|
GENTAMICIN 14 MG/ML FORTIFIED OPHTHALMIC DROPS
|
Facility
|
IP
|
$209.86
|
|
|
Service Code
|
NDC 09900000088
|
| Hospital Charge Code |
500593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.34 |
| Max. Negotiated Rate |
$188.87 |
| Rate for Payer: Aetna American Axle |
$136.41
|
| Rate for Payer: Aetna Commercial |
$178.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.41
|
| Rate for Payer: Cash Price |
$167.89
|
| Rate for Payer: Cofinity Advantage |
$146.90
|
| Rate for Payer: Cofinity Commercial |
$180.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.89
|
| Rate for Payer: Healthscope Commercial |
$188.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.40
|
| Rate for Payer: PHP Commercial |
$178.38
|
| Rate for Payer: Priority Health SBD |
$132.21
|
| Rate for Payer: UMR Bronson Commercial |
$92.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.40
|
|
|
GENTAMICIN 14 MG/ML FORTIFIED OPHTHALMIC DROPS
|
Facility
|
OP
|
$209.86
|
|
|
Service Code
|
NDC 09900000088
|
| Hospital Charge Code |
500593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.65 |
| Max. Negotiated Rate |
$188.87 |
| Rate for Payer: Aetna American Axle |
$136.41
|
| Rate for Payer: Aetna Commercial |
$178.38
|
| Rate for Payer: Aetna Medicare |
$104.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.41
|
| Rate for Payer: BCBS Complete |
$83.94
|
| Rate for Payer: Cash Price |
$167.89
|
| Rate for Payer: Cofinity Advantage |
$146.90
|
| Rate for Payer: Cofinity Commercial |
$180.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.89
|
| Rate for Payer: Healthscope Commercial |
$188.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$167.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.40
|
| Rate for Payer: PHP Commercial |
$178.38
|
| Rate for Payer: Priority Health SBD |
$132.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.41
|
| Rate for Payer: UHC Core |
$109.34
|
| Rate for Payer: UHC Exchange |
$82.47
|
| Rate for Payer: UMR Bronson Commercial |
$77.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.40
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$19.55
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$17.59 |
| Rate for Payer: Aetna American Axle |
$12.71
|
| Rate for Payer: Aetna American Axle |
$22.36
|
| Rate for Payer: Aetna American Axle |
$218.66
|
| Rate for Payer: Aetna American Axle |
$14.95
|
| Rate for Payer: Aetna American Axle |
$30.43
|
| Rate for Payer: Aetna Commercial |
$16.62
|
| Rate for Payer: Aetna Commercial |
$19.55
|
| Rate for Payer: Aetna Commercial |
$39.79
|
| Rate for Payer: Aetna Commercial |
$29.24
|
| Rate for Payer: Aetna Commercial |
$285.94
|
| Rate for Payer: Aetna Medicare |
$23.41
|
| Rate for Payer: Aetna Medicare |
$11.50
|
| Rate for Payer: Aetna Medicare |
$9.78
|
| Rate for Payer: Aetna Medicare |
$168.20
|
| Rate for Payer: Aetna Medicare |
$17.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.43
|
| Rate for Payer: BCBS Complete |
$13.76
|
| Rate for Payer: BCBS Complete |
$7.82
|
| Rate for Payer: BCBS Complete |
$9.20
|
| Rate for Payer: BCBS Complete |
$134.56
|
| Rate for Payer: BCBS Complete |
$18.72
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: Cash Price |
$27.52
|
| Rate for Payer: Cash Price |
$37.45
|
| Rate for Payer: Cash Price |
$18.40
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cash Price |
$269.12
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cash Price |
$269.12
|
| Rate for Payer: Cash Price |
$27.52
|
| Rate for Payer: Cash Price |
$18.40
|
| Rate for Payer: Cash Price |
$37.45
|
| Rate for Payer: Cofinity Advantage |
$24.08
|
| Rate for Payer: Cofinity Advantage |
$16.10
|
| Rate for Payer: Cofinity Advantage |
$235.48
|
| Rate for Payer: Cofinity Advantage |
$32.77
|
| Rate for Payer: Cofinity Advantage |
$13.69
|
| Rate for Payer: Cofinity Commercial |
$29.58
|
| Rate for Payer: Cofinity Commercial |
$16.81
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$289.30
|
| Rate for Payer: Cofinity Commercial |
$40.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.12
|
| Rate for Payer: Healthscope Commercial |
$302.76
|
| Rate for Payer: Healthscope Commercial |
$42.13
|
| Rate for Payer: Healthscope Commercial |
$30.96
|
| Rate for Payer: Healthscope Commercial |
