|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$305.90
|
|
|
Service Code
|
NDC 00904741061
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.18 |
| Max. Negotiated Rate |
$275.31 |
| Rate for Payer: Aetna American Axle |
$198.84
|
| Rate for Payer: Aetna Commercial |
$260.01
|
| Rate for Payer: Aetna Medicare |
$152.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.84
|
| Rate for Payer: BCBS Complete |
$122.36
|
| Rate for Payer: Cash Price |
$244.72
|
| Rate for Payer: Cofinity Advantage |
$214.13
|
| Rate for Payer: Cofinity Commercial |
$263.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.72
|
| Rate for Payer: Healthscope Commercial |
$275.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$229.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$244.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$229.43
|
| Rate for Payer: PHP Commercial |
$260.01
|
| Rate for Payer: Priority Health SBD |
$192.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.84
|
| Rate for Payer: UHC Core |
$159.37
|
| Rate for Payer: UHC Exchange |
$120.22
|
| Rate for Payer: UMR Bronson Commercial |
$113.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$229.43
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.43 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna American Axle |
$218.59
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$168.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.59
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Advantage |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| 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: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.22
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.59
|
| Rate for Payer: UHC Core |
$175.21
|
| Rate for Payer: UHC Exchange |
$132.17
|
| 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
|
$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 Advantage |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| 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: Opus (Opus Packaging Group) HMA |
$2.49
|
| Rate for Payer: PHP Commercial |
$2.82
|
| 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
|
$2.52
|
|
|
Service Code
|
NDC 60687044411
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna American Axle |
$1.64
|
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna Medicare |
$1.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: BCBS Complete |
$1.01
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Advantage |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.89
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.64
|
| Rate for Payer: UHC Core |
$1.31
|
| Rate for Payer: UHC Exchange |
$0.99
|
| Rate for Payer: UMR Bronson Commercial |
$0.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$162.15
|
|
|
Service Code
|
NDC 16729017301
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna Medicare |
$81.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: BCBS Complete |
$64.86
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Advantage |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| 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: MI Amish Medical Board Commercial |
$129.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$121.61
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.40
|
| Rate for Payer: UHC Core |
$84.48
|
| Rate for Payer: UHC Exchange |
$63.72
|
| Rate for Payer: UMR Bronson Commercial |
$60.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
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 |
$298.21 |
| 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 Advantage |
$231.94
|
| Rate for Payer: Cofinity Commercial |
$284.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.08
|
| Rate for Payer: Healthscope Commercial |
$298.21
|
| 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: Opus (Opus Packaging Group) HMA |
$248.51
|
| Rate for Payer: PHP Commercial |
$281.65
|
| 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
|
$251.52
|
|
|
Service Code
|
NDC 60687044401
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.06 |
| Max. Negotiated Rate |
$226.37 |
| Rate for Payer: Aetna American Axle |
$163.49
|
| Rate for Payer: Aetna Commercial |
$213.79
|
| Rate for Payer: Aetna Medicare |
$125.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.49
|
| Rate for Payer: BCBS Complete |
$100.61
|
| Rate for Payer: Cash Price |
$201.22
|
| Rate for Payer: Cofinity Advantage |
$176.06
|
| Rate for Payer: Cofinity Commercial |
$216.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.22
|
| Rate for Payer: Healthscope Commercial |
$226.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$201.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.64
|
| Rate for Payer: PHP Commercial |
$213.79
|
| Rate for Payer: Priority Health SBD |
$158.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.49
|
| Rate for Payer: UHC Core |
$131.04
|
| Rate for Payer: UHC Exchange |
$98.85
|
| Rate for Payer: UMR Bronson Commercial |
$93.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.64
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$3,149.00
|
|
|
Service Code
|
NDC 72888006900
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,385.56 |
| Max. Negotiated Rate |
$2,834.10 |
| Rate for Payer: Aetna American Axle |
$2,046.85
|
| Rate for Payer: Aetna Commercial |
$2,676.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,046.85
|
| Rate for Payer: Cash Price |
$2,519.20
|
| Rate for Payer: Cofinity Advantage |
$2,204.30
|
| Rate for Payer: Cofinity Commercial |
$2,708.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,519.20
|
| Rate for Payer: Healthscope Commercial |
$2,834.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,204.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,361.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,676.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,361.75
|
| Rate for Payer: PHP Commercial |
$2,676.65
|
