|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
OP
|
$22.89
|
|
|
Service Code
|
NDC 61269022041
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna Medicare |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.88
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$8.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 51672200306
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Aetna American Axle |
$10.53
|
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.53
|
| Rate for Payer: BCBS Complete |
$6.48
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$13.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.96
|
| Rate for Payer: Healthscope Commercial |
$14.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.77
|
| Rate for Payer: PHP Commercial |
$13.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.53
|
| Rate for Payer: Priority Health SBD |
$10.21
|
| Rate for Payer: UMR Bronson Commercial |
$5.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.15
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
OP
|
$22.89
|
|
|
Service Code
|
NDC 61269022063
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna Medicare |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.88
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$8.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
IP
|
$22.89
|
|
|
Service Code
|
NDC 61269022041
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.88
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$10.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 51672200306
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Aetna American Axle |
$10.53
|
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.53
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$13.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.96
|
| Rate for Payer: Healthscope Commercial |
$14.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.77
|
| Rate for Payer: PHP Commercial |
$13.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.53
|
| Rate for Payer: Priority Health SBD |
$10.21
|
| Rate for Payer: UMR Bronson Commercial |
$7.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.15
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$25.68
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.30 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna American Axle |
$16.69
|
| Rate for Payer: Aetna Commercial |
$21.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.69
|
| Rate for Payer: Cash Price |
$20.54
|
| Rate for Payer: Cofinity Commercial |
$17.98
|
| Rate for Payer: Cofinity Commercial |
$22.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.54
|
| Rate for Payer: Healthscope Commercial |
$23.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.83
|
| Rate for Payer: PHP Commercial |
$21.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.69
|
| Rate for Payer: Priority Health SBD |
$16.18
|
| Rate for Payer: UMR Bronson Commercial |
$11.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.26
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
OP
|
$25.68
|
|
|
Service Code
|
NDC 00168025815
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna American Axle |
$16.69
|
| Rate for Payer: Aetna Commercial |
$21.83
|
| Rate for Payer: Aetna Medicare |
$12.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.69
|
| Rate for Payer: BCBS Complete |
$10.27
|
| Rate for Payer: Cash Price |
$20.54
|
| Rate for Payer: Cofinity Commercial |
$17.98
|
| Rate for Payer: Cofinity Commercial |
$22.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.54
|
| Rate for Payer: Healthscope Commercial |
$23.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.83
|
| Rate for Payer: PHP Commercial |
$21.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.69
|
| Rate for Payer: Priority Health SBD |
$16.18
|
| Rate for Payer: UMR Bronson Commercial |
$9.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.26
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
OP
|
$19.51
|
|
|
Service Code
|
NDC 68462029817
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna American Axle |
$12.68
|
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna Medicare |
$9.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: BCBS Complete |
$7.80
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cofinity Commercial |
$13.66
|
| Rate for Payer: Cofinity Commercial |
$16.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.61
|
| Rate for Payer: Healthscope Commercial |
$17.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.58
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health SBD |
$12.29
|
| Rate for Payer: UMR Bronson Commercial |
$7.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.63
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$19.51
|
|
|
Service Code
|
NDC 68462029817
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna American Axle |
$12.68
|
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cofinity Commercial |
$13.66
|
| Rate for Payer: Cofinity Commercial |
$16.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.61
|
| Rate for Payer: Healthscope Commercial |
$17.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.58
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health SBD |
$12.29
|
| Rate for Payer: UMR Bronson Commercial |
$8.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.63
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$18.43
|
|
|
Service Code
|
NDC 00093541919
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna American Axle |
$11.98
|
| Rate for Payer: Aetna Commercial |
$15.67
|
| Rate for Payer: Aetna Medicare |
$9.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.98
|
| Rate for Payer: BCBS Complete |
$7.37
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Commercial |
$15.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.74
|
| Rate for Payer: Healthscope Commercial |
$16.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.67
|
| Rate for Payer: PHP Commercial |
$15.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.98
|
| Rate for Payer: Priority Health SBD |
$11.61
|
| Rate for Payer: UMR Bronson Commercial |
$6.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.82
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$18.43
|
|
|
Service Code
|
NDC 00093541919
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna American Axle |
$11.98
|
| Rate for Payer: Aetna Commercial |
