|
FLUVOXAMINE 100 MG TABLET
|
Facility
|
IP
|
$414.20
|
|
|
Service Code
|
NDC 51079099320
|
| Hospital Charge Code |
10084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.25 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Aetna American Axle |
$269.23
|
| Rate for Payer: Aetna Commercial |
$352.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.23
|
| Rate for Payer: Cash Price |
$331.36
|
| Rate for Payer: Cofinity Commercial |
$289.94
|
| Rate for Payer: Cofinity Commercial |
$356.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$289.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$331.36
|
| Rate for Payer: Healthscope Commercial |
$372.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$289.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$310.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$352.07
|
| Rate for Payer: PHP Commercial |
$352.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.23
|
| Rate for Payer: Priority Health SBD |
$260.95
|
| Rate for Payer: UMR Bronson Commercial |
$182.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$310.65
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.56 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna American Axle |
$145.60
|
| Rate for Payer: Aetna Commercial |
$190.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.60
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cofinity Commercial |
$156.80
|
| Rate for Payer: Cofinity Commercial |
$192.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.20
|
| Rate for Payer: Healthscope Commercial |
$201.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.40
|
| Rate for Payer: PHP Commercial |
$190.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.60
|
| Rate for Payer: Priority Health SBD |
$141.12
|
| Rate for Payer: UMR Bronson Commercial |
$98.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 62584089711
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna American Axle |
$0.98
|
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.98
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cofinity Commercial |
$1.05
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.20
|
| Rate for Payer: Healthscope Commercial |
$1.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.28
|
| Rate for Payer: PHP Commercial |
$1.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.98
|
| Rate for Payer: Priority Health SBD |
$0.95
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
NDC 65162036110
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.72 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna American Axle |
$122.20
|
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.20
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health SBD |
$118.44
|
| Rate for Payer: UMR Bronson Commercial |
$82.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$149.60
|
|
|
Service Code
|
NDC 62584089701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$134.64 |
| Rate for Payer: Aetna American Axle |
$97.24
|
| Rate for Payer: Aetna Commercial |
$127.16
|
| Rate for Payer: Aetna Medicare |
$74.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.24
|
| Rate for Payer: BCBS Complete |
$59.84
|
| Rate for Payer: Cash Price |
$119.68
|
| Rate for Payer: Cofinity Commercial |
$104.72
|
| Rate for Payer: Cofinity Commercial |
$128.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.68
|
| Rate for Payer: Healthscope Commercial |
$134.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.16
|
| Rate for Payer: PHP Commercial |
$127.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.24
|
| Rate for Payer: Priority Health SBD |
$94.25
|
| Rate for Payer: UMR Bronson Commercial |
$55.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.20
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
NDC 65162036110
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.56 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna American Axle |
$122.20
|
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.20
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health SBD |
$118.44
|
| Rate for Payer: UMR Bronson Commercial |
$69.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$149.60
|
|
|
Service Code
|
NDC 62584089701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.82 |
| Max. Negotiated Rate |
$134.64 |
| Rate for Payer: Aetna American Axle |
$97.24
|
| Rate for Payer: Aetna Commercial |
$127.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.24
|
| Rate for Payer: Cash Price |
$119.68
|
| Rate for Payer: Cofinity Commercial |
$104.72
|
| Rate for Payer: Cofinity Commercial |
$128.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.68
|
| Rate for Payer: Healthscope Commercial |
$134.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.16
|
| Rate for Payer: PHP Commercial |
$127.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.24
|
| Rate for Payer: Priority Health SBD |
$94.25
|
| Rate for Payer: UMR Bronson Commercial |
$65.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.20
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 62584089711
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna American Axle |
$0.98
|
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.98
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cofinity Commercial |