$17.59
|
| Rate for Payer: Healthscope Commercial |
$20.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.11
|
| Rate for Payer: PHP Commercial |
$19.55
|
| Rate for Payer: PHP Commercial |
$285.94
|
| Rate for Payer: PHP Commercial |
$39.79
|
| Rate for Payer: PHP Commercial |
$29.24
|
| Rate for Payer: PHP Commercial |
$16.62
|
| Rate for Payer: Priority Health SBD |
$211.93
|
| Rate for Payer: Priority Health SBD |
$12.32
|
| Rate for Payer: Priority Health SBD |
$21.67
|
| Rate for Payer: Priority Health SBD |
$29.49
|
| Rate for Payer: Priority Health SBD |
$14.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UMR Bronson Commercial |
$7.23
|
| Rate for Payer: UMR Bronson Commercial |
$12.73
|
| Rate for Payer: UMR Bronson Commercial |
$124.47
|
| Rate for Payer: UMR Bronson Commercial |
$17.32
|
| Rate for Payer: UMR Bronson Commercial |
$8.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.66
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$34.40
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$30.96 |
| Rate for Payer: Aetna American Axle |
$22.36
|
| Rate for Payer: Aetna American Axle |
$218.66
|
| Rate for Payer: Aetna American Axle |
$30.43
|
| Rate for Payer: Aetna American Axle |
$14.95
|
| Rate for Payer: Aetna American Axle |
$12.71
|
| Rate for Payer: Aetna Commercial |
$16.62
|
| Rate for Payer: Aetna Commercial |
$285.94
|
| Rate for Payer: Aetna Commercial |
$29.24
|
| Rate for Payer: Aetna Commercial |
$39.79
|
| Rate for Payer: Aetna Commercial |
$19.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.43
|
| Rate for Payer: Cash Price |
$269.12
|
| Rate for Payer: Cash Price |
$18.40
|
| Rate for Payer: Cash Price |
$37.45
|
| Rate for Payer: Cash Price |
$27.52
|
| Rate for Payer: Cash Price |
$15.64
|
| Rate for Payer: Cofinity Advantage |
$13.69
|
| Rate for Payer: Cofinity Advantage |
$32.77
|
| Rate for Payer: Cofinity Advantage |
$16.10
|
| Rate for Payer: Cofinity Advantage |
$24.08
|
| Rate for Payer: Cofinity Advantage |
$235.48
|
| Rate for Payer: Cofinity Commercial |
$40.26
|
| Rate for Payer: Cofinity Commercial |
$16.81
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$289.30
|
| Rate for Payer: Cofinity Commercial |
$29.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.45
|
| Rate for Payer: Healthscope Commercial |
$17.59
|
| Rate for Payer: Healthscope Commercial |
$20.70
|
| Rate for Payer: Healthscope Commercial |
$302.76
|
| Rate for Payer: Healthscope Commercial |
$30.96
|
| Rate for Payer: Healthscope Commercial |
$42.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.80
|
| Rate for Payer: PHP Commercial |
$285.94
|
| Rate for Payer: PHP Commercial |
$16.62
|
| Rate for Payer: PHP Commercial |
$29.24
|
| Rate for Payer: PHP Commercial |
$39.79
|
| Rate for Payer: PHP Commercial |
$19.55
|
| Rate for Payer: Priority Health SBD |
$21.67
|
| Rate for Payer: Priority Health SBD |
$29.49
|
| Rate for Payer: Priority Health SBD |
$14.49
|
| Rate for Payer: Priority Health SBD |
$12.32
|
| Rate for Payer: Priority Health SBD |
$211.93
|
| Rate for Payer: UMR Bronson Commercial |
$10.12
|
| Rate for Payer: UMR Bronson Commercial |
$20.60
|
| Rate for Payer: UMR Bronson Commercial |
$148.02
|
| Rate for Payer: UMR Bronson Commercial |
$8.60
|
| Rate for Payer: UMR Bronson Commercial |
$15.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.25
|
|
|
GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
15906
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
15906
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
GENTAMICIN 9 MG/ML FORTIFIED OPHTHAMIC DROPS
|
Facility
|
IP
|
$177.35
|
|
|
Service Code
|
NDC 09900000087
|
| Hospital Charge Code |
500592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.03 |
| Max. Negotiated Rate |
$159.62 |
| Rate for Payer: Aetna American Axle |
$115.28
|
| Rate for Payer: Aetna Commercial |
$150.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.28
|
| Rate for Payer: Cash Price |
$141.88
|
| Rate for Payer: Cofinity Advantage |
$124.14
|
| Rate for Payer: Cofinity Commercial |
$152.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.88
|
| Rate for Payer: Healthscope Commercial |
$159.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$133.01
|
| Rate for Payer: PHP Commercial |