$15.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.98
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Commercial |
$15.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.74
|
| Rate for Payer: Healthscope Commercial |
$16.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.67
|
| Rate for Payer: PHP Commercial |
$15.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.98
|
| Rate for Payer: Priority Health SBD |
$11.61
|
| Rate for Payer: UMR Bronson Commercial |
$8.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.82
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$22.51
|
|
|
Service Code
|
NDC 51079028801
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$20.26 |
| Rate for Payer: Aetna American Axle |
$14.63
|
| Rate for Payer: Aetna Commercial |
$19.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.63
|
| Rate for Payer: Cash Price |
$18.01
|
| Rate for Payer: Cofinity Commercial |
$15.76
|
| Rate for Payer: Cofinity Commercial |
$19.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.01
|
| Rate for Payer: Healthscope Commercial |
$20.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.13
|
| Rate for Payer: PHP Commercial |
$19.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.63
|
| Rate for Payer: Priority Health SBD |
$14.18
|
| Rate for Payer: UMR Bronson Commercial |
$9.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.88
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$884.63
|
|
|
Service Code
|
NDC 00093541984
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$327.31 |
| Max. Negotiated Rate |
$796.17 |
| Rate for Payer: Aetna American Axle |
$575.01
|
| Rate for Payer: Aetna Commercial |
$751.94
|
| Rate for Payer: Aetna Medicare |
$442.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$575.01
|
| Rate for Payer: BCBS Complete |
$353.85
|
| Rate for Payer: Cash Price |
$707.70
|
| Rate for Payer: Cofinity Commercial |
$619.24
|
| Rate for Payer: Cofinity Commercial |
$760.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$619.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$707.70
|
| Rate for Payer: Healthscope Commercial |
$796.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$619.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$663.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$751.94
|
| Rate for Payer: PHP Commercial |
$751.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$575.01
|
| Rate for Payer: Priority Health SBD |
$557.32
|
| Rate for Payer: UMR Bronson Commercial |
$327.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$663.47
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$884.63
|
|
|
Service Code
|
NDC 00093541984
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$389.24 |
| Max. Negotiated Rate |
$796.17 |
| Rate for Payer: Aetna American Axle |
$575.01
|
| Rate for Payer: Aetna Commercial |
$751.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$575.01
|
| Rate for Payer: Cash Price |
$707.70
|
| Rate for Payer: Cofinity Commercial |
$619.24
|
| Rate for Payer: Cofinity Commercial |
$760.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$619.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$707.70
|
| Rate for Payer: Healthscope Commercial |
$796.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$619.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$663.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$751.94
|
| Rate for Payer: PHP Commercial |
$751.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$575.01
|
| Rate for Payer: Priority Health SBD |
$557.32
|
| Rate for Payer: UMR Bronson Commercial |
$389.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$663.47
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$900.14
|
|
|
Service Code
|
NDC 51079028804
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$333.05 |
| Max. Negotiated Rate |
$810.13 |
| Rate for Payer: Aetna American Axle |
$585.09
|
| Rate for Payer: Aetna Commercial |
$765.12
|
| Rate for Payer: Aetna Medicare |
$450.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$585.09
|
| Rate for Payer: BCBS Complete |
$360.06
|
| Rate for Payer: Cash Price |
$720.11
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Cofinity Commercial |
$774.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$720.11
|
| Rate for Payer: Healthscope Commercial |
$810.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$630.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$675.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$765.12
|
| Rate for Payer: PHP Commercial |
$765.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$585.09
|
| Rate for Payer: Priority Health SBD |
$567.09
|
| Rate for Payer: UMR Bronson Commercial |
$333.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$675.11
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$900.14
|
|
|
Service Code
|
NDC 51079028804
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$396.06 |
| Max. Negotiated Rate |
$810.13 |
| Rate for Payer: Aetna American Axle |
$585.09
|
| Rate for Payer: Aetna Commercial |
$765.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$585.09
|
| Rate for Payer: Cash Price |
$720.11
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Cofinity Commercial |
$774.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$720.11
|
| Rate for Payer: Healthscope Commercial |
$810.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$630.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$675.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$765.12
|
| Rate for Payer: PHP Commercial |
$765.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$585.09
|
| Rate for Payer: Priority Health SBD |
$567.09
|
| Rate for Payer: UMR Bronson Commercial |
$396.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$675.11
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$22.51
|
|
|
Service Code
|
NDC 51079028801
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$20.26 |
| Rate for Payer: Aetna American Axle |
$14.63
|
| Rate for Payer: Aetna Commercial |
$19.13
|
| Rate for Payer: Aetna Medicare |
$11.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.63
|
| Rate for Payer: BCBS Complete |
$9.00
|
| Rate for Payer: Cash Price |
$18.01
|
| Rate for Payer: Cofinity Commercial |
$15.76
|
| Rate for Payer: Cofinity Commercial |
$19.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.01
|
| Rate for Payer: Healthscope Commercial |
$20.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.13
