|
FELBAMATE 400 MG TABLET
|
Facility
|
IP
|
$771.56
|
|
|
Service Code
|
NDC 53746073490
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$339.49 |
| Max. Negotiated Rate |
$694.40 |
| Rate for Payer: Aetna American Axle |
$501.51
|
| Rate for Payer: Aetna Commercial |
$655.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$501.51
|
| Rate for Payer: Cash Price |
$617.25
|
| Rate for Payer: Cofinity Commercial |
$540.09
|
| Rate for Payer: Cofinity Commercial |
$663.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$540.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$617.25
|
| Rate for Payer: Healthscope Commercial |
$694.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$540.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$578.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$655.83
|
| Rate for Payer: PHP Commercial |
$655.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.51
|
| Rate for Payer: Priority Health SBD |
$486.08
|
| Rate for Payer: UMR Bronson Commercial |
$339.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$578.67
|
|
|
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 Commercial |
$294.67
|
| Rate for Payer: Cofinity Commercial |
$362.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.67
|
| 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: PHP Commercial |
$357.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.62
|
| 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
|
$5,057.90
|
|
|
Service Code
|
NDC 00037043001
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,871.42 |
| Max. Negotiated Rate |
$4,552.11 |
| Rate for Payer: Aetna American Axle |
$3,287.64
|
| Rate for Payer: Aetna Commercial |
$4,299.22
|
| Rate for Payer: Aetna Medicare |
$2,528.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,287.64
|
| Rate for Payer: BCBS Complete |
$2,023.16
|
| Rate for Payer: Cash Price |
$4,046.32
|
| Rate for Payer: Cofinity Commercial |
$3,540.53
|
| Rate for Payer: Cofinity Commercial |
$4,349.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,540.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,046.32
|
| Rate for Payer: Healthscope Commercial |
$4,552.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,540.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,793.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,299.22
|
| Rate for Payer: PHP Commercial |
$4,299.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,287.64
|
| Rate for Payer: Priority Health SBD |
$3,186.48
|
| Rate for Payer: UMR Bronson Commercial |
$1,871.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,793.42
|
|
|
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 Commercial |
$523.31
|
| Rate for Payer: Cofinity Commercial |
$642.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$523.31
|
| 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: PHP Commercial |
$635.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$485.93
|
| Rate for Payer: Priority Health SBD |
$470.98
|
| Rate for Payer: UMR Bronson Commercial |
$276.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$560.69
|
|
|
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 Commercial |
$294.67
|
| Rate for Payer: Cofinity Commercial |
$362.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.67
|
| 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: PHP Commercial |
$357.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.62
|
| Rate for Payer: Priority Health SBD |
$265.20
|
| Rate for Payer: UMR Bronson Commercial |
$155.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.72
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
IP
|
$5,057.90
|
|
|
Service Code
|
NDC 00037043001
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,225.48 |
| Max. Negotiated Rate |
$4,552.11 |
| Rate for Payer: Aetna American Axle |
$3,287.64
|
| Rate for Payer: Aetna Commercial |
$4,299.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,287.64
|
| Rate for Payer: Cash Price |
$4,046.32
|
| Rate for Payer: Cofinity Commercial |
$3,540.53
|
| Rate for Payer: Cofinity Commercial |
$4,349.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,540.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,046.32
|
| Rate for Payer: Healthscope Commercial |
$4,552.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,540.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,793.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,299.22
|
| Rate for Payer: PHP Commercial |
$4,299.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,287.64
|
| Rate for Payer: Priority Health SBD |
$3,186.48
|
| Rate for Payer: UMR Bronson Commercial |
$2,225.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,793.42
|
|
|
FELBAMATE 400 MG TABLET
|
Facility
|
OP
|
$771.56
|
|
|
Service Code
|
NDC 53746073490
|
| Hospital Charge Code |
10024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.48 |
| Max. Negotiated Rate |
$694.40 |
| Rate for Payer: Aetna American Axle |
$501.51
|
| Rate for Payer: Aetna Commercial |
$655.83
|
| Rate for Payer: Aetna Medicare |
$385.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$501.51
|
| Rate for Payer: BCBS Complete |
$308.62
|
| Rate for Payer: Cash Price |
$617.25
|
| Rate for Payer: Cofinity Commercial |
$540.09
|
| Rate for Payer: Cofinity Commercial |