$150.75
|
| Rate for Payer: Priority Health SBD |
$111.73
|
| Rate for Payer: UMR Bronson Commercial |
$78.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.01
|
|
|
GENTAMICIN 9 MG/ML FORTIFIED OPHTHAMIC DROPS
|
Facility
|
OP
|
$177.35
|
|
|
Service Code
|
NDC 09900000087
|
| Hospital Charge Code |
500592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.62 |
| Max. Negotiated Rate |
$159.62 |
| Rate for Payer: Aetna American Axle |
$115.28
|
| Rate for Payer: Aetna Commercial |
$150.75
|
| Rate for Payer: Aetna Medicare |
$88.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.28
|
| Rate for Payer: BCBS Complete |
$70.94
|
| Rate for Payer: Cash Price |
$141.88
|
| Rate for Payer: Cofinity Advantage |
$124.14
|
| Rate for Payer: Cofinity Commercial |
$152.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.88
|
| Rate for Payer: Healthscope Commercial |
$159.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$141.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$133.01
|
| Rate for Payer: PHP Commercial |
$150.75
|
| Rate for Payer: Priority Health SBD |
$111.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.28
|
| Rate for Payer: UHC Core |
$92.40
|
| Rate for Payer: UHC Exchange |
$69.70
|
| Rate for Payer: UMR Bronson Commercial |
$65.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.01
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$27.93
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
117665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$25.14 |
| Rate for Payer: Aetna American Axle |
$18.15
|
| Rate for Payer: Aetna Commercial |
$23.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.15
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cofinity Advantage |
$19.55
|
| Rate for Payer: Cofinity Commercial |
$24.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.34
|
| Rate for Payer: Healthscope Commercial |
$25.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.95
|
| Rate for Payer: PHP Commercial |
$23.74
|
| Rate for Payer: Priority Health SBD |
$17.60
|
| Rate for Payer: UMR Bronson Commercial |
$12.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.95
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$27.93
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
117665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$25.14 |
| Rate for Payer: Aetna American Axle |
$18.15
|
| Rate for Payer: Aetna Commercial |
$23.74
|
| Rate for Payer: Aetna Medicare |
$13.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.15
|
| Rate for Payer: BCBS Complete |
$11.17
|
| Rate for Payer: BCBS Trust/PPO |
$7.00
|
| Rate for Payer: BCN Commercial |
$7.00
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cofinity Advantage |
$19.55
|
| Rate for Payer: Cofinity Commercial |
$24.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.34
|
| Rate for Payer: Healthscope Commercial |
$25.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.95
|
| Rate for Payer: PHP Commercial |
$23.74
|
| Rate for Payer: Priority Health SBD |
$17.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.58
|
| Rate for Payer: UHC Core |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UMR Bronson Commercial |
$10.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.95
|
|
|
GIVOSIRAN 189 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$107,575.00
|
|
|
Service Code
|
HCPCS J0223
|
| Hospital Charge Code |
192158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.27 |
| Max. Negotiated Rate |
$96,817.50 |
| Rate for Payer: Aetna American Axle |
$69,923.75
|
| Rate for Payer: Aetna Commercial |
$91,438.75
|
| Rate for Payer: Aetna Medicare |
$125.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69,923.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$151.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$151.22
|
| Rate for Payer: BCBS Complete |
$66.44
|
| Rate for Payer: BCBS MAPPO |
$120.98
|
| Rate for Payer: BCBS Trust/PPO |
$391.33
|
| Rate for Payer: BCN Commercial |
$391.33
|
| Rate for Payer: BCN Medicare Advantage |
$120.98
|
| Rate for Payer: Cash Price |
$86,060.00
|
| Rate for Payer: Cash Price |
$86,060.00
|
| Rate for Payer: Cofinity Advantage |
$75,302.50
|
| Rate for Payer: Cofinity Commercial |