|
| Rate for Payer: PHP Commercial |
$19.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.63
|
| Rate for Payer: Priority Health SBD |
$14.18
|
| Rate for Payer: UMR Bronson Commercial |
$8.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.88
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$358.08
|
|
|
Service Code
|
NDC 60687041501
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.56 |
| Max. Negotiated Rate |
$322.27 |
| Rate for Payer: Aetna American Axle |
$232.75
|
| Rate for Payer: Aetna Commercial |
$304.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$232.75
|
| Rate for Payer: Cash Price |
$286.46
|
| Rate for Payer: Cofinity Commercial |
$250.66
|
| Rate for Payer: Cofinity Commercial |
$307.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$250.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$286.46
|
| Rate for Payer: Healthscope Commercial |
$322.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$250.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$268.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$304.37
|
| Rate for Payer: PHP Commercial |
$304.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.75
|
| Rate for Payer: Priority Health SBD |
$225.59
|
| Rate for Payer: UMR Bronson Commercial |
$157.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$268.56
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$3.59
|
|
|
Service Code
|
NDC 60687041511
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna American Axle |
$2.33
|
| Rate for Payer: Aetna Commercial |
$3.05
|
| Rate for Payer: Aetna Medicare |
$1.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.33
|
| Rate for Payer: BCBS Complete |
$1.44
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Cofinity Commercial |
$2.51
|
| Rate for Payer: Cofinity Commercial |
$3.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.87
|
| Rate for Payer: Healthscope Commercial |
$3.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.05
|
| Rate for Payer: PHP Commercial |
$3.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.33
|
| Rate for Payer: Priority Health SBD |
$2.26
|
| Rate for Payer: UMR Bronson Commercial |
$1.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.69
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$358.08
|
|
|
Service Code
|
NDC 60687041501
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.49 |
| Max. Negotiated Rate |
$322.27 |
| Rate for Payer: Aetna American Axle |
$232.75
|
| Rate for Payer: Aetna Commercial |
$304.37
|
| Rate for Payer: Aetna Medicare |
$179.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$232.75
|
| Rate for Payer: BCBS Complete |
$143.23
|
| Rate for Payer: Cash Price |
$286.46
|
| Rate for Payer: Cofinity Commercial |
$250.66
|
| Rate for Payer: Cofinity Commercial |
$307.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$250.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$286.46
|
| Rate for Payer: Healthscope Commercial |
$322.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$250.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$268.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$304.37
|
| Rate for Payer: PHP Commercial |
$304.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.75
|
| Rate for Payer: Priority Health SBD |
$225.59
|
| Rate for Payer: UMR Bronson Commercial |
$132.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$268.56
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$381.60
|
|
|
Service Code
|
NDC 51079092220
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.90 |
| Max. Negotiated Rate |
$343.44 |
| Rate for Payer: Aetna American Axle |
$248.04
|
| Rate for Payer: Aetna Commercial |
$324.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.04
|
| Rate for Payer: Cash Price |
$305.28
|
| Rate for Payer: Cofinity Commercial |
$267.12
|
| Rate for Payer: Cofinity Commercial |
$328.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$267.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.28
|
| Rate for Payer: Healthscope Commercial |
$343.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$267.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$286.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.36
|
| Rate for Payer: PHP Commercial |
$324.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.04
|
| Rate for Payer: Priority Health SBD |
$240.41
|
| Rate for Payer: UMR Bronson Commercial |
$167.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.20
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.59
|
|
|
Service Code
|
NDC 60687041511
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna American Axle |
$2.33
|
| Rate for Payer: Aetna Commercial |
$3.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.33
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Cofinity Commercial |
$2.51
|
| Rate for Payer: Cofinity Commercial |
$3.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.87
|
| Rate for Payer: Healthscope Commercial |
$3.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.05
|
| Rate for Payer: PHP Commercial |
$3.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.33
|
| Rate for Payer: Priority Health SBD |
$2.26
|
| Rate for Payer: UMR Bronson Commercial |
$1.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.69
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079092201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$794.76
|
|
|
Service Code
|
NDC 00093777201
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$349.69 |
| Max. Negotiated Rate |
$715.28 |
| Rate for Payer: Aetna American Axle |
$516.59
|
| Rate for Payer: Aetna Commercial |
$675.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.59
|
| Rate for Payer: Cash Price |
$635.81
|
| Rate for Payer: Cofinity Commercial |
$556.33
|
| Rate for Payer: Cofinity Commercial |
$683.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$556.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.81
|
| Rate for Payer: Healthscope Commercial |
$715.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$556.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$596.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.55
|
| Rate for Payer: PHP Commercial |
$675.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$516.59
|
| Rate for Payer: Priority Health SBD |
$500.70
|
| Rate for Payer: UMR Bronson Commercial |
$349.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$596.07
|
|
