|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038301
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$961.80 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Commercial |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,530.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,858.03
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,420.85
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$961.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038301
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$808.79 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna Medicare |
$1,092.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: BCBS Complete |
$874.37
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Commercial |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,530.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,858.03
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,420.85
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$808.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$976.50
|
|
|
Service Code
|
NDC 70010003001
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$429.66 |
| Max. Negotiated Rate |
$878.85 |
| Rate for Payer: Aetna American Axle |
$634.72
|
| Rate for Payer: Aetna Commercial |
$830.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$634.72
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cofinity Commercial |
$683.55
|
| Rate for Payer: Cofinity Commercial |
$839.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$683.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$781.20
|
| Rate for Payer: Healthscope Commercial |
$878.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$683.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$732.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$830.02
|
| Rate for Payer: PHP Commercial |
$830.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$634.72
|
| Rate for Payer: Priority Health SBD |
$615.20
|
| Rate for Payer: UMR Bronson Commercial |
$429.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$732.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$976.50
|
|
|
Service Code
|
NDC 70010003001
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$361.30 |
| Max. Negotiated Rate |
$878.85 |
| Rate for Payer: Aetna American Axle |
$634.72
|
| Rate for Payer: Aetna Commercial |
$830.02
|
| Rate for Payer: Aetna Medicare |
$488.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$634.72
|
| Rate for Payer: BCBS Complete |
$390.60
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cofinity Commercial |
$683.55
|
| Rate for Payer: Cofinity Commercial |
$839.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$683.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$781.20
|
| Rate for Payer: Healthscope Commercial |
$878.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$683.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$732.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$830.02
|
| Rate for Payer: PHP Commercial |
$830.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$634.72
|
| Rate for Payer: Priority Health SBD |
$615.20
|
| Rate for Payer: UMR Bronson Commercial |
$361.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$732.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$720.30
|
|
|
Service Code
|
NDC 57664033788
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.51 |
| Max. Negotiated Rate |
$648.27 |
| Rate for Payer: Aetna American Axle |
$468.20
|
| Rate for Payer: Aetna Commercial |
$612.26
|
| Rate for Payer: Aetna Medicare |
$360.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.20
|
| Rate for Payer: BCBS Complete |
$288.12
|
| Rate for Payer: Cash Price |
$576.24
|
| Rate for Payer: Cofinity Commercial |
$504.21
|
| Rate for Payer: Cofinity Commercial |
$619.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$504.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$576.24
|
| Rate for Payer: Healthscope Commercial |
$648.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$504.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$540.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$612.26
|
| Rate for Payer: PHP Commercial |
$612.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.20
|
| Rate for Payer: Priority Health SBD |
$453.79
|
| Rate for Payer: UMR Bronson Commercial |
$266.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$540.22
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$759.50
|
|
|
Service Code
|
NDC 00115148701
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.18 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.68
|
| Rate for Payer: Priority Health SBD |
$478.48
|
| Rate for Payer: UMR Bronson Commercial |
$334.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$759.50
|
|
|
Service Code
|
NDC 00115148701
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.02 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna Medicare |
$379.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: BCBS Complete |
$303.80
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.68
|
| Rate for Payer: Priority Health SBD |
$478.48
|
| Rate for Payer: UMR Bronson Commercial |
$281.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$788.20
|
|
|
Service Code
|
NDC 00228305911
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.81 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Commercial |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$551.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.97
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$512.33
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$346.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$720.30
|
|
|
Service Code
|
NDC 57664033788
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$316.93 |
| Max. Negotiated Rate |
$648.27 |
| Rate for Payer: Aetna American Axle |
$468.20
|
| Rate for Payer: Aetna Commercial |
$612.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$468.20
|
| Rate for Payer: Cash Price |
$576.24
|
| Rate for Payer: Cofinity Commercial |
$504.21
|
| Rate for Payer: Cofinity Commercial |
$619.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$504.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$576.24
|
| Rate for Payer: Healthscope Commercial |
$648.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$504.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$540.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$612.26
|
| Rate for Payer: PHP Commercial |