$1.05
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.20
|
| Rate for Payer: Healthscope Commercial |
$1.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.28
|
| Rate for Payer: PHP Commercial |
$1.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.98
|
| Rate for Payer: Priority Health SBD |
$0.95
|
| Rate for Payer: UMR Bronson Commercial |
$0.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
NDC 69315012701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.16 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna American Axle |
$106.60
|
| Rate for Payer: Aetna Commercial |
$139.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cofinity Commercial |
$114.80
|
| Rate for Payer: Cofinity Commercial |
$141.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$114.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.20
|
| Rate for Payer: Healthscope Commercial |
$147.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.40
|
| Rate for Payer: PHP Commercial |
$139.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.60
|
| Rate for Payer: Priority Health SBD |
$103.32
|
| Rate for Payer: UMR Bronson Commercial |
$72.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
NDC 69315012701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.68 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna American Axle |
$106.60
|
| Rate for Payer: Aetna Commercial |
$139.40
|
| Rate for Payer: Aetna Medicare |
$82.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.60
|
| Rate for Payer: BCBS Complete |
$65.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cofinity Commercial |
$114.80
|
| Rate for Payer: Cofinity Commercial |
$141.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$114.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.20
|
| Rate for Payer: Healthscope Commercial |
$147.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.40
|
| Rate for Payer: PHP Commercial |
$139.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.60
|
| Rate for Payer: Priority Health SBD |
$103.32
|
| Rate for Payer: UMR Bronson Commercial |
$60.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$147.40
|
|
|
Service Code
|
NDC 00904722461
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.86 |
| Max. Negotiated Rate |
$132.66 |
| Rate for Payer: Aetna American Axle |
$95.81
|
| Rate for Payer: Aetna Commercial |
$125.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.81
|
| Rate for Payer: Cash Price |
$117.92
|
| Rate for Payer: Cofinity Commercial |
$103.18
|
| Rate for Payer: Cofinity Commercial |
$126.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.92
|
| Rate for Payer: Healthscope Commercial |
$132.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.29
|
| Rate for Payer: PHP Commercial |
$125.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.81
|
| Rate for Payer: Priority Health SBD |
$92.86
|
| Rate for Payer: UMR Bronson Commercial |
$64.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.55
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.88 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna American Axle |
$145.60
|
| Rate for Payer: Aetna Commercial |
$190.40
|
| Rate for Payer: Aetna Medicare |
$112.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.60
|
| Rate for Payer: BCBS Complete |
$89.60
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cofinity Commercial |
$156.80
|
| Rate for Payer: Cofinity Commercial |
$192.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.20
|
| Rate for Payer: Healthscope Commercial |
$201.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.40
|
| Rate for Payer: PHP Commercial |
$190.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.60
|
| Rate for Payer: Priority Health SBD |
$141.12
|
| Rate for Payer: UMR Bronson Commercial |
$82.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.00
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$147.40
|
|
|
Service Code
|
NDC 00904722461
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.54 |
| Max. Negotiated Rate |
$132.66 |
| Rate for Payer: Aetna American Axle |
$95.81
|
| Rate for Payer: Aetna Commercial |
$125.29
|
| Rate for Payer: Aetna Medicare |
$73.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.81
|
| Rate for Payer: BCBS Complete |
$58.96
|
| Rate for Payer: Cash Price |
$117.92
|
| Rate for Payer: Cofinity Commercial |
$103.18
|
| Rate for Payer: Cofinity Commercial |
$126.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.92
|
| Rate for Payer: Healthscope Commercial |
$132.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.29
|
| Rate for Payer: PHP Commercial |
$125.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.81
|
| Rate for Payer: Priority Health SBD |
$92.86
|
| Rate for Payer: UMR Bronson Commercial |
$54.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.55
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$284.49
|
|
|
Service Code
|
NDC 63323148110
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.18 |
| Max. Negotiated Rate |
$256.04 |
| Rate for Payer: Aetna American Axle |
$184.92
|
| Rate for Payer: Aetna Commercial |
$241.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.92
|
| Rate for Payer: Cash Price |
$227.59
|
| Rate for Payer: Cofinity Commercial |
$199.14
|
| Rate for Payer: Cofinity Commercial |