$92,514.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86,060.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$120.98
|
| Rate for Payer: Healthscope Commercial |
$96,817.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75,302.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80,681.25
|
| Rate for Payer: Mclaren Medicaid |
$120.98
|
| Rate for Payer: Mclaren Medicare |
$120.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$127.03
|
| Rate for Payer: Meridian Medicaid |
$127.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$139.13
|
| Rate for Payer: Molina Medicare/Medicaid |
$133.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91,438.75
|
| Rate for Payer: Nomi Health Commercial |
$362.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80,681.25
|
| Rate for Payer: PACE Medicare |
$114.93
|
| Rate for Payer: PACE SWMI |
$120.98
|
| Rate for Payer: PHP Commercial |
$91,438.75
|
| Rate for Payer: PHP Medicare Advantage |
$120.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$63.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$370.15
|
| Rate for Payer: Priority Health Medicare |
$120.98
|
| Rate for Payer: Priority Health SBD |
$67,772.25
|
| Rate for Payer: Priority Health Tiered Network |
$296.12
|
| Rate for Payer: Railroad Medicare Medicare |
$120.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$199.14
|
| Rate for Payer: UHC Core |
$199.14
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$120.98
|
| Rate for Payer: UHC Exchange |
$199.14
|
| Rate for Payer: UHC Medicaid |
$63.27
|
| Rate for Payer: UHCCP Medicaid |
$63.27
|
| Rate for Payer: UMR Bronson Commercial |
$39,802.75
|
| Rate for Payer: VA VA |
$120.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80,681.25
|
|
|
GIVOSIRAN 189 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$107,575.00
|
|
|
Service Code
|
HCPCS J0223
|
| Hospital Charge Code |
192158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47,333.00 |
| Max. Negotiated Rate |
$96,817.50 |
| Rate for Payer: Aetna American Axle |
$69,923.75
|
| Rate for Payer: Aetna Commercial |
$91,438.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69,923.75
|
| Rate for Payer: Cash Price |
$86,060.00
|
| Rate for Payer: Cofinity Advantage |
$75,302.50
|
| Rate for Payer: Cofinity Commercial |
$92,514.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86,060.00
|
| Rate for Payer: Healthscope Commercial |
$96,817.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75,302.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80,681.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91,438.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80,681.25
|
| Rate for Payer: PHP Commercial |
$91,438.75
|
| Rate for Payer: Priority Health SBD |
$67,772.25
|
| Rate for Payer: UMR Bronson Commercial |
$47,333.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80,681.25
|
|
|
GLASSIA (ALPHA-1-PROTEINASE INHIBITOR) 1 GRAM/50 ML(2 %) IV SOLN
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
HCPCS J0257
|
| Hospital Charge Code |
106274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna American Axle |
$1.02
|
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.02
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Advantage |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.18
|
| Rate for Payer: PHP Commercial |
$1.33
|
| Rate for Payer: Priority Health SBD |
$0.99
|
| Rate for Payer: UMR Bronson Commercial |
$0.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.18
|
|
|
GLASSIA (ALPHA-1-PROTEINASE INHIBITOR) 1 GRAM/50 ML(2 %) IV SOLN
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
HCPCS J0257
|
| Hospital Charge Code |
106274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna American Axle |
$1.02
|
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna Medicare |
$5.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.08
|
| Rate for Payer: BCBS Complete |
$3.11
|
| Rate for Payer: BCBS MAPPO |
$5.66
|
| Rate for Payer: BCBS Trust/PPO |
$18.46
|
| Rate for Payer: BCN Commercial |
$18.46
|
| Rate for Payer: BCN Medicare Advantage |
$5.66
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Advantage |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.66
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.18
|
| Rate for Payer: Mclaren Medicaid |
