|
DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS
|
Facility
|
OP
|
$1,216.03
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
9759
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$218.07 |
| Max. Negotiated Rate |
$1,094.43 |
| Rate for Payer: Aetna American Axle |
$790.42
|
| Rate for Payer: Aetna Commercial |
$1,033.63
|
| Rate for Payer: Aetna Medicare |
$608.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$790.42
|
| Rate for Payer: BCBS Complete |
$486.41
|
| Rate for Payer: BCBS Trust/PPO |
$218.07
|
| Rate for Payer: BCN Commercial |
$218.07
|
| Rate for Payer: Cash Price |
$972.82
|
| Rate for Payer: Cash Price |
$972.82
|
| Rate for Payer: Cofinity Advantage |
$851.22
|
| Rate for Payer: Cofinity Commercial |
$1,045.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$972.82
|
| Rate for Payer: Healthscope Commercial |
$1,094.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$851.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$912.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$972.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,033.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$912.02
|
| Rate for Payer: PHP Commercial |
$1,033.63
|
| Rate for Payer: Priority Health SBD |
$766.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$790.42
|
| Rate for Payer: UHC Core |
$633.55
|
| Rate for Payer: UHC Exchange |
$477.90
|
| Rate for Payer: UMR Bronson Commercial |
$449.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$912.02
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$607.25
|
|
|
Service Code
|
NDC 47781017601
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.68 |
| Max. Negotiated Rate |
$546.52 |
| Rate for Payer: Aetna American Axle |
$394.71
|
| Rate for Payer: Aetna Commercial |
$516.16
|
| Rate for Payer: Aetna Medicare |
$303.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$394.71
|
| Rate for Payer: BCBS Complete |
$242.90
|
| Rate for Payer: Cash Price |
$485.80
|
| Rate for Payer: Cofinity Advantage |
$425.07
|
| Rate for Payer: Cofinity Commercial |
$522.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$485.80
|
| Rate for Payer: Healthscope Commercial |
$546.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$425.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$455.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$485.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$516.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$455.44
|
| Rate for Payer: PHP Commercial |
$516.16
|
| Rate for Payer: Priority Health SBD |
$382.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$394.71
|
| Rate for Payer: UHC Core |
$316.38
|
| Rate for Payer: UHC Exchange |
$238.65
|
| Rate for Payer: UMR Bronson Commercial |
$224.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$455.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 00555097202
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.27
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.27
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Advantage |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$422.62
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$247.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$327.25
|
|
|
Service Code
|
NDC 64850050201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.99 |
| Max. Negotiated Rate |
$294.52 |
| Rate for Payer: Aetna American Axle |
$212.71
|
| Rate for Payer: Aetna Commercial |
$278.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.71
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Cofinity Advantage |
$229.07
|
| Rate for Payer: Cofinity Commercial |
$281.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.80
|
| Rate for Payer: Healthscope Commercial |
$294.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.44
|
| Rate for Payer: PHP Commercial |
$278.16
|
| Rate for Payer: Priority Health SBD |
$206.17
|
| Rate for Payer: UMR Bronson Commercial |
$143.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$822.50
|
|
|
Service Code
|
NDC 00527150237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$304.32 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna Medicare |
$411.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: BCBS Complete |
$329.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$658.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$534.62
|
| Rate for Payer: UHC Core |
$428.52
|
| Rate for Payer: UHC Exchange |
$323.24
|
| Rate for Payer: UMR Bronson Commercial |
$304.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$605.50
|
|
|
Service Code
|
NDC 68382095201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.42 |
| Max. Negotiated Rate |
$544.95 |
| Rate for Payer: Aetna American Axle |
$393.57
|
| Rate for Payer: Aetna Commercial |
$514.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.57
|
| Rate for Payer: Cash Price |
$484.40
|
| Rate for Payer: Cofinity Advantage |
$423.85
|
| Rate for Payer: Cofinity Commercial |
$520.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.40
|
| Rate for Payer: Healthscope Commercial |
$544.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$454.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$454.12
|
| Rate for Payer: PHP Commercial |
$514.67
|
| Rate for Payer: Priority Health SBD |
$381.46
|
| Rate for Payer: UMR Bronson Commercial |
$266.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$454.12
