|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
OP
|
$3.53
|
|
|
Service Code
|
NDC 50268003711
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna American Axle |
$2.29
|
| Rate for Payer: Aetna Commercial |
$3.00
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.29
|
| Rate for Payer: BCBS Complete |
$1.41
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Cofinity Commercial |
$3.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.82
|
| Rate for Payer: Healthscope Commercial |
$3.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.00
|
| Rate for Payer: PHP Commercial |
$3.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.29
|
| Rate for Payer: Priority Health SBD |
$2.22
|
| Rate for Payer: UMR Bronson Commercial |
$1.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.65
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$281.20
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.04 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna American Axle |
$182.78
|
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: Aetna Medicare |
$140.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.78
|
| Rate for Payer: BCBS Complete |
$112.48
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$196.84
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health SBD |
$177.16
|
| Rate for Payer: UMR Bronson Commercial |
$104.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$281.20
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.73 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna American Axle |
$182.78
|
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.78
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$196.84
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health SBD |
$177.16
|
| Rate for Payer: UMR Bronson Commercial |
$123.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$1.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: BCBS Complete |
$1.13
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$240.35
|
|
|
Service Code
|
NDC 00904020161
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.93 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Medicare |
$120.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: BCBS Complete |
$96.14
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.23
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$88.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$253.65
|
|
|
Service Code
|
NDC 00904741061
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.61 |
| Max. Negotiated Rate |
$228.28 |
| Rate for Payer: Aetna American Axle |
$164.87
|
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.87
|
| Rate for Payer: Cash Price |
$202.92
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Commercial |
$218.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.92
|
| Rate for Payer: Healthscope Commercial |
$228.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.60
|
| Rate for Payer: PHP Commercial |
$215.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.87
|
| Rate for Payer: Priority Health SBD |
$159.80
|
| Rate for Payer: UMR Bronson Commercial |
$111.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.24
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$253.65
|
|
|
Service Code
|
NDC 00904741061
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.85 |
| Max. Negotiated Rate |
$228.28 |
| Rate for Payer: Aetna American Axle |
$164.87
|
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Aetna Medicare |
$126.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.87
|
| Rate for Payer: BCBS Complete |
$101.46
|
| Rate for Payer: Cash Price |
$202.92
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Commercial |
$218.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.92
|
| Rate for Payer: Healthscope Commercial |
$228.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.60
|
| Rate for Payer: PHP Commercial |
$215.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.87
|
| Rate for Payer: Priority Health SBD |
$159.80
|
| Rate for Payer: UMR Bronson Commercial |
$93.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.24
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$240.35
|
|
|
Service Code
|
NDC 00904020161
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.75 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.23
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$105.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 00904718461
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.07 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.35
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$99.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$225.15
|
|
|
Service Code
|
NDC 00904718461
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna American Axle |
$146.35
|
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: Aetna Medicare |
$112.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.35
|
| Rate for Payer: BCBS Complete |
$90.06
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$157.60
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.35
|
| Rate for Payer: Priority Health SBD |
$141.84
|
| Rate for Payer: UMR Bronson Commercial |
$83.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 51079013301
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna American Axle |
$2.16
|
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.66
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.16
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.49
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$421.80
|
|
|
Service Code
|
NDC 60687044401
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.07 |
| Max. Negotiated Rate |
$379.62 |
| Rate for Payer: Aetna American Axle |
$274.17
|
| Rate for Payer: Aetna Commercial |
$358.53
|
| Rate for Payer: Aetna Medicare |
$210.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.17
|
| Rate for Payer: BCBS Complete |
$168.72
|
| Rate for Payer: Cash Price |
$337.44
|
| Rate for Payer: Cofinity Commercial |
$295.26
|
| Rate for Payer: Cofinity Commercial |
$362.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$295.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.44
|
| Rate for Payer: Healthscope Commercial |
$379.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$295.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$358.53
|
| Rate for Payer: PHP Commercial |
$358.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.17
|
| Rate for Payer: Priority Health SBD |
$265.73
|
| Rate for Payer: UMR Bronson Commercial |
$156.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.35
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$331.55
|
|
|
Service Code
|
NDC 51079013320
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.67 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna Medicare |
$165.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: BCBS Complete |
$132.62
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.08
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.51
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$122.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$421.80
|
|
|
Service Code
|
NDC 60687044401
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.59 |