$5.66
|
| Rate for Payer: Mclaren Medicare |
$5.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.94
|
| Rate for Payer: Meridian Medicaid |
$5.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.33
|
| Rate for Payer: Nomi Health Commercial |
$16.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.18
|
| Rate for Payer: PACE Medicare |
$5.38
|
| Rate for Payer: PACE SWMI |
$5.66
|
| Rate for Payer: PHP Commercial |
$1.33
|
| Rate for Payer: PHP Medicare Advantage |
$5.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$17.79
|
| Rate for Payer: Priority Health Medicare |
$5.66
|
| Rate for Payer: Priority Health SBD |
$0.99
|
| Rate for Payer: Priority Health Tiered Network |
$14.23
|
| Rate for Payer: Railroad Medicare Medicare |
$5.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.39
|
| Rate for Payer: UHC Core |
$9.39
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.66
|
| Rate for Payer: UHC Exchange |
$9.39
|
| Rate for Payer: UHC Medicaid |
$2.96
|
| Rate for Payer: UHCCP Medicaid |
$2.96
|
| Rate for Payer: UMR Bronson Commercial |
$0.58
|
| Rate for Payer: VA VA |
$5.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.18
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 16729000101
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.17 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna Medicare |
$97.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.78
|
| Rate for Payer: UHC Core |
$101.62
|
| Rate for Payer: UHC Exchange |
$76.65
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 55111032001
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Advantage |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$58.16
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 55111032001
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.69 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna Medicare |
$38.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Advantage |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$58.16
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.41
|
| Rate for Payer: UHC Core |
$40.40
|
| Rate for Payer: UHC Exchange |
$30.48
|
| Rate for Payer: UMR Bronson Commercial |
$28.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 16729000101
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$277.44
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.07 |
| Max. Negotiated Rate |
$249.70 |
| Rate for Payer: Aetna American Axle |
$180.34
|
| Rate for Payer: Aetna Commercial |
$235.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.34
|
| Rate for Payer: Cash Price |
$221.95
|
| Rate for Payer: Cofinity Advantage |
$194.21
|
| Rate for Payer: Cofinity Commercial |
$238.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.95
|
| Rate for Payer: Healthscope Commercial |
$249.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.08
|
| Rate for Payer: PHP Commercial |
$235.82
|
| Rate for Payer: Priority Health SBD |
$174.79
|
| Rate for Payer: UMR Bronson Commercial |
$122.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.08
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$277.44
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.65 |
| Max. Negotiated Rate |
$249.70 |
| Rate for Payer: Aetna American Axle |
$180.34
|
| Rate for Payer: Aetna Commercial |
$235.82
|
| Rate for Payer: Aetna Medicare |
$138.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.34
|
| Rate for Payer: BCBS Complete |
$110.98
|
| Rate for Payer: Cash Price |
$221.95
|
| Rate for Payer: Cofinity Advantage |
$194.21
|
| Rate for Payer: Cofinity Commercial |
$238.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.95
|
| Rate for Payer: Healthscope Commercial |
$249.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$221.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.08
|
| Rate for Payer: PHP Commercial |
$235.82
|
| Rate for Payer: Priority Health SBD |
$174.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$180.34
|
| Rate for Payer: UHC Core |
$144.55
|
| Rate for Payer: UHC Exchange |
$109.03
|
| Rate for Payer: UMR Bronson Commercial |
$102.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.08
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$2.78
|
|
|
Service Code
|
NDC 68084032611