| Rate for Payer: Priority Health SBD |
$1,983.87
|
| Rate for Payer: UMR Bronson Commercial |
$1,385.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,361.75
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$324.30
|
|
|
Service Code
|
NDC 72888006901
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.69 |
| Max. Negotiated Rate |
$291.87 |
| Rate for Payer: Aetna American Axle |
$210.79
|
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.79
|
| Rate for Payer: Cash Price |
$259.44
|
| Rate for Payer: Cofinity Advantage |
$227.01
|
| Rate for Payer: Cofinity Commercial |
$278.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.44
|
| Rate for Payer: Healthscope Commercial |
$291.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$243.22
|
| Rate for Payer: PHP Commercial |
$275.65
|
| Rate for Payer: Priority Health SBD |
$204.31
|
| Rate for Payer: UMR Bronson Commercial |
$142.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.22
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
IP
|
$251.52
|
|
|
Service Code
|
NDC 60687044401
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.67 |
| Max. Negotiated Rate |
$226.37 |
| Rate for Payer: Aetna American Axle |
$163.49
|
| Rate for Payer: Aetna Commercial |
$213.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.49
|
| Rate for Payer: Cash Price |
$201.22
|
| Rate for Payer: Cofinity Advantage |
$176.06
|
| Rate for Payer: Cofinity Commercial |
$216.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.22
|
| Rate for Payer: Healthscope Commercial |
$226.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.64
|
| Rate for Payer: PHP Commercial |
$213.79
|
| Rate for Payer: Priority Health SBD |
$158.46
|
| Rate for Payer: UMR Bronson Commercial |
$110.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.64
|
|
|
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 |
$298.39 |
| 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 Advantage |
$232.09
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$265.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.66
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$215.51
|
| Rate for Payer: UHC Core |
$172.74
|
| Rate for Payer: UHC Exchange |
$130.30
|
| Rate for Payer: UMR Bronson Commercial |
$122.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
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 |
$218.59
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$168.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.59
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Advantage |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| 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: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.22
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.59
|
| Rate for Payer: UHC Core |
$175.21
|
| Rate for Payer: UHC Exchange |
$132.17
|
| 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
|
$2.52
|
|
|
Service Code
|
NDC 60687044411
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna American Axle |
$1.64
|
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Advantage |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.89
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1.59
|
| Rate for Payer: UMR Bronson Commercial |
$1.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
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 |
$298.21 |
| 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 Advantage |
$231.94
|
| Rate for Payer: Cofinity Commercial |
$284.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.08
|
| Rate for Payer: Healthscope Commercial |
$298.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$265.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.51
|
| Rate for Payer: PHP Commercial |
$281.65
|
| Rate for Payer: Priority Health SBD |
$208.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$215.38
|
| Rate for Payer: UHC Core |
$172.63
|
| Rate for Payer: UHC Exchange |
$130.22
|
| Rate for Payer: UMR Bronson Commercial |
$122.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.51
|
|
|
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 |
$298.39 |
| 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 Advantage |
$232.09
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.66
|
| Rate for Payer: PHP Commercial |
$281.82
|
| 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
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$3,149.00
|
|
|
Service Code
|
NDC 72888006900
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,165.13 |
| Max. Negotiated Rate |
$2,834.10 |
| Rate for Payer: Aetna American Axle |
$2,046.85
|
| Rate for Payer: Aetna Commercial |
$2,676.65
|
| Rate for Payer: Aetna Medicare |
$1,574.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,046.85
|
| Rate for Payer: BCBS Complete |
$1,259.60
|
| Rate for Payer: Cash Price |
$2,519.20
|
| Rate for Payer: Cofinity Advantage |
$2,204.30
|
| Rate for Payer: Cofinity Commercial |
$2,708.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,519.20
|
| Rate for Payer: Healthscope Commercial |
$2,834.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,204.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,361.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,519.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,676.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,361.75
|
| Rate for Payer: PHP Commercial |
$2,676.65
|
| Rate for Payer: Priority Health SBD |
$1,983.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,046.85
|
| Rate for Payer: UHC Core |
$1,640.63
|
| Rate for Payer: UHC Exchange |
$1,237.56
|
| Rate for Payer: UMR Bronson Commercial |
$1,165.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,361.75
|
|
|
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 Advantage |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| 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: MI Amish Medical Board Commercial |
$2.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.49