| Max. Negotiated Rate |
$379.62 |
| Rate for Payer: Aetna American Axle |
$274.17
|
| Rate for Payer: Aetna Commercial |
$358.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.17
|
| Rate for Payer: Cash Price |
$337.44
|
| Rate for Payer: Cofinity Commercial |
$295.26
|
| Rate for Payer: Cofinity Commercial |
$362.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$295.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.44
|
| Rate for Payer: Healthscope Commercial |
$379.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$295.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$358.53
|
| Rate for Payer: PHP Commercial |
$358.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.17
|
| Rate for Payer: Priority Health SBD |
$265.73
|
| Rate for Payer: UMR Bronson Commercial |
$185.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.35
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 60687044411
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Aetna American Axle |
$2.74
|
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Aetna Medicare |
$2.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.74
|
| Rate for Payer: BCBS Complete |
$1.69
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.95
|
| Rate for Payer: Cofinity Commercial |
$3.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.59
|
| Rate for Payer: PHP Commercial |
$3.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.74
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.16
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$331.35
|
|
|
Service Code
|
NDC 70756020311
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.79 |
| Max. Negotiated Rate |
$298.22 |
| Rate for Payer: Aetna American Axle |
$215.38
|
| Rate for Payer: Aetna Commercial |
$281.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.38
|
| Rate for Payer: Cash Price |
$265.08
|
| Rate for Payer: Cofinity Commercial |
$231.94
|
| Rate for Payer: Cofinity Commercial |
$284.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.08
|
| Rate for Payer: Healthscope Commercial |
$298.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.65
|
| Rate for Payer: PHP Commercial |
$281.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.38
|
| Rate for Payer: Priority Health SBD |
$208.75
|
| Rate for Payer: UMR Bronson Commercial |
$145.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.51
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 00904718561
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.43 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna American Axle |
$218.60
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$168.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.60
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.60
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UMR Bronson Commercial |
$124.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 00904718561
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.97 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna American Axle |
$218.60
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.60
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.60
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UMR Bronson Commercial |
$147.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$331.35
|
|
|
Service Code
|
NDC 70756020311
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.60 |
| Max. Negotiated Rate |
$298.22 |
| Rate for Payer: Aetna American Axle |
$215.38
|
| Rate for Payer: Aetna Commercial |
$281.65
|
| Rate for Payer: Aetna Medicare |
$165.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.38
|
| Rate for Payer: BCBS Complete |
$132.54
|
| Rate for Payer: Cash Price |
$265.08
|
| Rate for Payer: Cofinity Commercial |
$231.94
|
| Rate for Payer: Cofinity Commercial |
$284.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.08
|
| Rate for Payer: Healthscope Commercial |
$298.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.65
|
| Rate for Payer: PHP Commercial |
$281.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.38
|
| Rate for Payer: Priority Health SBD |
$208.75
|
| Rate for Payer: UMR Bronson Commercial |
$122.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.51
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$409.45
|
|
|
Service Code
|
NDC 00904020261
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.50 |
| Max. Negotiated Rate |
$368.50 |
| Rate for Payer: Aetna American Axle |
$266.14
|
| Rate for Payer: Aetna Commercial |
$348.03
|
| Rate for Payer: Aetna Medicare |
$204.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.14
|
| Rate for Payer: BCBS Complete |
$163.78
|
| Rate for Payer: Cash Price |
$327.56
|
| Rate for Payer: Cofinity Commercial |
$286.62
|
| Rate for Payer: Cofinity Commercial |
$352.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$286.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.56
|
| Rate for Payer: Healthscope Commercial |
$368.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$348.03
|
| Rate for Payer: PHP Commercial |
$348.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.14
|
| Rate for Payer: Priority Health SBD |
$257.95
|
| Rate for Payer: UMR Bronson Commercial |
$151.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.09
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 51079013301
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna American Axle |
$2.16
|
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna Medicare |
$1.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: BCBS Complete |
$1.33
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.66
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.16
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.49
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 16729017301
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.35 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UMR Bronson Commercial |
$71.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$409.45
|
|
|
Service Code
|
NDC 00904020261
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.16 |
| Max. Negotiated Rate |
$368.50 |
| Rate for Payer: Aetna American Axle |
$266.14
|
| Rate for Payer: Aetna Commercial |
$348.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.14
|
| Rate for Payer: Cash Price |
$327.56
|
| Rate for Payer: Cofinity Commercial |
$286.62
|
| Rate for Payer: Cofinity Commercial |
$352.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$286.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.56
|
| Rate for Payer: Healthscope Commercial |
$368.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$348.03
|
| Rate for Payer: PHP Commercial |
$348.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.14
|
| Rate for Payer: Priority Health SBD |
$257.95
|
| Rate for Payer: UMR Bronson Commercial |
$180.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.09
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$331.55
|
|
|
Service Code
|
NDC 51079013320
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.88 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.08
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.51
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$145.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
