|
FELBAMATE 400 MG TABLET
|
Facility
|
OP
|
$5,310.98
|
|
|
Service Code
|
NDC 00037043001
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,965.06 |
| Max. Negotiated Rate |
$4,779.88 |
| Rate for Payer: Aetna American Axle |
$3,452.14
|
| Rate for Payer: Aetna Commercial |
$4,514.33
|
| Rate for Payer: Aetna Medicare |
$2,655.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,452.14
|
| Rate for Payer: BCBS Complete |
$2,124.39
|
| Rate for Payer: Cash Price |
$4,248.78
|
| Rate for Payer: Cofinity Advantage |
$3,717.69
|
| Rate for Payer: Cofinity Commercial |
$4,567.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,248.78
|
| Rate for Payer: Healthscope Commercial |
$4,779.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,717.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,983.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,248.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,514.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,983.24
|
| Rate for Payer: PHP Commercial |
$4,514.33
|
| Rate for Payer: Priority Health SBD |
$3,345.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,452.14
|
| Rate for Payer: UHC Core |
$2,767.02
|
| Rate for Payer: UHC Exchange |
$2,087.22
|
| Rate for Payer: UMR Bronson Commercial |
$1,965.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,983.24
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
OP
|
$776.31
|
|
|
Service Code
|
NDC 53746073490
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.23 |
| Max. Negotiated Rate |
$698.68 |
| Rate for Payer: Aetna American Axle |
$504.60
|
| Rate for Payer: Aetna Commercial |
$659.86
|
| Rate for Payer: Aetna Medicare |
$388.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$504.60
|
| Rate for Payer: BCBS Complete |
$310.52
|
| Rate for Payer: Cash Price |
$621.05
|
| Rate for Payer: Cofinity Advantage |
$543.42
|
| Rate for Payer: Cofinity Commercial |
$667.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$621.05
|
| Rate for Payer: Healthscope Commercial |
$698.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$543.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$582.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$621.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$659.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$582.23
|
| Rate for Payer: PHP Commercial |
$659.86
|
| Rate for Payer: Priority Health SBD |
$489.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$504.60
|
| Rate for Payer: UHC Core |
$404.46
|
| Rate for Payer: UHC Exchange |
$305.09
|
| Rate for Payer: UMR Bronson Commercial |
$287.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$582.23
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
IP
|
$747.59
|
|
|
Service Code
|
NDC 65162073409
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$328.94 |
| Max. Negotiated Rate |
$672.83 |
| Rate for Payer: Aetna American Axle |
$485.93
|
| Rate for Payer: Aetna Commercial |
$635.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$485.93
|
| Rate for Payer: Cash Price |
$598.07
|
| Rate for Payer: Cofinity Advantage |
$523.31
|
| Rate for Payer: Cofinity Commercial |
$642.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$598.07
|
| Rate for Payer: Healthscope Commercial |
$672.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$523.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$560.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$635.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$560.69
|
| Rate for Payer: PHP Commercial |
$635.45
|
| Rate for Payer: Priority Health SBD |
$470.98
|
| Rate for Payer: UMR Bronson Commercial |
$328.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$560.69
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
IP
|
$5,310.98
|
|
|
Service Code
|
NDC 00037043001
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,336.83 |
| Max. Negotiated Rate |
$4,779.88 |
| Rate for Payer: Aetna American Axle |
$3,452.14
|
| Rate for Payer: Aetna Commercial |
$4,514.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,452.14
|
| Rate for Payer: Cash Price |
$4,248.78
|
| Rate for Payer: Cofinity Advantage |
$3,717.69
|
| Rate for Payer: Cofinity Commercial |
$4,567.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,248.78
|
| Rate for Payer: Healthscope Commercial |
$4,779.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,717.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,983.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,514.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,983.24
|
| Rate for Payer: PHP Commercial |
$4,514.33
|
| Rate for Payer: Priority Health SBD |
$3,345.92
|
| Rate for Payer: UMR Bronson Commercial |
$2,336.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,983.24
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
IP
|
$420.96
|
|
|
Service Code
|
NDC 62559073001
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.22 |
| Max. Negotiated Rate |
$378.86 |
| Rate for Payer: Aetna American Axle |
$273.62
|
| Rate for Payer: Aetna Commercial |
$357.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.62
|
| Rate for Payer: Cash Price |
$336.77
|
| Rate for Payer: Cofinity Advantage |
$294.67
|
| Rate for Payer: Cofinity Commercial |
$362.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.77
|