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna American Axle |
$1.81
|
| Rate for Payer: Aetna Commercial |
$2.36
|
| Rate for Payer: Aetna Medicare |
$1.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.81
|
| Rate for Payer: BCBS Complete |
$1.11
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cofinity Advantage |
$1.95
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.22
|
| Rate for Payer: Healthscope Commercial |
$2.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.08
|
| Rate for Payer: PHP Commercial |
$2.36
|
| Rate for Payer: Priority Health SBD |
$1.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.81
|
| Rate for Payer: UHC Core |
$1.45
|
| Rate for Payer: UHC Exchange |
$1.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.08
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$2.78
|
|
|
Service Code
|
NDC 68084032611
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna American Axle |
$1.81
|
| Rate for Payer: Aetna Commercial |
$2.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.81
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cofinity Advantage |
$1.95
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.22
|
| Rate for Payer: Healthscope Commercial |
$2.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.08
|
| Rate for Payer: PHP Commercial |
$2.36
|
| Rate for Payer: Priority Health SBD |
$1.75
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.08
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
OP
|
$296.16
|
|
|
Service Code
|
NDC 68084032701
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.58 |
| Max. Negotiated Rate |
$266.54 |
| Rate for Payer: Aetna American Axle |
$192.50
|
| Rate for Payer: Aetna Commercial |
$251.74
|
| Rate for Payer: Aetna Medicare |
$148.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.50
|
| Rate for Payer: BCBS Complete |
$118.46
|
| Rate for Payer: Cash Price |
$236.93
|
| Rate for Payer: Cofinity Advantage |
$207.31
|
| Rate for Payer: Cofinity Commercial |
$254.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.93
|
| Rate for Payer: Healthscope Commercial |
$266.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$207.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$236.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$251.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$222.12
|
| Rate for Payer: PHP Commercial |
$251.74
|
| Rate for Payer: Priority Health SBD |
$186.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$192.50
|
| Rate for Payer: UHC Core |
$154.30
|
| Rate for Payer: UHC Exchange |
$116.39
|
| Rate for Payer: UMR Bronson Commercial |
$109.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.12
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
NDC 68084032711
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna American Axle |
$1.93
|
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.93
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cofinity Advantage |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$2.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.38
|
| Rate for Payer: Healthscope Commercial |
$2.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.52
|
| Rate for Payer: Priority Health SBD |
$1.87
|
| Rate for Payer: UMR Bronson Commercial |
$1.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.23
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
OP
|
$2.97
|
|
|
Service Code
|
NDC 68084032711
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna American Axle |
$1.93
|
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Aetna Medicare |
$1.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.93
|
| Rate for Payer: BCBS Complete |
$1.19
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cofinity Advantage |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$2.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.38
|
| Rate for Payer: Healthscope Commercial |
$2.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.52
|
| Rate for Payer: Priority Health SBD |
$1.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.93
|
| Rate for Payer: UHC Core |
$1.55
|
| Rate for Payer: UHC Exchange |
$1.17
|
| Rate for Payer: UMR Bronson Commercial |
$1.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.23
|
|