$663.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$540.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$617.25
|
| Rate for Payer: Healthscope Commercial |
$694.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$540.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$578.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$655.83
|
| Rate for Payer: PHP Commercial |
$655.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.51
|
| Rate for Payer: Priority Health SBD |
$486.08
|
| Rate for Payer: UMR Bronson Commercial |
$285.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$578.67
|
|
|
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 Commercial |
$523.31
|
| Rate for Payer: Cofinity Commercial |
$642.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$523.31
|
| 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: PHP Commercial |
$635.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$485.93
|
| 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 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$909.61
|
|
|
Service Code
|
NDC 70954005110
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$336.56 |
| Max. Negotiated Rate |
$818.65 |
| Rate for Payer: Aetna American Axle |
$591.25
|
| Rate for Payer: Aetna Commercial |
$773.17
|
| Rate for Payer: Aetna Medicare |
$454.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$591.25
|
| Rate for Payer: BCBS Complete |
$363.84
|
| Rate for Payer: Cash Price |
$727.69
|
| Rate for Payer: Cofinity Commercial |
$636.73
|
| Rate for Payer: Cofinity Commercial |
$782.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$636.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$727.69
|
| Rate for Payer: Healthscope Commercial |
$818.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$636.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$682.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$773.17
|
| Rate for Payer: PHP Commercial |
$773.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$591.25
|
| Rate for Payer: Priority Health SBD |
$573.05
|
| Rate for Payer: UMR Bronson Commercial |
$336.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$682.21
|
|
|
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 Commercial |
$4,297.43
|
| Rate for Payer: Cofinity Commercial |
$5,279.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,297.43
|
| 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 |
$4,604.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,218.30
|
| Rate for Payer: PHP Commercial |
$5,218.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,990.47
|
| Rate for Payer: Priority Health SBD |
$3,867.68
|
| Rate for Payer: UMR Bronson Commercial |
$2,271.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,604.38
|
|
|
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 Commercial |
$1,587.87
|
| Rate for Payer: Cofinity Commercial |
$1,950.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,587.87
|
| 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 |
$1,701.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,928.12
|
| Rate for Payer: PHP Commercial |
$1,928.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,474.45
|
| 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 |
$1,701.28
|
|
|
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 Commercial |
$4,297.43
|
| Rate for Payer: Cofinity Commercial |
$5,279.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,297.43
|
| 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 |
$4,604.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,218.30
|
| Rate for Payer: PHP Commercial |
$5,218.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,990.47
|
| 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 |
$4,604.38
|
|
|
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 Commercial |
$1,587.87
|
| Rate for Payer: Cofinity Commercial |
$1,950.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,587.87
|
| 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 |
$1,701.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,928.12
|
| Rate for Payer: PHP Commercial |
$1,928.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,474.45
|
| Rate for Payer: Priority Health SBD |
$1,429.08
|
| Rate for Payer: UMR Bronson Commercial |
$839.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,701.28
|
|
|
FELBAMATE 600 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$909.61
|
|
|
Service Code
|
NDC 70954005110
|
| Hospital Charge Code |
10023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$400.23 |
| Max. Negotiated Rate |
$818.65 |
| Rate for Payer: Aetna American Axle |
$591.25
|
| Rate for Payer: Aetna Commercial |
$773.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$591.25
|
| Rate for Payer: Cash Price |
$727.69
|
| Rate for Payer: Cofinity Commercial |
$636.73
|
| Rate for Payer: Cofinity Commercial |
$782.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$636.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$727.69
|
| Rate for Payer: Healthscope Commercial |
$818.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$636.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$682.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$773.17
|
| Rate for Payer: PHP Commercial |
$773.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$591.25
|
| Rate for Payer: Priority Health SBD |
$573.05
|
| Rate for Payer: UMR Bronson Commercial |
