercial |
$331.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.34
|
| Rate for Payer: Cash Price |
$311.81
|
| Rate for Payer: Cofinity Commercial |
$272.83
|
| Rate for Payer: Cofinity Commercial |
$335.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.81
|
| Rate for Payer: Healthscope Commercial |
$350.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$272.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$331.30
|
| Rate for Payer: PHP Commercial |
$331.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$272.83
|
| Rate for Payer: Priority Health SBD |
$245.55
|
| Rate for Payer: UMR Bronson Commercial |
$171.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.32
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 59651-270-01
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.22 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.98
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UMR Bronson Commercial |
$128.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 68084-112-11
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna American Axle |
$2.54
|
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.54
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$2.73
|
| Rate for Payer: Cofinity Commercial |
$3.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.12
|
| Rate for Payer: Healthscope Commercial |
$3.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.32
|
| Rate for Payer: PHP Commercial |
$3.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.73
|
| Rate for Payer: Priority Health SBD |
$2.46
|
| Rate for Payer: UMR Bronson Commercial |
$1.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.92
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$255.36
|
|
|
Service Code
|
NDC 0591-0845-01
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.36 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna American Axle |
$165.98
|
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.98
|
| Rate for Payer: Cash Price |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$178.75
|
| Rate for Payer: Cofinity Commercial |
$219.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.29
|
| Rate for Payer: Healthscope Commercial |
$229.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.06
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.75
|
| Rate for Payer: Priority Health SBD |
$160.88
|
| Rate for Payer: UMR Bronson Commercial |
$112.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.52
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$72.11
|
|
|
Service Code
|
NDC 59762-0540-1
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.73 |
| Max. Negotiated Rate |
$64.90 |
| Rate for Payer: Aetna American Axle |
$46.87
|
| Rate for Payer: Aetna Commercial |
$61.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.87
|
| Rate for Payer: Cash Price |
$57.69
|
| Rate for Payer: Cofinity Commercial |
$50.48
|
| Rate for Payer: Cofinity Commercial |
$62.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.69
|
| Rate for Payer: Healthscope Commercial |
$64.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$61.29
|
| Rate for Payer: PHP Commercial |
$61.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.48
|
| Rate for Payer: Priority Health SBD |
$45.43
|
| Rate for Payer: UMR Bronson Commercial |
$31.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.08
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$141.56
|
|
|
Service Code
|
NDC 68084-295-21
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.29 |
| Max. Negotiated Rate |
$127.40 |
| Rate for Payer: Aetna American Axle |
$92.01
|
| Rate for Payer: Aetna Commercial |
$120.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.01
|
| Rate for Payer: Cash Price |
$113.25
|
| Rate for Payer: Cofinity Commercial |
$121.74
|
| Rate for Payer: Cofinity Commercial |
$99.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.25
|
| Rate for Payer: Healthscope Commercial |
$127.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.33
|
| Rate for Payer: PHP Commercial |
$120.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.09
|
| Rate for Payer: Priority Health SBD |
$89.18
|
| Rate for Payer: UMR Bronson Commercial |
$62.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.17
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$76.67
|
|
|
Service Code
|
NDC 0591-0900-30
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.73 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna American Axle |
$49.84
|
| Rate for Payer: Aetna Commercial |
$65.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.84
|
| Rate for Payer: Cash Price |
$61.34
|
| Rate for Payer: Cofinity Commercial |
$53.67
|
| Rate for Payer: Cofinity Commercial |
$65.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.34
|
| Rate for Payer: Healthscope Commercial |
$69.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.17
|
| Rate for Payer: PHP Commercial |
$65.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.67
|
| Rate for Payer: Priority Health SBD |
$48.30
|
| Rate for Payer: UMR Bronson Commercial |
$33.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.50
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 0049-0174-02
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.36 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.40
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 59651-781-01
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$226.30 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.02
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.02
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$256.50
|
|
|
Service Code
|
NDC 0591-0844-01
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.86 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Aetna American Axle |
$166.72
|
| Rate for Payer: Aetna Commercial |
$218.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.72
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cofinity Commercial |
$179.55
|
| Rate for Payer: Cofinity Commercial |
$220.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.20
|
| Rate for Payer: Healthscope Commercial |
$230.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$218.02
|
| Rate for Payer: PHP Commercial |
$218.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.55
|
| Rate for Payer: Priority Health SBD |
$161.60
|
| Rate for Payer: UMR Bronson Commercial |
$112.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.38
|
|
