|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$985.25
|
|
|
Service Code
|
NDC 70010003001
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$364.54 |
| Max. Negotiated Rate |
$886.73 |
| Rate for Payer: Aetna American Axle |
$640.41
|
| Rate for Payer: Aetna Commercial |
$837.46
|
| Rate for Payer: Aetna Medicare |
$492.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$640.41
|
| Rate for Payer: BCBS Complete |
$394.10
|
| Rate for Payer: Cash Price |
$788.20
|
| Rate for Payer: Cofinity Advantage |
$689.67
|
| Rate for Payer: Cofinity Commercial |
$847.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$788.20
|
| Rate for Payer: Healthscope Commercial |
$886.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$689.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$738.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$788.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$837.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$738.94
|
| Rate for Payer: PHP Commercial |
$837.46
|
| Rate for Payer: Priority Health SBD |
$620.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$640.41
|
| Rate for Payer: UHC Core |
$513.32
|
| Rate for Payer: UHC Exchange |
$387.20
|
| Rate for Payer: UMR Bronson Commercial |
$364.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$738.94
|
|
|
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
|
OP
|
$759.50
|
|
|
Service Code
|
NDC 00115148701
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.01 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna Medicare |
$379.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: BCBS Complete |
$303.80
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Advantage |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$607.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.62
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health SBD |
$478.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$493.68
|
| Rate for Payer: UHC Core |
$395.70
|
| Rate for Payer: UHC Exchange |
$298.48
|
| Rate for Payer: UMR Bronson Commercial |
$281.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
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
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$455.70
|
|
|
Service Code
|
NDC 31722018701
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.61 |
| Max. Negotiated Rate |
$410.13 |
| Rate for Payer: Aetna American Axle |
$296.20
|
| Rate for Payer: Aetna Commercial |
$387.35
|
| Rate for Payer: Aetna Medicare |
$227.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.20
|
| Rate for Payer: BCBS Complete |
$182.28
|
| Rate for Payer: Cash Price |
$364.56
|
| Rate for Payer: Cofinity Advantage |
$318.99
|
| Rate for Payer: Cofinity Commercial |
$391.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.56
|
| Rate for Payer: Healthscope Commercial |
$410.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$318.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$364.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$341.77
|
| Rate for Payer: PHP Commercial |
$387.35
|
| Rate for Payer: Priority Health SBD |
$287.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$296.20
|
| Rate for Payer: UHC Core |
$237.42
|
| Rate for Payer: UHC Exchange |
$179.09
|
| Rate for Payer: UMR Bronson Commercial |
$168.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.77
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$990.50
|
|
|
Service Code
|
NDC 70010003101
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$366.49 |
| Max. Negotiated Rate |
$891.45 |
| Rate for Payer: Aetna American Axle |
$643.83
|
| Rate for Payer: Aetna Commercial |
$841.92
|
| Rate for Payer: Aetna Medicare |
$495.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$643.83
|
| Rate for Payer: BCBS Complete |
$396.20
|
| Rate for Payer: Cash Price |
$792.40
|
| Rate for Payer: Cofinity Advantage |
$693.35
|
| Rate for Payer: Cofinity Commercial |
$851.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$792.40
|
| Rate for Payer: Healthscope Commercial |
$891.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$693.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$742.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$792.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$841.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$742.88
|
| Rate for Payer: PHP Commercial |
$841.92
|
| Rate for Payer: Priority Health SBD |
$624.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$643.83
|
| Rate for Payer: UHC Core |
$516.05
|
| Rate for Payer: UHC Exchange |
$389.27
|
| Rate for Payer: UMR Bronson Commercial |
$366.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$742.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$716.10
|
|
|
Service Code
|
NDC 66993059602
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.08 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Advantage |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.08
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$315.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$759.50
|
|
|
Service Code
|
NDC 00115148801
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.01 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna Medicare |
$379.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: BCBS Complete |
$303.80
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Advantage |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$607.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.62
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health SBD |
$478.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$493.68
|
| Rate for Payer: UHC Core |
$395.70
|
| Rate for Payer: UHC Exchange |
$298.48
|
| Rate for Payer: UMR Bronson Commercial |
$281.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$759.50
|
|
|
Service Code
|
NDC 00115148801
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.18 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Advantage |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.62
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health SBD |
$478.49
|
| Rate for Payer: UMR Bronson Commercial |
$334.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$788.20
|
|
|
Service Code
|
NDC 00228306311
|
| Hospital Charge Code |
33006
|
|
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 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$907.20
|
|
|
Service Code
|
NDC 43975033310
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$335.66 |
| Max. Negotiated Rate |
$816.48 |
| Rate for Payer: Aetna American Axle |
$589.68
|
| Rate for Payer: Aetna Commercial |
$771.12
|
| Rate for Payer: Aetna Medicare |
$453.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$589.68
|
| Rate for Payer: BCBS Complete |
$362.88
|
| Rate for Payer: Cash Price |
$725.76
|
| Rate for Payer: Cofinity Advantage |
$635.04
|
| Rate for Payer: Cofinity Commercial |
$780.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$725.76
|
| Rate for Payer: Healthscope Commercial |
$816.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$635.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$680.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$725.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$771.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$680.40
|
| Rate for Payer: PHP Commercial |
$771.12
|
| Rate for Payer: Priority Health SBD |
$571.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$589.68
|
| Rate for Payer: UHC Core |
$472.65
|
| Rate for Payer: UHC Exchange |
$356.53
|
| Rate for Payer: UMR Bronson Commercial |
$335.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$680.40
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$455.70
|
|
|
Service Code
|
NDC 31722018701
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.51 |
| Max. Negotiated Rate |
$410.13 |
| Rate for Payer: Aetna American Axle |
$296.20
|
| Rate for Payer: Aetna Commercial |
$387.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.20
|
| Rate for Payer: Cash Price |