| Rate for Payer: Healthscope Commercial |
$378.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.72
|
| Rate for Payer: PHP Commercial |
$357.82
|
| Rate for Payer: Priority Health SBD |
$265.20
|
| Rate for Payer: UMR Bronson Commercial |
$185.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.72
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
OP
|
$420.96
|
|
|
Service Code
|
NDC 62559073001
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.76 |
| Max. Negotiated Rate |
$378.86 |
| Rate for Payer: Aetna American Axle |
$273.62
|
| Rate for Payer: Aetna Commercial |
$357.82
|
| Rate for Payer: Aetna Medicare |
$210.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.62
|
| Rate for Payer: BCBS Complete |
$168.38
|
| Rate for Payer: Cash Price |
$336.77
|
| Rate for Payer: Cofinity Advantage |
$294.67
|
| Rate for Payer: Cofinity Commercial |
$362.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.77
|
| Rate for Payer: Healthscope Commercial |
$378.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$336.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.72
|
| Rate for Payer: PHP Commercial |
$357.82
|
| Rate for Payer: Priority Health SBD |
$265.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.62
|
| Rate for Payer: UHC Core |
$219.32
|
| Rate for Payer: UHC Exchange |
$165.44
|
| Rate for Payer: UMR Bronson Commercial |
$155.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.72
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
OP
|
$747.59
|
|
|
Service Code
|
NDC 65162073409
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$276.61 |
| Max. Negotiated Rate |
$672.83 |
| Rate for Payer: Aetna American Axle |
$485.93
|
| Rate for Payer: Aetna Commercial |
$635.45
|
| Rate for Payer: Aetna Medicare |
$373.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$485.93
|
| Rate for Payer: BCBS Complete |
$299.04
|
| Rate for Payer: Cash Price |
$598.07
|
| Rate for Payer: Cofinity Advantage |
$523.31
|
| Rate for Payer: Cofinity Commercial |
$642.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$598.07
|
| Rate for Payer: Healthscope Commercial |
$672.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$523.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$560.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$598.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$635.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$560.69
|
| Rate for Payer: PHP Commercial |
$635.45
|
| Rate for Payer: Priority Health SBD |
$470.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$485.93
|
| Rate for Payer: UHC Core |
$389.49
|
| Rate for Payer: UHC Exchange |
$293.80
|
| Rate for Payer: UMR Bronson Commercial |
$276.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$560.69
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2,268.38
|
|
|
Service Code
|
NDC 51525044208
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$998.09 |
| Max. Negotiated Rate |
$2,041.54 |
| Rate for Payer: Aetna American Axle |
$1,474.45
|
| Rate for Payer: Aetna Commercial |
$1,928.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,474.45
|
| Rate for Payer: Cash Price |
$1,814.70
|
| Rate for Payer: Cofinity Advantage |
$1,587.87
|
| Rate for Payer: Cofinity Commercial |
$1,950.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,814.70
|
| Rate for Payer: Healthscope Commercial |
$2,041.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,587.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,701.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,928.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,701.29
|
| Rate for Payer: PHP Commercial |
$1,928.12
|
| Rate for Payer: Priority Health SBD |
$1,429.08
|
| Rate for Payer: UMR Bronson Commercial |
$998.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,701.29
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$6,139.18
|
|
|
Service Code
|
NDC 00037044267
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,271.50 |
| Max. Negotiated Rate |
$5,525.26 |
| Rate for Payer: Aetna American Axle |
$3,990.47
|
| Rate for Payer: Aetna Commercial |
$5,218.30
|
| Rate for Payer: Aetna Medicare |
$3,069.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,990.47
|
| Rate for Payer: BCBS Complete |
$2,455.67
|
| Rate for Payer: Cash Price |
$4,911.34
|
| Rate for Payer: Cofinity Advantage |
$4,297.43
|
| Rate for Payer: Cofinity Commercial |
$5,279.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,911.34
|
| Rate for Payer: Healthscope Commercial |
$5,525.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,297.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,604.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,911.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,218.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,604.39
|
| Rate for Payer: PHP Commercial |
$5,218.30
|
| Rate for Payer: Priority Health SBD |
$3,867.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,990.47
|
| Rate for Payer: UHC Core |
$3,198.51
|
| Rate for Payer: UHC Exchange |
$2,412.70
|
| Rate for Payer: UMR Bronson Commercial |
$2,271.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,604.39
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$911.86
|
|
|
Service Code
|
NDC 70954005110
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.39 |
