|
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
|
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
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
|
OP
|
$338.40
|
|
|
Service Code
|
NDC 60687049601
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.21 |
| Max. Negotiated Rate |
$304.56 |
| Rate for Payer: Aetna American Axle |
$219.96
|
| Rate for Payer: Aetna Commercial |
$287.64
|
| Rate for Payer: Aetna Medicare |
$169.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.96
|
| Rate for Payer: BCBS Complete |
$135.36
|
| Rate for Payer: Cash Price |
$270.72
|
| Rate for Payer: Cofinity Commercial |
$236.88
|
| Rate for Payer: Cofinity Commercial |
$291.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.72
|
| Rate for Payer: Healthscope Commercial |
$304.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$236.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.64
|
| Rate for Payer: PHP Commercial |
$287.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.96
|
| Rate for Payer: Priority Health SBD |
$213.19
|
| Rate for Payer: UMR Bronson Commercial |
$125.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.80
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
|
OP
|
$71.91
|
|
|
Service Code
|
NDC 67877019990
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$64.72 |
| Rate for Payer: Aetna American Axle |
$46.74
|
| Rate for Payer: Aetna Commercial |
$61.12
|
| Rate for Payer: Aetna Medicare |
$35.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.74
|
| Rate for Payer: BCBS Complete |
$28.76
|
| Rate for Payer: Cash Price |
$57.53
|
| Rate for Payer: Cofinity Commercial |
$50.34
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.53
|
| Rate for Payer: Healthscope Commercial |
$64.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.12
|
| Rate for Payer: PHP Commercial |
$61.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.74
|
| Rate for Payer: Priority Health SBD |
$45.30
|
| Rate for Payer: UMR Bronson Commercial |
$26.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.93
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
|
IP
|
$71.91
|
|
|
Service Code
|
NDC 67877019990
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.64 |
| Max. Negotiated Rate |
$64.72 |
| Rate for Payer: Aetna American Axle |
$46.74
|
| Rate for Payer: Aetna Commercial |
$61.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.74
|
| Rate for Payer: Cash Price |
$57.53
|
| Rate for Payer: Cofinity Commercial |
$50.34
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.53
|
| Rate for Payer: Healthscope Commercial |
$64.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.12
|
| Rate for Payer: PHP Commercial |
$61.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.74
|
| Rate for Payer: Priority Health SBD |
$45.30
|
| Rate for Payer: UMR Bronson Commercial |
$31.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.93
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
NDC 60687049611
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna American Axle |
$2.20
|
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.71
|
| Rate for Payer: Healthscope Commercial |
$3.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.88
|
| Rate for Payer: PHP Commercial |
$2.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.20
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.54
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
|
IP
|
$3.39
|
|
|
Service Code
|
NDC 60687049611
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna American Axle |
$2.20
|
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.71
|
| Rate for Payer: Healthscope Commercial |
$3.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.88
|
| Rate for Payer: PHP Commercial |
$2.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.20
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.54
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
|
IP
|
$338.40
|
|
|
Service Code
|
NDC 60687049601
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.90 |
| Max. Negotiated Rate |
$304.56 |
| Rate for Payer: Aetna American Axle |
$219.96
|
| Rate for Payer: Aetna Commercial |
$287.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.96
|
| Rate for Payer: Cash Price |
$270.72
|
| Rate for Payer: Cofinity Commercial |
$236.88
|
| Rate for Payer: Cofinity Commercial |
$291.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.72
|
| Rate for Payer: Healthscope Commercial |
$304.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$236.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.64
|
| Rate for Payer: PHP Commercial |
$287.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.96
|
| Rate for Payer: Priority Health SBD |
$213.19
|
| Rate for Payer: UMR Bronson Commercial |
$148.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.80
|
|
|
AMLODIPINE 2.5 MG TABLET
|
Facility
|
OP
|
$406.08
|
|
|
Service Code
|
NDC 59762152001
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.25 |
| Max. Negotiated Rate |
$365.47 |
| Rate for Payer: Aetna American Axle |
$263.95
|
| Rate for Payer: Aetna Commercial |
$345.17
|
| Rate for Payer: Aetna Medicare |
$203.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.95
|
| Rate for Payer: BCBS Complete |
$162.43
|
| Rate for Payer: Cash Price |
$324.86
|
| Rate for Payer: Cofinity Commercial |
$284.26
|
| Rate for Payer: Cofinity Commercial |