$612.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.20
|
| Rate for Payer: Priority Health SBD |
$453.79
|
| Rate for Payer: UMR Bronson Commercial |
$316.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$540.22
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$788.20
|
|
|
Service Code
|
NDC 00228305911
|
| Hospital Charge Code |
31587
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$291.63 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna Medicare |
$394.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: BCBS Complete |
$315.28
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Commercial |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$551.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.97
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$512.33
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$291.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$759.50
|
|
|
Service Code
|
NDC 00115148801
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.18 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.68
|
| Rate for Payer: Priority Health SBD |
$478.48
|
| Rate for Payer: UMR Bronson Commercial |
$334.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038501
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$808.79 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna Medicare |
$1,092.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: BCBS Complete |
$874.37
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Commercial |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,530.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,858.03
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,420.85
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$808.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$788.20
|
|
|
Service Code
|
NDC 00228306311
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.81 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Commercial |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$551.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.97
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$512.33
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$346.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$788.20
|
|
|
Service Code
|
NDC 00228306311
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$291.63 |
| Max. Negotiated Rate |
$709.38 |
| Rate for Payer: Aetna American Axle |
$512.33
|
| Rate for Payer: Aetna Commercial |
$669.97
|
| Rate for Payer: Aetna Medicare |
$394.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.33
|
| Rate for Payer: BCBS Complete |
$315.28
|
| Rate for Payer: Cash Price |
$630.56
|
| Rate for Payer: Cofinity Commercial |
$551.74
|
| Rate for Payer: Cofinity Commercial |
$677.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$551.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.56
|
| Rate for Payer: Healthscope Commercial |
$709.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.97
|
| Rate for Payer: PHP Commercial |
$669.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$512.33
|
| Rate for Payer: Priority Health SBD |
$496.57
|
| Rate for Payer: UMR Bronson Commercial |
$291.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.15
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$907.20
|
|
|
Service Code
|
NDC 43975033310
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$335.66 |
| Max. Negotiated Rate |
$816.48 |
| Rate for Payer: Aetna American Axle |
$589.68
|
| Rate for Payer: Aetna Commercial |
$771.12
|
| Rate for Payer: Aetna Medicare |
$453.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$589.68
|
| Rate for Payer: BCBS Complete |
$362.88
|
| Rate for Payer: Cash Price |
$725.76
|
| Rate for Payer: Cofinity Commercial |
$635.04
|
| Rate for Payer: Cofinity Commercial |
$780.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$635.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$725.76
|
| Rate for Payer: Healthscope Commercial |
$816.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$635.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$680.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$771.12
|
| Rate for Payer: PHP Commercial |
$771.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$589.68
|
| Rate for Payer: Priority Health SBD |
$571.54
|
| Rate for Payer: UMR Bronson Commercial |
$335.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$680.40
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$907.20
|
|
|
Service Code
|
NDC 43975033310
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$399.17 |
| Max. Negotiated Rate |
$816.48 |
| Rate for Payer: Aetna American Axle |
$589.68
|
| Rate for Payer: Aetna Commercial |
$771.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$589.68
|
| Rate for Payer: Cash Price |
$725.76
|
| Rate for Payer: Cofinity Commercial |
$635.04
|
| Rate for Payer: Cofinity Commercial |
$780.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$635.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$725.76
|
| Rate for Payer: Healthscope Commercial |
$816.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$635.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$680.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$771.12
|
| Rate for Payer: PHP Commercial |
$771.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$589.68
|
| Rate for Payer: Priority Health SBD |
$571.54
|
| Rate for Payer: UMR Bronson Commercial |
$399.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$680.40
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$759.50
|
|
|
Service Code
|
NDC 00115148801
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.02 |
| Max. Negotiated Rate |
$683.55 |
| Rate for Payer: Aetna American Axle |
$493.68
|
| Rate for Payer: Aetna Commercial |
$645.58
|
| Rate for Payer: Aetna Medicare |
$379.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.68
|
| Rate for Payer: BCBS Complete |
$303.80
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Commercial |
$653.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.60
|
| Rate for Payer: Healthscope Commercial |
$683.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.58
|
| Rate for Payer: PHP Commercial |
$645.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.68
|
| Rate for Payer: Priority Health SBD |
$478.48
|
| Rate for Payer: UMR Bronson Commercial |
$281.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.62
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$2,185.92