| Max. Negotiated Rate |
$820.67 |
| Rate for Payer: Aetna American Axle |
$592.71
|
| Rate for Payer: Aetna Commercial |
$775.08
|
| Rate for Payer: Aetna Medicare |
$455.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$592.71
|
| Rate for Payer: BCBS Complete |
$364.74
|
| Rate for Payer: Cash Price |
$729.49
|
| Rate for Payer: Cofinity Advantage |
$638.30
|
| Rate for Payer: Cofinity Commercial |
$784.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$729.49
|
| Rate for Payer: Healthscope Commercial |
$820.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$638.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$683.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$729.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$775.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$683.89
|
| Rate for Payer: PHP Commercial |
$775.08
|
| Rate for Payer: Priority Health SBD |
$574.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$592.71
|
| Rate for Payer: UHC Core |
$475.08
|
| Rate for Payer: UHC Exchange |
$358.36
|
| Rate for Payer: UMR Bronson Commercial |
$337.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$683.89
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$911.86
|
|
|
Service Code
|
NDC 70954005110
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$401.22 |
| Max. Negotiated Rate |
$820.67 |
| Rate for Payer: Aetna American Axle |
$592.71
|
| Rate for Payer: Aetna Commercial |
$775.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$592.71
|
| Rate for Payer: Cash Price |
$729.49
|
| Rate for Payer: Cofinity Advantage |
$638.30
|
| Rate for Payer: Cofinity Commercial |
$784.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$729.49
|
| Rate for Payer: Healthscope Commercial |
$820.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$638.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$683.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$775.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$683.89
|
| Rate for Payer: PHP Commercial |
$775.08
|
| Rate for Payer: Priority Health SBD |
$574.47
|
| Rate for Payer: UMR Bronson Commercial |
$401.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$683.89
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$2,268.38
|
|
|
Service Code
|
NDC 51525044208
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$839.30 |
| Max. Negotiated Rate |
$2,041.54 |
| Rate for Payer: Aetna American Axle |
$1,474.45
|
| Rate for Payer: Aetna Commercial |
$1,928.12
|
| Rate for Payer: Aetna Medicare |
$1,134.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,474.45
|
| Rate for Payer: BCBS Complete |
$907.35
|
| Rate for Payer: Cash Price |
$1,814.70
|
| Rate for Payer: Cofinity Advantage |
$1,587.87
|
| Rate for Payer: Cofinity Commercial |
$1,950.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,814.70
|
| Rate for Payer: Healthscope Commercial |
$2,041.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,587.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,701.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,814.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,928.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,701.29
|
| Rate for Payer: PHP Commercial |
$1,928.12
|
| Rate for Payer: Priority Health SBD |
$1,429.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,474.45
|
| Rate for Payer: UHC Core |
$1,181.83
|
| Rate for Payer: UHC Exchange |
$891.47
|
| Rate for Payer: UMR Bronson Commercial |
$839.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,701.29
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$6,139.18
|
|
|
Service Code
|
NDC 00037044267
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,701.24 |
| Max. Negotiated Rate |
$5,525.26 |
| Rate for Payer: Aetna American Axle |
$3,990.47
|
| Rate for Payer: Aetna Commercial |
$5,218.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,990.47
|
| Rate for Payer: Cash Price |
$4,911.34
|
| Rate for Payer: Cofinity Advantage |
$4,297.43
|
| Rate for Payer: Cofinity Commercial |
$5,279.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,911.34
|
| Rate for Payer: Healthscope Commercial |
$5,525.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,297.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,604.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,218.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,604.39
|
| Rate for Payer: PHP Commercial |
$5,218.30
|
| Rate for Payer: Priority Health SBD |
$3,867.68
|
| Rate for Payer: UMR Bronson Commercial |
$2,701.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,604.39
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
IP
|
$809.86
|
|
|
Service Code
|
NDC 65162073509
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$356.34 |
| Max. Negotiated Rate |
$728.87 |
| Rate for Payer: Aetna American Axle |
$526.41
|
| Rate for Payer: Aetna Commercial |
$688.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$526.41
|
| Rate for Payer: Cash Price |
$647.89
|
| Rate for Payer: Cofinity Advantage |
$566.90
|
| Rate for Payer: Cofinity Commercial |
$696.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$647.89
|
| Rate for Payer: Healthscope Commercial |
$728.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$566.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$607.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$688.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$607.39