$349.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$324.86
|
| Rate for Payer: Healthscope Commercial |
$365.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.17
|
| Rate for Payer: PHP Commercial |
$345.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.95
|
| Rate for Payer: Priority Health SBD |
$255.83
|
| Rate for Payer: UMR Bronson Commercial |
$150.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.56
|
|
|
AMLODIPINE 2.5 MG TABLET
|
Facility
|
IP
|
$406.08
|
|
|
Service Code
|
NDC 59762152001
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.68 |
| Max. Negotiated Rate |
$365.47 |
| Rate for Payer: Aetna American Axle |
$263.95
|
| Rate for Payer: Aetna Commercial |
$345.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.95
|
| Rate for Payer: Cash Price |
$324.86
|
| Rate for Payer: Cofinity Commercial |
$284.26
|
| Rate for Payer: Cofinity Commercial |
$349.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$324.86
|
| Rate for Payer: Healthscope Commercial |
$365.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.17
|
| Rate for Payer: PHP Commercial |
$345.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.95
|
| Rate for Payer: Priority Health SBD |
$255.83
|
| Rate for Payer: UMR Bronson Commercial |
$178.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.56
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
IP
|
$1.84
|
|
|
Service Code
|
NDC 51079045101
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna American Axle |
$1.20
|
| Rate for Payer: Aetna Commercial |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.20
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Commercial |
$1.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.47
|
| Rate for Payer: Healthscope Commercial |
$1.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.56
|
| Rate for Payer: PHP Commercial |
$1.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.20
|
| Rate for Payer: Priority Health SBD |
$1.16
|
| Rate for Payer: UMR Bronson Commercial |
$0.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.38
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 51079045120
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.82 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna American Axle |
$119.14
|
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna Medicare |
$91.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: BCBS Complete |
$73.32
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health SBD |
$115.48
|
| Rate for Payer: UMR Bronson Commercial |
$67.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.48
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
OP
|
$1.84
|
|
|
Service Code
|
NDC 51079045101
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna American Axle |
$1.20
|
| Rate for Payer: Aetna Commercial |
$1.56
|
| Rate for Payer: Aetna Medicare |
$0.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.20
|
| Rate for Payer: BCBS Complete |
$0.74
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Commercial |
$1.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.47
|
| Rate for Payer: Healthscope Commercial |
$1.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.56
|
| Rate for Payer: PHP Commercial |
$1.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.20
|
| Rate for Payer: Priority Health SBD |
$1.16
|
| Rate for Payer: UMR Bronson Commercial |
$0.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.38
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 51079045120
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.65 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna American Axle |
$119.14
|
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health SBD |
$115.48
|
| Rate for Payer: UMR Bronson Commercial |
$80.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.48
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
OP
|
$173.90
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.04
|
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna Medicare |
$86.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: BCBS Complete |
$69.56
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$121.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.04
|
| Rate for Payer: Priority Health SBD |
$109.56
|
| Rate for Payer: UMR Bronson Commercial |
$64.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.42
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.04
|
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$121.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.04
|
| Rate for Payer: Priority Health SBD |
$109.56
|
| Rate for Payer: UMR Bronson Commercial |
$76.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.42
|
|
|
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$2,019.65
|
|
|
Service Code
|
NDC 52652500101
|
| Hospital Charge Code |
190812
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$747.27 |
| Max. Negotiated Rate |
$1,817.68 |
| Rate for Payer: Aetna American Axle |
$1,312.77
|
| Rate for Payer: Aetna Commercial |
$1,716.70
|
| Rate for Payer: Aetna Medicare |
$1,009.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,312.77
|
| Rate for Payer: BCBS Complete |
$807.86
|
| Rate for Payer: Cash Price |
$1,615.72
|
| Rate for Payer: Cofinity Commercial |
$1,413.76
|
| Rate for Payer: Cofinity Commercial |
$1,736.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,413.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,615.72