|
|
|
Service Code
|
NDC 54092038501
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$961.80 |
| Max. Negotiated Rate |
$1,967.33 |
| Rate for Payer: Aetna American Axle |
$1,420.85
|
| Rate for Payer: Aetna Commercial |
$1,858.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.85
|
| Rate for Payer: Cash Price |
$1,748.74
|
| Rate for Payer: Cofinity Commercial |
$1,530.14
|
| Rate for Payer: Cofinity Commercial |
$1,879.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,530.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.74
|
| Rate for Payer: Healthscope Commercial |
$1,967.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,858.03
|
| Rate for Payer: PHP Commercial |
$1,858.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,420.85
|
| Rate for Payer: Priority Health SBD |
$1,377.13
|
| Rate for Payer: UMR Bronson Commercial |
$961.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.44
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$455.70
|
|
|
Service Code
|
NDC 31722018701
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.61 |
| Max. Negotiated Rate |
$410.13 |
| Rate for Payer: Aetna American Axle |
$296.20
|
| Rate for Payer: Aetna Commercial |
$387.34
|
| Rate for Payer: Aetna Medicare |
$227.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.20
|
| Rate for Payer: BCBS Complete |
$182.28
|
| Rate for Payer: Cash Price |
$364.56
|
| Rate for Payer: Cofinity Commercial |
$318.99
|
| Rate for Payer: Cofinity Commercial |
$391.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$318.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.56
|
| Rate for Payer: Healthscope Commercial |
$410.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$318.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.34
|
| Rate for Payer: PHP Commercial |
$387.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.20
|
| Rate for Payer: Priority Health SBD |
$287.09
|
| Rate for Payer: UMR Bronson Commercial |
$168.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.78
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$716.10
|
|
|
Service Code
|
NDC 66993059602
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.08 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Commercial |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$501.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$465.46
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$315.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$716.10
|
|
|
Service Code
|
NDC 66993059602
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$264.96 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna Medicare |
$358.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: BCBS Complete |
$286.44
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Commercial |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$501.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$465.46
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$264.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 15 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$455.70
|
|
|
Service Code
|
NDC 31722018701
|
| Hospital Charge Code |
33006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.51 |
| Max. Negotiated Rate |
$410.13 |
| Rate for Payer: Aetna American Axle |
$296.20
|
| Rate for Payer: Aetna Commercial |
$387.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.20
|
| Rate for Payer: Cash Price |
$364.56
|
| Rate for Payer: Cofinity Commercial |
$318.99
|
| Rate for Payer: Cofinity Commercial |
$391.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$318.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.56
|
| Rate for Payer: Healthscope Commercial |
$410.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$318.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.34
|
| Rate for Payer: PHP Commercial |
$387.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.20
|
| Rate for Payer: Priority Health SBD |
$287.09
|
| Rate for Payer: UMR Bronson Commercial |
$200.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.78
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 30 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
IP
|
$716.10
|
|
|
Service Code
|
NDC 66993059902
|
| Hospital Charge Code |
31589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.08 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Commercial |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$501.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$465.46
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$315.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE ER 30 MG 24HR CAPSULE,EXTEND RELEASE
|
Facility
|
OP
|
$716.10
|
|
|
Service Code
|
NDC 66993059902
|
| Hospital Charge Code |
31589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$264.96 |
| Max. Negotiated Rate |
$644.49 |
| Rate for Payer: Aetna American Axle |
$465.46
|
| Rate for Payer: Aetna Commercial |
$608.68
|
| Rate for Payer: Aetna Medicare |
$358.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$465.46
|
| Rate for Payer: BCBS Complete |
$286.44
|
| Rate for Payer: Cash Price |
$572.88
|
| Rate for Payer: Cofinity Commercial |
$501.27
|
| Rate for Payer: Cofinity Commercial |
$615.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$501.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$572.88
|
| Rate for Payer: Healthscope Commercial |
$644.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$608.68
|
| Rate for Payer: PHP Commercial |
$608.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$465.46
|
| Rate for Payer: Priority Health SBD |
$451.14
|
| Rate for Payer: UMR Bronson Commercial |
$264.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.08
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$7.54
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Aetna American Axle |
$4.90
|
| Rate for Payer: Aetna Commercial |
$6.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.90
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cofinity Commercial |
$5.28
|
| Rate for Payer: Cofinity Commercial |
$6.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.03
|
| Rate for Payer: Healthscope Commercial |
$6.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.41
|
| Rate for Payer: PHP Commercial |
$6.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.90
|
| Rate for Payer: Priority Health SBD |
$4.75
|
| Rate for Payer: UMR Bronson Commercial |
$3.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.66
|
|