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.16
|
| Rate for Payer: UHC Core |
$1.73
|
| Rate for Payer: UHC Exchange |
$1.30
|
| 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 Advantage |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| 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: Opus (Opus Packaging Group) HMA |
$121.61
|
| Rate for Payer: PHP Commercial |
$137.83
|
| 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
|
$404.20
|
|
|
Service Code
|
NDC 69367039001
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$324.30
|
|
|
Service Code
|
NDC 72888006901
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.99 |
| Max. Negotiated Rate |
$291.87 |
| Rate for Payer: Aetna American Axle |
$210.79
|
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna Medicare |
$162.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.79
|
| Rate for Payer: BCBS Complete |
$129.72
|
| Rate for Payer: Cash Price |
$259.44
|
| Rate for Payer: Cofinity Advantage |
$227.01
|
| Rate for Payer: Cofinity Commercial |
$278.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.44
|
| Rate for Payer: Healthscope Commercial |
$291.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$259.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$243.22
|
| Rate for Payer: PHP Commercial |
$275.65
|
| Rate for Payer: Priority Health SBD |
$204.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.79
|
| Rate for Payer: UHC Core |
$168.96
|
| Rate for Payer: UHC Exchange |
$127.45
|
| Rate for Payer: UMR Bronson Commercial |
$119.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.22
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 69367039001
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.55 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$202.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$323.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.73
|
| Rate for Payer: UHC Core |
$210.59
|
| Rate for Payer: UHC Exchange |
$158.85
|
| Rate for Payer: UMR Bronson Commercial |
$149.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
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 |
$218.59
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.59
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Advantage |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| 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: Opus (Opus Packaging Group) HMA |
$252.22
|
| Rate for Payer: PHP Commercial |
$285.86
|
| 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
|
|
|
AMIVANTAMAB-VMJW 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$17,091.98
|
|
|
Service Code
|
HCPCS J9061
|
| Hospital Charge Code |
197370
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$15,382.78 |
| Rate for Payer: Aetna American Axle |
$11,109.79
|
| Rate for Payer: Aetna Commercial |
$14,528.18
|
| Rate for Payer: Aetna Medicare |
$23.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,109.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.29
|
| Rate for Payer: BCBS Complete |
$12.43
|
| Rate for Payer: BCBS MAPPO |
$22.63
|
| Rate for Payer: BCBS Trust/PPO |
$73.14
|
| Rate for Payer: BCN Commercial |
$73.14
|
| Rate for Payer: BCN Medicare Advantage |
$22.63
|
| Rate for Payer: Cash Price |
$13,673.58
|
| Rate for Payer: Cash Price |
$13,673.58
|
| Rate for Payer: Cofinity Advantage |
$11,964.39
|
| Rate for Payer: Cofinity Commercial |
$14,699.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,673.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.63
|
| Rate for Payer: Healthscope Commercial |
$15,382.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11,964.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,818.99
|
| Rate for Payer: Mclaren Medicaid |
$22.63
|
| Rate for Payer: Mclaren Medicare |
$22.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.76
|
| Rate for Payer: Meridian Medicaid |
$23.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.02
|
| Rate for Payer: Molina Medicare/Medicaid |
$24.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,528.18
|
| Rate for Payer: Nomi Health Commercial |
$67.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12,818.99
|
| Rate for Payer: PACE Medicare |
$21.50
|
| Rate for Payer: PACE SWMI |
$22.63
|
| Rate for Payer: PHP Commercial |
$14,528.18
|
| Rate for Payer: PHP Medicare Advantage |
$22.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$71.10
|
| Rate for Payer: Priority Health Medicare |
$22.63
|
| Rate for Payer: Priority Health SBD |
$10,767.95
|
| Rate for Payer: Priority Health Tiered Network |
$56.88
|
| Rate for Payer: Railroad Medicare Medicare |
$22.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.22
|
| Rate for Payer: UHC Core |
$37.22
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$22.63
|
| Rate for Payer: UHC Exchange |
$37.22
|
| Rate for Payer: UHC Medicaid |
$11.84
|
| Rate for Payer: UHCCP Medicaid |
$11.84
|
| Rate for Payer: UMR Bronson Commercial |
$6,324.03
|
| Rate for Payer: VA VA |
$22.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,818.99
|
|
|
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 Advantage |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| 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: Opus (Opus Packaging Group) HMA |
$2.54
|
| Rate for Payer: PHP Commercial |
$2.88
|
| 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
|
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 Advantage |
$236.88
|
| Rate for Payer: Cofinity Commercial |
$291.02
|
| 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: MI Amish Medical Board Commercial |
$270.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.80
|
| Rate for Payer: PHP Commercial |
$287.64
|
| Rate for Payer: Priority Health SBD |
$213.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.96
|
| Rate for Payer: UHC Core |
$176.31
|
| Rate for Payer: UHC Exchange |
$132.99
|
| Rate for Payer: UMR Bronson Commercial |
$125.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.80
|
|