|
| Rate for Payer: Healthscope Commercial |
$1,817.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,413.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,514.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,716.70
|
| Rate for Payer: PHP Commercial |
$1,716.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,312.77
|
| Rate for Payer: Priority Health SBD |
$1,272.38
|
| Rate for Payer: UMR Bronson Commercial |
$747.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,514.74
|
|
|
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$2,019.65
|
|
|
Service Code
|
NDC 52652500101
|
| Hospital Charge Code |
190812
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$888.65 |
| Max. Negotiated Rate |
$1,817.68 |
| Rate for Payer: Aetna American Axle |
$1,312.77
|
| Rate for Payer: Aetna Commercial |
$1,716.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,312.77
|
| Rate for Payer: Cash Price |
$1,615.72
|
| Rate for Payer: Cofinity Commercial |
$1,413.76
|
| Rate for Payer: Cofinity Commercial |
$1,736.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,413.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,615.72
|
| Rate for Payer: Healthscope Commercial |
$1,817.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,413.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,514.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,716.70
|
| Rate for Payer: PHP Commercial |
$1,716.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,312.77
|
| Rate for Payer: Priority Health SBD |
$1,272.38
|
| Rate for Payer: UMR Bronson Commercial |
$888.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,514.74
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
IP
|
$26.22
|
|
|
Service Code
|
NDC 45802052555
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$23.60 |
| Rate for Payer: Aetna American Axle |
$17.04
|
| Rate for Payer: Aetna Commercial |
$22.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
| Rate for Payer: Cash Price |
$20.98
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Cofinity Commercial |
$22.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.98
|
| Rate for Payer: Healthscope Commercial |
$23.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.29
|
| Rate for Payer: PHP Commercial |
$22.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.04
|
| Rate for Payer: Priority Health SBD |
$16.52
|
| Rate for Payer: UMR Bronson Commercial |
$11.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.66
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 00904598426
|
| Hospital Charge Code |
10380
|
|
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
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
OP
|
$22.84
|
|
|
Service Code
|
NDC 63044048409
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna Medicare |
$11.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: BCBS Complete |
$9.14
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$19.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.85
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: UMR Bronson Commercial |
$8.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 00904598426
|
| Hospital Charge Code |
10380
|
|
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
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
IP
|
$22.84
|
|
|
Service Code
|
NDC 63044048409
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$19.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.85
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: UMR Bronson Commercial |
$10.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
OP
|
$26.22
|
|
|
Service Code
|
NDC 45802052555
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$23.60 |
| Rate for Payer: Aetna American Axle |
$17.04
|
| Rate for Payer: Aetna Commercial |
$22.29
|
| Rate for Payer: Aetna Medicare |
$13.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
| Rate for Payer: BCBS Complete |
$10.49
|
| Rate for Payer: Cash Price |
$20.98
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Cofinity Commercial |
$22.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.98
|
| Rate for Payer: Healthscope Commercial |
$23.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.29
|
| Rate for Payer: PHP Commercial |
$22.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.04
|
| Rate for Payer: Priority Health SBD |
$16.52
|
| Rate for Payer: UMR Bronson Commercial |
$9.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.66
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
|
IP
|
$65.37
|
|
|
Service Code
|
NDC 45802041954
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$58.83 |
| Rate for Payer: Aetna American Axle |
$42.49
|
| Rate for Payer: Aetna Commercial |
$55.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.49
|
| Rate for Payer: Cash Price |
$52.30
|
| Rate for Payer: Cofinity Commercial |
$45.76
|
| Rate for Payer: Cofinity Commercial |
$56.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.30
|
| Rate for Payer: Healthscope Commercial |
$58.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.56
|
| Rate for Payer: PHP Commercial |
$55.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.49
|
| Rate for Payer: Priority Health SBD |
$41.18
|
| Rate for Payer: UMR Bronson Commercial |
$28.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.03
|
|