|
| Rate for Payer: PHP Commercial |
$688.38
|
| Rate for Payer: Priority Health SBD |
$510.21
|
| Rate for Payer: UMR Bronson Commercial |
$356.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$607.39
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
OP
|
$795.75
|
|
|
Service Code
|
NDC 53746073590
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.43 |
| Max. Negotiated Rate |
$716.17 |
| Rate for Payer: Aetna American Axle |
$517.24
|
| Rate for Payer: Aetna Commercial |
$676.39
|
| Rate for Payer: Aetna Medicare |
$397.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$517.24
|
| Rate for Payer: BCBS Complete |
$318.30
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cofinity Advantage |
$557.02
|
| Rate for Payer: Cofinity Commercial |
$684.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$636.60
|
| Rate for Payer: Healthscope Commercial |
$716.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$557.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$596.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$636.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$676.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$596.81
|
| Rate for Payer: PHP Commercial |
$676.39
|
| Rate for Payer: Priority Health SBD |
$501.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$517.24
|
| Rate for Payer: UHC Core |
$414.59
|
| Rate for Payer: UHC Exchange |
$312.73
|
| Rate for Payer: UMR Bronson Commercial |
$294.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$596.81
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
IP
|
$6,086.87
|
|
|
Service Code
|
NDC 00037043101
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,678.22 |
| Max. Negotiated Rate |
$5,478.18 |
| Rate for Payer: Aetna American Axle |
$3,956.47
|
| Rate for Payer: Aetna Commercial |
$5,173.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,956.47
|
| Rate for Payer: Cash Price |
$4,869.50
|
| Rate for Payer: Cofinity Advantage |
$4,260.81
|
| Rate for Payer: Cofinity Commercial |
$5,234.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,869.50
|
| Rate for Payer: Healthscope Commercial |
$5,478.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,260.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,565.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,173.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,565.15
|
| Rate for Payer: PHP Commercial |
$5,173.84
|
| Rate for Payer: Priority Health SBD |
$3,834.73
|
| Rate for Payer: UMR Bronson Commercial |
$2,678.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,565.15
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
OP
|
$809.86
|
|
|
Service Code
|
NDC 65162073509
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.65 |
| Max. Negotiated Rate |
$728.87 |
| Rate for Payer: Aetna American Axle |
$526.41
|
| Rate for Payer: Aetna Commercial |
$688.38
|
| Rate for Payer: Aetna Medicare |
$404.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$526.41
|
| Rate for Payer: BCBS Complete |
$323.94
|
| Rate for Payer: Cash Price |
$647.89
|
| Rate for Payer: Cofinity Advantage |
$566.90
|
| Rate for Payer: Cofinity Commercial |
$696.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$647.89
|
| Rate for Payer: Healthscope Commercial |
$728.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$566.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$607.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$647.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$688.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$607.39
|
| Rate for Payer: PHP Commercial |
$688.38
|
| Rate for Payer: Priority Health SBD |
$510.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$526.41
|
| Rate for Payer: UHC Core |
$421.94
|
| Rate for Payer: UHC Exchange |
$318.27
|
| Rate for Payer: UMR Bronson Commercial |
$299.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$607.39
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
IP
|
$526.08
|
|
|
Service Code
|
NDC 62559073101
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.48 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna American Axle |
$341.95
|
| Rate for Payer: Aetna Commercial |
$447.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$341.95
|
| Rate for Payer: Cash Price |
$420.86
|
| Rate for Payer: Cofinity Advantage |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$452.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$420.86
|
| Rate for Payer: Healthscope Commercial |
$473.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$368.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$394.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$447.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$394.56
|
| Rate for Payer: PHP Commercial |
$447.17
|
| Rate for Payer: Priority Health SBD |
$331.43
|
| Rate for Payer: UMR Bronson Commercial |
$231.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$394.56
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
OP
|
$6,086.87
|
|
|
Service Code
|
NDC 00037043101
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,252.14 |
| Max. Negotiated Rate |
$5,478.18 |
| Rate for Payer: Aetna American Axle |
$3,956.47
|