$244.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.59
|
| Rate for Payer: Healthscope Commercial |
$256.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.82
|
| Rate for Payer: PHP Commercial |
$241.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.92
|
| Rate for Payer: Priority Health SBD |
$179.23
|
| Rate for Payer: UMR Bronson Commercial |
$125.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.37
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 39822110001
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.84 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna American Axle |
$134.20
|
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health SBD |
$130.07
|
| Rate for Payer: UMR Bronson Commercial |
$90.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$17.07
|
|
|
Service Code
|
NDC 63323018411
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna American Axle |
$11.10
|
| Rate for Payer: Aetna American Axle |
$18.49
|
| Rate for Payer: Aetna American Axle |
$3.70
|
| Rate for Payer: Aetna American Axle |
$7.40
|
| Rate for Payer: Aetna American Axle |
$14.79
|
| Rate for Payer: Aetna Commercial |
$9.67
|
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Commercial |
$19.35
|
| Rate for Payer: Aetna Commercial |
$24.18
|
| Rate for Payer: Aetna Commercial |
$14.51
|
| Rate for Payer: Aetna Medicare |
$14.22
|
| Rate for Payer: Aetna Medicare |
$8.54
|
| Rate for Payer: Aetna Medicare |
$2.84
|
| Rate for Payer: Aetna Medicare |
$11.38
|
| Rate for Payer: Aetna Medicare |
$5.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.49
|
| Rate for Payer: BCBS Complete |
$2.28
|
| Rate for Payer: BCBS Complete |
$4.55
|
| Rate for Payer: BCBS Complete |
$11.38
|
| Rate for Payer: BCBS Complete |
$9.10
|
| Rate for Payer: BCBS Complete |
$6.83
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cash Price |
$9.10
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cash Price |
$22.76
|
| Rate for Payer: Cash Price |
$18.21
|
| Rate for Payer: Cofinity Commercial |
$3.98
|
| Rate for Payer: Cofinity Commercial |
$14.68
|
| Rate for Payer: Cofinity Commercial |
$24.47
|
| Rate for Payer: Cofinity Commercial |
$7.97
|
| Rate for Payer: Cofinity Commercial |
$19.57
|
| Rate for Payer: Cofinity Commercial |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$19.92
|
| Rate for Payer: Cofinity Commercial |
$9.79
|
| Rate for Payer: Cofinity Commercial |
$11.95
|
| Rate for Payer: Cofinity Commercial |
$4.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.21
|
| Rate for Payer: Healthscope Commercial |
$10.24
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: Healthscope Commercial |
$5.12
|
| Rate for Payer: Healthscope Commercial |
$25.60
|
| Rate for Payer: Healthscope Commercial |
$15.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: PHP Commercial |
$24.18
|
| Rate for Payer: PHP Commercial |
$19.35
|
| Rate for Payer: PHP Commercial |
$9.67
|
| Rate for Payer: PHP Commercial |
$14.51
|
| Rate for Payer: PHP Commercial |
$4.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.10
|
| Rate for Payer: Priority Health SBD |
$10.75
|
| Rate for Payer: Priority Health SBD |
$7.17
|
| Rate for Payer: Priority Health SBD |
$14.34
|
| Rate for Payer: Priority Health SBD |
$17.92
|
| Rate for Payer: Priority Health SBD |
$3.58
|
| Rate for Payer: UMR Bronson Commercial |
$2.11
|
| Rate for Payer: UMR Bronson Commercial |
$10.53
|
| Rate for Payer: UMR Bronson Commercial |
$6.32
|
| Rate for Payer: UMR Bronson Commercial |
$4.21
|
| Rate for Payer: UMR Bronson Commercial |
$8.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.07
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$158.59
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.68 |
| Max. Negotiated Rate |
$142.73 |
| Rate for Payer: Aetna American Axle |
$103.08
|
| Rate for Payer: Aetna Commercial |
$134.80
|
| Rate for Payer: Aetna Medicare |
$79.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.08
|
| Rate for Payer: BCBS Complete |
$63.44
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$111.01
|
| Rate for Payer: Cofinity Commercial |
$136.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.87
|
| Rate for Payer: Healthscope Commercial |
$142.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$118.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.80
|
| Rate for Payer: PHP Commercial |
$134.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: Priority Health SBD |
$99.91
|
| Rate for Payer: UMR Bronson Commercial |
$58.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$118.94
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$158.59
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.78 |
| Max. Negotiated Rate |
$142.73 |
| Rate for Payer: Aetna American Axle |
$103.08
|
| Rate for Payer: Aetna Commercial |
$134.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.08
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$111.01
|
| Rate for Payer: Cofinity Commercial |
$136.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.87
|
| Rate for Payer: Healthscope Commercial |
$142.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$118.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.80
|
| Rate for Payer: PHP Commercial |
$134.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: Priority Health SBD |