$400.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$682.21
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
OP
|
$788.40
|
|
|
Service Code
|
NDC 53746073590
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$291.71 |
| Max. Negotiated Rate |
$709.56 |
| Rate for Payer: Aetna American Axle |
$512.46
|
| Rate for Payer: Aetna Commercial |
$670.14
|
| Rate for Payer: Aetna Medicare |
$394.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.46
|
| Rate for Payer: BCBS Complete |
$315.36
|
| Rate for Payer: Cash Price |
$630.72
|
| Rate for Payer: Cofinity Commercial |
$551.88
|
| Rate for Payer: Cofinity Commercial |
$678.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$551.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.72
|
| Rate for Payer: Healthscope Commercial |
$709.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$670.14
|
| Rate for Payer: PHP Commercial |
$670.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$512.46
|
| Rate for Payer: Priority Health SBD |
$496.69
|
| Rate for Payer: UMR Bronson Commercial |
$291.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.30
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
IP
|
$788.40
|
|
|
Service Code
|
NDC 53746073590
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$346.90 |
| Max. Negotiated Rate |
$709.56 |
| Rate for Payer: Aetna American Axle |
$512.46
|
| Rate for Payer: Aetna Commercial |
$670.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.46
|
| Rate for Payer: Cash Price |
$630.72
|
| Rate for Payer: Cofinity Commercial |
$551.88
|
| Rate for Payer: Cofinity Commercial |
$678.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$551.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.72
|
| Rate for Payer: Healthscope Commercial |
$709.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$551.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$591.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$670.14
|
| Rate for Payer: PHP Commercial |
$670.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$512.46
|
| Rate for Payer: Priority Health SBD |
$496.69
|
| Rate for Payer: UMR Bronson Commercial |
$346.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$591.30
|
|
|
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 Commercial |
$566.90
|
| Rate for Payer: Cofinity Commercial |
$696.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$566.90
|
| 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 |
$607.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$688.38
|
| Rate for Payer: PHP Commercial |
$688.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$526.41
|
| 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 |
$607.40
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
OP
|
$5,796.79
|
|
|
Service Code
|
NDC 00037043101
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,144.81 |
| Max. Negotiated Rate |
$5,217.11 |
| Rate for Payer: Aetna American Axle |
$3,767.91
|
| Rate for Payer: Aetna Commercial |
$4,927.27
|
| Rate for Payer: Aetna Medicare |
$2,898.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,767.91
|
| Rate for Payer: BCBS Complete |
$2,318.72
|
| Rate for Payer: Cash Price |
$4,637.43
|
| Rate for Payer: Cofinity Commercial |
$4,057.75
|
| Rate for Payer: Cofinity Commercial |
$4,985.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,057.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,637.43
|
| Rate for Payer: Healthscope Commercial |
$5,217.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,057.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,347.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,927.27
|
| Rate for Payer: PHP Commercial |
$4,927.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,767.91
|
| Rate for Payer: Priority Health SBD |
$3,651.98
|
| Rate for Payer: UMR Bronson Commercial |
$2,144.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,347.59
|
|
|
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 Commercial |
$566.90
|
| Rate for Payer: Cofinity Commercial |
$696.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$566.90
|
| 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 |
$607.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$688.38
|
| Rate for Payer: PHP Commercial |
$688.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$526.41
|
| Rate for Payer: Priority Health SBD |
$510.21
|
| Rate for Payer: UMR Bronson Commercial |
$299.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$607.40
|
|
|
FELBAMATE 600 MG TABLET
|
Facility
|
IP
|
$5,796.79
|
|
|
Service Code
|
NDC 00037043101
|
| Hospital Charge Code |
10025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,550.59 |
| Max. Negotiated Rate |
$5,217.11 |
| Rate for Payer: Aetna American Axle |
$3,767.91
|
| Rate for Payer: Aetna Commercial |
$4,927.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,767.91
|
| Rate for Payer: Cash Price |
$4,637.43
|
| Rate for Payer: Cofinity Commercial |
$4,057.75
|
| Rate for Payer: Cofinity Commercial |
$4,985.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,057.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,637.43
|
| Rate for Payer: Healthscope Commercial |
$5,217.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,057.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,347.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,927.27