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$563.50
|
|
|
Service Code
|
NDC 00555097202
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.27
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna Medicare |
$281.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.27
|
| Rate for Payer: BCBS Complete |
$225.40
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Advantage |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$422.62
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.27
|
| Rate for Payer: UHC Core |
$293.58
|
| Rate for Payer: UHC Exchange |
$221.46
|
| Rate for Payer: UMR Bronson Commercial |
$208.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$607.25
|
|
|
Service Code
|
NDC 47781017601
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.19 |
| Max. Negotiated Rate |
$546.52 |
| Rate for Payer: Aetna American Axle |
$394.71
|
| Rate for Payer: Aetna Commercial |
$516.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$394.71
|
| Rate for Payer: Cash Price |
$485.80
|
| Rate for Payer: Cofinity Advantage |
$425.07
|
| Rate for Payer: Cofinity Commercial |
$522.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$485.80
|
| Rate for Payer: Healthscope Commercial |
$546.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$425.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$455.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$516.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$455.44
|
| Rate for Payer: PHP Commercial |
$516.16
|
| Rate for Payer: Priority Health SBD |
$382.57
|
| Rate for Payer: UMR Bronson Commercial |
$267.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$455.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
|
Service Code
|
NDC 00527150237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$361.90 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
| Rate for Payer: UMR Bronson Commercial |
$361.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$605.50
|
|
|
Service Code
|
NDC 68382095201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.03 |
| Max. Negotiated Rate |
$544.95 |
| Rate for Payer: Aetna American Axle |
$393.57
|
| Rate for Payer: Aetna Commercial |
$514.67
|
| Rate for Payer: Aetna Medicare |
$302.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.57
|
| Rate for Payer: BCBS Complete |
$242.20
|
| Rate for Payer: Cash Price |
$484.40
|
| Rate for Payer: Cofinity Advantage |
$423.85
|
| Rate for Payer: Cofinity Commercial |
$520.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$484.40
|
| Rate for Payer: Healthscope Commercial |
$544.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$454.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$484.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$454.12
|
| Rate for Payer: PHP Commercial |
$514.67
|
| Rate for Payer: Priority Health SBD |
$381.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$393.57
|
| Rate for Payer: UHC Core |
$315.47
|
| Rate for Payer: UHC Exchange |
$237.96
|
| Rate for Payer: UMR Bronson Commercial |
$224.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$454.12
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$327.25
|
|
|
Service Code
|
NDC 64850050201
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.08 |
| Max. Negotiated Rate |
$294.52 |
| Rate for Payer: Aetna American Axle |
$212.71
|
| Rate for Payer: Aetna Commercial |
$278.16
|
| Rate for Payer: Aetna Medicare |
$163.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.71
|
| Rate for Payer: BCBS Complete |
$130.90
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Cofinity Advantage |
$229.07
|
| Rate for Payer: Cofinity Commercial |
$281.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.80
|
| Rate for Payer: Healthscope Commercial |
$294.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$261.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.44
|
| Rate for Payer: PHP Commercial |
$278.16
|
| Rate for Payer: Priority Health SBD |
$206.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$212.71
|
| Rate for Payer: UHC Core |
$170.50
|
| Rate for Payer: UHC Exchange |
$128.61
|
| Rate for Payer: UMR Bronson Commercial |
$121.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$822.50
|
|
|
Service Code
|
NDC 00527076237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$361.90 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
| Rate for Payer: UMR Bronson Commercial |
$361.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
IP
|
$610.75
|
|
|
Service Code
|
NDC 13107007001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.73 |
| Max. Negotiated Rate |
$549.67 |
| Rate for Payer: Aetna American Axle |
$396.99
|
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Advantage |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$458.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$458.06
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health SBD |
$384.77
|
| Rate for Payer: UMR Bronson Commercial |
$268.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$458.06
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$610.75
|
|
|
Service Code
|
NDC 13107007001
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.98 |
| Max. Negotiated Rate |
$549.67 |
| Rate for Payer: Aetna American Axle |
$396.99
|
| Rate for Payer: Aetna Commercial |
$519.14
|
| Rate for Payer: Aetna Medicare |