| Rate for Payer: Aetna Commercial |
$5,173.84
|
| Rate for Payer: Aetna Medicare |
$3,043.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,956.47
|
| Rate for Payer: BCBS Complete |
$2,434.75
|
| Rate for Payer: Cash Price |
$4,869.50
|
| Rate for Payer: Cofinity Advantage |
$4,260.81
|
| Rate for Payer: Cofinity Commercial |
$5,234.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,869.50
|
| Rate for Payer: Healthscope Commercial |
$5,478.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,260.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,565.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,869.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,173.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,565.15
|
| Rate for Payer: PHP Commercial |
$5,173.84
|
| Rate for Payer: Priority Health SBD |
$3,834.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,956.47
|
| Rate for Payer: UHC Core |
$3,171.26
|
| Rate for Payer: UHC Exchange |
$2,392.14
|
| Rate for Payer: UMR Bronson Commercial |
$2,252.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,565.15
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
OP
|
$526.08
|
|
|
Service Code
|
NDC 62559073101
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.65 |
| Max. Negotiated Rate |
$473.47 |
| Rate for Payer: Aetna American Axle |
$341.95
|
| Rate for Payer: Aetna Commercial |
$447.17
|
| Rate for Payer: Aetna Medicare |
$263.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$341.95
|
| Rate for Payer: BCBS Complete |
$210.43
|
| Rate for Payer: Cash Price |
$420.86
|
| Rate for Payer: Cofinity Advantage |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$452.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$420.86
|
| Rate for Payer: Healthscope Commercial |
$473.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$368.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$394.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$420.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$447.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$394.56
|
| Rate for Payer: PHP Commercial |
$447.17
|
| Rate for Payer: Priority Health SBD |
$331.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$341.95
|
| Rate for Payer: UHC Core |
$274.09
|
| Rate for Payer: UHC Exchange |
$206.75
|
| Rate for Payer: UMR Bronson Commercial |
$194.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$394.56
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
IP
|
$795.75
|
|
|
Service Code
|
NDC 53746073590
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$350.13 |
| Max. Negotiated Rate |
$716.17 |
| Rate for Payer: Aetna American Axle |
$517.24
|
| Rate for Payer: Aetna Commercial |
$676.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$517.24
|
| Rate for Payer: Cash Price |
$636.60
|
| Rate for Payer: Cofinity Advantage |
$557.02
|
| Rate for Payer: Cofinity Commercial |
$684.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$636.60
|
| Rate for Payer: Healthscope Commercial |
$716.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$557.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$596.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$676.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$596.81
|
| Rate for Payer: PHP Commercial |
$676.39
|
| Rate for Payer: Priority Health SBD |
$501.32
|
| Rate for Payer: UMR Bronson Commercial |
$350.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$596.81
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$5,958.82
|
|
|
Service Code
|
APR-DRG 5313
|
| Min. Negotiated Rate |
$5,675.07 |
| Max. Negotiated Rate |
$5,958.82 |
| Rate for Payer: BCBS Complete |
$5,958.82
|
| Rate for Payer: Mclaren Medicaid |
$5,675.07
|
| Rate for Payer: Meridian Medicaid |
$5,958.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,675.07
|
| Rate for Payer: UHC Medicaid |
$5,675.07
|
| Rate for Payer: UHCCP Medicaid |
$5,675.07
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$3,277.23
|
|
|
Service Code
|
APR-DRG 5311
|
| Min. Negotiated Rate |
$3,121.17 |
| Max. Negotiated Rate |
$3,277.23 |
| Rate for Payer: BCBS Complete |
$3,277.23
|
| Rate for Payer: Mclaren Medicaid |
$3,121.17
|
| Rate for Payer: Meridian Medicaid |
$3,277.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,121.17
|
| Rate for Payer: UHC Medicaid |
$3,121.17
|
| Rate for Payer: UHCCP Medicaid |
$3,121.17
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$4,434.61
|
|
|
Service Code
|
APR-DRG 5312
|
| Min. Negotiated Rate |
$4,223.44 |
| Max. Negotiated Rate |
$4,434.61 |
| Rate for Payer: BCBS Complete |
$4,434.61
|
| Rate for Payer: Mclaren Medicaid |
$4,223.44
|
| Rate for Payer: Meridian Medicaid |
$4,434.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,223.44
|
| Rate for Payer: UHC Medicaid |
$4,223.44
|
| Rate for Payer: UHCCP Medicaid |
$4,223.44
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$9,368.01
|
|
|
Service Code
|
APR-DRG 5314
|
| Min. Negotiated Rate |
$8,921.91 |
| Max. Negotiated Rate |
$9,368.01 |
| Rate for Payer: BCBS Complete |
$9,368.01
|
| Rate for Payer: Mclaren Medicaid |
$8,921.91
|
| Rate for Payer: Meridian Medicaid |
$9,368.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,921.91
|
| Rate for Payer: UHC Medicaid |
$8,921.91
|
| Rate for Payer: UHCCP Medicaid |
$8,921.91
|
|