|
| Rate for Payer: PHP Commercial |
$4,927.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,767.91
|
| Rate for Payer: Priority Health SBD |
$3,651.98
|
| Rate for Payer: UMR Bronson Commercial |
$2,550.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,347.59
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
IP
|
$176.99
|
|
|
Service Code
|
NDC 68180038909
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$159.29 |
| Rate for Payer: Aetna American Axle |
$115.04
|
| Rate for Payer: Aetna Commercial |
$150.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.04
|
| Rate for Payer: Cash Price |
$141.59
|
| Rate for Payer: Cofinity Commercial |
$123.89
|
| Rate for Payer: Cofinity Commercial |
$152.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.59
|
| Rate for Payer: Healthscope Commercial |
$159.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.44
|
| Rate for Payer: PHP Commercial |
$150.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.04
|
| Rate for Payer: Priority Health SBD |
$111.50
|
| Rate for Payer: UMR Bronson Commercial |
$77.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.74
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
IP
|
$176.13
|
|
|
Service Code
|
NDC 69097045805
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.50 |
| Max. Negotiated Rate |
$158.52 |
| Rate for Payer: Aetna American Axle |
$114.48
|
| Rate for Payer: Aetna Commercial |
$149.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.48
|
| Rate for Payer: Cash Price |
$140.90
|
| Rate for Payer: Cofinity Commercial |
$123.29
|
| Rate for Payer: Cofinity Commercial |
$151.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.90
|
| Rate for Payer: Healthscope Commercial |
$158.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.71
|
| Rate for Payer: PHP Commercial |
$149.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.48
|
| Rate for Payer: Priority Health SBD |
$110.96
|
| Rate for Payer: UMR Bronson Commercial |
$77.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.10
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
IP
|
$855.07
|
|
|
Service Code
|
NDC 00904716161
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$376.23 |
| Max. Negotiated Rate |
$769.56 |
| Rate for Payer: Aetna American Axle |
$555.80
|
| Rate for Payer: Aetna Commercial |
$726.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$555.80
|
| Rate for Payer: Cash Price |
$684.06
|
| Rate for Payer: Cofinity Commercial |
$598.55
|
| Rate for Payer: Cofinity Commercial |
$735.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$598.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$684.06
|
| Rate for Payer: Healthscope Commercial |
$769.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$598.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$641.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$726.81
|
| Rate for Payer: PHP Commercial |
$726.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$555.80
|
| Rate for Payer: Priority Health SBD |
$538.69
|
| Rate for Payer: UMR Bronson Commercial |
$376.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$641.30
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
OP
|
$176.99
|
|
|
Service Code
|
NDC 68180038909
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.49 |
| Max. Negotiated Rate |
$159.29 |
| Rate for Payer: Aetna American Axle |
$115.04
|
| Rate for Payer: Aetna Commercial |
$150.44
|
| Rate for Payer: Aetna Medicare |
$88.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.04
|
| Rate for Payer: BCBS Complete |
$70.80
|
| Rate for Payer: Cash Price |
$141.59
|
| Rate for Payer: Cofinity Commercial |
$123.89
|
| Rate for Payer: Cofinity Commercial |
$152.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.59
|
| Rate for Payer: Healthscope Commercial |
$159.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.44
|
| Rate for Payer: PHP Commercial |
$150.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.04
|
| Rate for Payer: Priority Health SBD |
$111.50
|
| Rate for Payer: UMR Bronson Commercial |
$65.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.74
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
OP
|
$952.75
|
|
|
Service Code
|
NDC 51079060820
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$352.52 |
| Max. Negotiated Rate |
$857.48 |
| Rate for Payer: Aetna American Axle |
$619.29
|
| Rate for Payer: Aetna Commercial |
$809.84
|
| Rate for Payer: Aetna Medicare |
$476.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$619.29
|
| Rate for Payer: BCBS Complete |
$381.10
|
| Rate for Payer: Cash Price |
$762.20
|
| Rate for Payer: Cofinity Commercial |
$666.92
|
| Rate for Payer: Cofinity Commercial |
$819.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$666.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$762.20
|
| Rate for Payer: Healthscope Commercial |
$857.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$666.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$714.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$809.84
|
| Rate for Payer: PHP Commercial |
$809.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$619.29
|
| Rate for Payer: Priority Health SBD |
$600.23
|
| Rate for Payer: UMR Bronson Commercial |
$352.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$714.56
|
|