$305.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.99
|
| Rate for Payer: BCBS Complete |
$244.30
|
| Rate for Payer: Cash Price |
$488.60
|
| Rate for Payer: Cofinity Advantage |
$427.52
|
| Rate for Payer: Cofinity Commercial |
$525.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.60
|
| Rate for Payer: Healthscope Commercial |
$549.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$458.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$488.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$458.06
|
| Rate for Payer: PHP Commercial |
$519.14
|
| Rate for Payer: Priority Health SBD |
$384.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$396.99
|
| Rate for Payer: UHC Core |
$318.20
|
| Rate for Payer: UHC Exchange |
$240.02
|
| Rate for Payer: UMR Bronson Commercial |
$225.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$458.06
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET
|
Facility
|
OP
|
$822.50
|
|
|
Service Code
|
NDC 00527076237
|
| Hospital Charge Code |
108419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$304.32 |
| Max. Negotiated Rate |
$740.25 |
| Rate for Payer: Aetna American Axle |
$534.62
|
| Rate for Payer: Aetna Commercial |
$699.12
|
| Rate for Payer: Aetna Medicare |
$411.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$534.62
|
| Rate for Payer: BCBS Complete |
$329.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cofinity Advantage |
$575.75
|
| Rate for Payer: Cofinity Commercial |
$707.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.00
|
| Rate for Payer: Healthscope Commercial |
$740.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$575.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$616.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$658.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$616.88
|
| Rate for Payer: PHP Commercial |
$699.12
|
| Rate for Payer: Priority Health SBD |
$518.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$534.62
|
| Rate for Payer: UHC Core |
$428.52
|
| Rate for Payer: UHC Exchange |
$323.24
|
| Rate for Payer: UMR Bronson Commercial |
$304.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$616.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
OP
|
$563.50
|
|
|
Service Code
|
NDC 00555097102
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.27
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna Medicare |
$281.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.27
|
| Rate for Payer: BCBS Complete |
$225.40
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Advantage |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$422.62
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.27
|
| Rate for Payer: UHC Core |
$293.58
|
| Rate for Payer: UHC Exchange |
$221.46
|
| Rate for Payer: UMR Bronson Commercial |
$208.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
OP
|
$3,938.55
|
|
|
Service Code
|
NDC 57844010501
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,457.26 |
| Max. Negotiated Rate |
$3,544.70 |
| Rate for Payer: Aetna American Axle |
$2,560.06
|
| Rate for Payer: Aetna Commercial |
$3,347.77
|
| Rate for Payer: Aetna Medicare |
$1,969.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,560.06
|
| Rate for Payer: BCBS Complete |
$1,575.42
|
| Rate for Payer: Cash Price |
$3,150.84
|
| Rate for Payer: Cofinity Advantage |
$2,756.99
|
| Rate for Payer: Cofinity Commercial |
$3,387.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,150.84
|
| Rate for Payer: Healthscope Commercial |
$3,544.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,756.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,953.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,150.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,347.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,953.91
|
| Rate for Payer: PHP Commercial |
$3,347.77
|
| Rate for Payer: Priority Health SBD |
$2,481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,560.06
|
| Rate for Payer: UHC Core |
$2,051.98
|
| Rate for Payer: UHC Exchange |
$1,547.85
|
| Rate for Payer: UMR Bronson Commercial |
$1,457.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,953.91
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
IP
|
$563.50
|
|
|
Service Code
|
NDC 00555097102
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.94 |
| Max. Negotiated Rate |
$507.15 |
| Rate for Payer: Aetna American Axle |
$366.27
|
| Rate for Payer: Aetna Commercial |
$478.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$366.27
|
| Rate for Payer: Cash Price |
$450.80
|
| Rate for Payer: Cofinity Advantage |
$394.45
|
| Rate for Payer: Cofinity Commercial |
$484.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.80
|
| Rate for Payer: Healthscope Commercial |
$507.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$394.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$422.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$478.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$422.62
|
| Rate for Payer: PHP Commercial |
$478.98
|
| Rate for Payer: Priority Health SBD |
$355.00
|
| Rate for Payer: UMR Bronson Commercial |
$247.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$422.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET
|
Facility
|
IP
|
$3,938.55
|
|
|
Service Code
|
NDC 57844010501
|
| Hospital Charge Code |
109893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,732.96 |