$364.56
|
| Rate for Payer: Cofinity Advantage |
$318.99
|
| Rate for Payer: Cofinity Commercial |
$391.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.56
|
| Rate for Payer: Healthscope Commercial |
$410.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$318.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$341.77
|
| Rate for Payer: PHP Commercial |
$387.35
|
| Rate for Payer: Priority Health SBD |
$287.09
|
| Rate for Payer: UMR Bronson Commercial |
$200.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.77
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$788.20
|
|
|
Service Code
|
NDC 00228306311
|
| Hospital Charge Code |
33006
|
|
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
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$716.10
|
|
|
Service Code
|
NDC 66993059602
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$264.96 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna Medicare |
$358.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: BCBS Complete |
$286.44
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Advantage |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$572.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.08
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$465.46
|
| Rate for Payer: UHC Core |
$373.09
|
| Rate for Payer: UHC Exchange |
$281.43
|
| Rate for Payer: UMR Bronson Commercial |
$264.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$990.50
|
|
|
Service Code
|
NDC 70010003101
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$435.82 |
| Max. Negotiated Rate |
$891.45 |
| Rate for Payer: Aetna American Axle |
$643.83
|
| Rate for Payer: Aetna Commercial |
$841.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$643.83
|
| Rate for Payer: Cash Price |
$792.40
|
| Rate for Payer: Cofinity Advantage |
$693.35
|
| Rate for Payer: Cofinity Commercial |
$851.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$792.40
|
| Rate for Payer: Healthscope Commercial |
$891.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$693.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$742.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$841.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$742.88
|
| Rate for Payer: PHP Commercial |
$841.92
|
| Rate for Payer: Priority Health SBD |
$624.01
|
| Rate for Payer: UMR Bronson Commercial |
$435.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$742.88
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038501
|
| Hospital Charge Code |
33006
|
|
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 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038501
|
| Hospital Charge Code |
33006
|
|
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 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$907.20
|
|
|
Service Code
|
NDC 43975033310
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$399.17 |
| Max. Negotiated Rate |
$816.48 |
| Rate for Payer: Aetna American Axle |
$589.68
|
| Rate for Payer: Aetna Commercial |
$771.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$589.68
|
| Rate for Payer: Cash Price |
$725.76
|
| Rate for Payer: Cofinity Advantage |
$635.04
|
| Rate for Payer: Cofinity Commercial |
$780.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$725.76
|
| Rate for Payer: Healthscope Commercial |
$816.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$635.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$680.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$771.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$680.40
|
| Rate for Payer: PHP Commercial |
$771.12
|
| Rate for Payer: Priority Health SBD |
$571.54
|
| Rate for Payer: UMR Bronson Commercial |
$399.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$680.40
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 30 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$716.10
|
|
|
Service Code
|
NDC 66993059902
|
| Hospital Charge Code |
31589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$264.96 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna Medicare |
$358.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: BCBS Complete |
$286.44
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Advantage |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$572.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.08
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$465.46
|
| Rate for Payer: UHC Core |
$373.09
|
| Rate for Payer: UHC Exchange |
$281.43
|
| Rate for Payer: UMR Bronson Commercial |
$264.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 30 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$716.10
|
|
|
Service Code
|
NDC 66993059902
|
| Hospital Charge Code |
31589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.08 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Advantage |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$537.08
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$315.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$7.01
|
|
|
Service Code
|
NDC 00904713572
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.31 |
| Rate for Payer: Aetna American Axle |
$4.56
|
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.56
|
| Rate for Payer: Cash Price |
$5.61
|
| Rate for Payer: Cofinity Advantage |
$4.91
|
| Rate for Payer: Cofinity Commercial |
$6.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.61
|
| Rate for Payer: Healthscope Commercial |
$6.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.26
|
| Rate for Payer: PHP Commercial |
$5.96
|
| Rate for Payer: Priority Health SBD |
$4.42
|
| Rate for Payer: UMR Bronson Commercial |
$3.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.26
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$9.32
|
|
|
Service Code
|
NDC 00121127600
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Aetna American Axle |
$6.06
|
| Rate for Payer: Aetna Commercial |
$7.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.06
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cofinity Advantage |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.46
|
| Rate for Payer: Healthscope Commercial |
$8.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.99
|
| Rate for Payer: PHP Commercial |
$7.92
|
| Rate for Payer: Priority Health SBD |
$5.87
|
| Rate for Payer: UMR Bronson Commercial |
$4.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.99
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
NDC 63739050601
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Advantage |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UMR Bronson Commercial |
$3.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.29
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$8.40
|
|
|
Service Code
|
NDC 69339015001
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna American Axle |
$5.46
|
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Aetna Medicare |
$4.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.46
|
| Rate for Payer: BCBS Complete |
$3.36
|
| Rate for Payer: Cash Price |
$6.72
|
| Rate for Payer: Cofinity Advantage |
$5.88
|
| Rate for Payer: Cofinity Commercial |
$7.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.72
|
| Rate for Payer: Healthscope Commercial |
$7.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.30
|
| Rate for Payer: PHP Commercial |
$7.14
|
| Rate for Payer: Priority Health SBD |
$5.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.46
|
| Rate for Payer: UHC Core |
$4.38
|
| Rate for Payer: UHC Exchange |
$3.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.30
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 63739050601
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna Medicare |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Advantage |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.59
|
| Rate for Payer: UHC Core |
$3.68
|
| Rate for Payer: UHC Exchange |
$2.77
|
| Rate for Payer: UMR Bronson Commercial |
$2.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.29
|
|