| Max. Negotiated Rate |
$3,544.70 |
| Rate for Payer: Aetna American Axle |
$2,560.06
|
| Rate for Payer: Aetna Commercial |
$3,347.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,560.06
|
| Rate for Payer: Cash Price |
$3,150.84
|
| Rate for Payer: Cofinity Advantage |
$2,756.99
|
| Rate for Payer: Cofinity Commercial |
$3,387.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,150.84
|
| Rate for Payer: Healthscope Commercial |
$3,544.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,756.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,953.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,347.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,953.91
|
| Rate for Payer: PHP Commercial |
$3,347.77
|
| Rate for Payer: Priority Health SBD |
$2,481.29
|
| Rate for Payer: UMR Bronson Commercial |
$1,732.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,953.91
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$720.30
|
|
|
Service Code
|
NDC 57664033788
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.51 |
| Max. Negotiated Rate |
$648.27 |
| Rate for Payer: Aetna American Axle |
$468.19
|
| Rate for Payer: Aetna Commercial |
$612.25
|
| Rate for Payer: Aetna Medicare |
$360.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.19
|
| Rate for Payer: BCBS Complete |
$288.12
|
| Rate for Payer: Cash Price |
$576.24
|
| Rate for Payer: Cofinity Advantage |
$504.21
|
| Rate for Payer: Cofinity Commercial |
$619.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$576.24
|
| Rate for Payer: Healthscope Commercial |
$648.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$504.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$540.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$576.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$612.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$540.23
|
| Rate for Payer: PHP Commercial |
$612.25
|
| Rate for Payer: Priority Health SBD |
$453.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$468.19
|
| Rate for Payer: UHC Core |
$375.28
|
| Rate for Payer: UHC Exchange |
$283.08
|
| Rate for Payer: UMR Bronson Commercial |
$266.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$540.23
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038301
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$808.79 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna Medicare |
$1,092.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: BCBS Complete |
$874.37
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Advantage |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,748.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,858.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,639.44
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,420.85
|
| Rate for Payer: UHC Core |
$1,138.86
|
| Rate for Payer: UHC Exchange |
$859.07
|
| Rate for Payer: UMR Bronson Commercial |
$808.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038301
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$961.80 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Advantage |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,858.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,639.44
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$961.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$720.30
|
|
|
Service Code
|
NDC 57664033788
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$316.93 |
| Max. Negotiated Rate |
$648.27 |
| Rate for Payer: Aetna American Axle |
$468.19
|
| Rate for Payer: Aetna Commercial |
$612.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.19
|
| Rate for Payer: Cash Price |
$576.24
|
| Rate for Payer: Cofinity Advantage |
$504.21
|
| Rate for Payer: Cofinity Commercial |
$619.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$576.24
|
| Rate for Payer: Healthscope Commercial |
$648.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$504.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$540.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$612.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$540.23
|
| Rate for Payer: PHP Commercial |
$612.25
|
| Rate for Payer: Priority Health SBD |
$453.79
|
| Rate for Payer: UMR Bronson Commercial |
$316.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$540.23
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$788.20
|
|
|
Service Code
|
NDC 00228305911
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.81 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Advantage |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$591.15
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$346.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$788.20
|
|
|
Service Code
|
NDC 00228305911
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$291.63 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna Medicare |
$394.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: BCBS Complete |
$315.28
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Advantage |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$630.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$591.15
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$512.33
|
| Rate for Payer: UHC Core |
$410.65
|
| Rate for Payer: UHC Exchange |
$309.76
|
| Rate for Payer: UMR Bronson Commercial |
$291.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