$99.91
|
| Rate for Payer: UMR Bronson Commercial |
$69.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$118.94
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$284.49
|
|
|
Service Code
|
NDC 63323148110
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.26 |
| Max. Negotiated Rate |
$256.04 |
| Rate for Payer: Aetna American Axle |
$184.92
|
| Rate for Payer: Aetna Commercial |
$241.82
|
| Rate for Payer: Aetna Medicare |
$142.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.92
|
| Rate for Payer: BCBS Complete |
$113.80
|
| Rate for Payer: Cash Price |
$227.59
|
| Rate for Payer: Cofinity Commercial |
$199.14
|
| Rate for Payer: Cofinity Commercial |
$244.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.59
|
| Rate for Payer: Healthscope Commercial |
$256.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.82
|
| Rate for Payer: PHP Commercial |
$241.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.92
|
| Rate for Payer: Priority Health SBD |
$179.23
|
| Rate for Payer: UMR Bronson Commercial |
$105.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.37
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 39822110001
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.39 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna American Axle |
$134.20
|
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health SBD |
$130.07
|
| Rate for Payer: UMR Bronson Commercial |
$76.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
FOLIC ACID-VIT B6-VIT B12 2.5 MG-25 MG-2 MG TABLET
|
Facility
|
OP
|
$285.56
|
|
|
Service Code
|
NDC 75834008090
|
| Hospital Charge Code |
38624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.66 |
| Max. Negotiated Rate |
$257.00 |
| Rate for Payer: Aetna American Axle |
$185.61
|
| Rate for Payer: Aetna Commercial |
$242.73
|
| Rate for Payer: Aetna Medicare |
$142.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.61
|
| Rate for Payer: BCBS Complete |
$114.22
|
| Rate for Payer: Cash Price |
$228.45
|
| Rate for Payer: Cofinity Commercial |
$199.89
|
| Rate for Payer: Cofinity Commercial |
$245.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.45
|
| Rate for Payer: Healthscope Commercial |
$257.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.73
|
| Rate for Payer: PHP Commercial |
$242.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.61
|
| Rate for Payer: Priority Health SBD |
$179.90
|
| Rate for Payer: UMR Bronson Commercial |
$105.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.17
|
|
|
FOLIC ACID-VIT B6-VIT B12 2.5 MG-25 MG-2 MG TABLET
|
Facility
|
IP
|
$307.59
|
|
|
Service Code
|
NDC 51991038490
|
| Hospital Charge Code |
38624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.34 |
| Max. Negotiated Rate |
$276.83 |
| Rate for Payer: Aetna American Axle |
$199.93
|
| Rate for Payer: Aetna Commercial |
$261.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.93
|
| Rate for Payer: Cash Price |
$246.07
|
| Rate for Payer: Cofinity Commercial |
$215.31
|
| Rate for Payer: Cofinity Commercial |
$264.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.07
|
| Rate for Payer: Healthscope Commercial |
$276.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.45
|
| Rate for Payer: PHP Commercial |
$261.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.93
|
| Rate for Payer: Priority Health SBD |
$193.78
|
| Rate for Payer: UMR Bronson Commercial |
$135.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.69
|
|
|
FOLIC ACID-VIT B6-VIT B12 2.5 MG-25 MG-2 MG TABLET
|
Facility
|
OP
|
$307.59
|
|
|
Service Code
|
NDC 51991038490
|
| Hospital Charge Code |
38624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.81 |
| Max. Negotiated Rate |
$276.83 |
| Rate for Payer: Aetna American Axle |
$199.93
|
| Rate for Payer: Aetna Commercial |
$261.45
|
| Rate for Payer: Aetna Medicare |
$153.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.93
|
| Rate for Payer: BCBS Complete |
$123.04
|
| Rate for Payer: Cash Price |
$246.07
|
| Rate for Payer: Cofinity Commercial |
$215.31
|
| Rate for Payer: Cofinity Commercial |
$264.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.07
|
| Rate for Payer: Healthscope Commercial |
$276.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.45
|
| Rate for Payer: PHP Commercial |
$261.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.93
|
| Rate for Payer: Priority Health SBD |
$193.78
|
| Rate for Payer: UMR Bronson Commercial |
$113.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.69
|
|
|
FOLIC ACID-VIT B6-VIT B12 2.5 MG-25 MG-2 MG TABLET
|
Facility
|
IP
|
$239.00
|
|
|
Service Code
|
NDC 69367022409
|
| Hospital Charge Code |
38624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.16 |
| Max. Negotiated Rate |
$215.10 |
| Rate for Payer: Aetna American Axle |
$155.35
|
| Rate for Payer: Aetna Commercial |
$203.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.35
|
| Rate for Payer: Cash Price |
$191.20
|
| Rate for Payer: Cofinity Commercial |
$167.30
|
| Rate for Payer: Cofinity Commercial |
$205.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.20
|
| Rate for Payer: Healthscope Commercial |
$215.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.15
|
| Rate for Payer: PHP Commercial |
$203.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.35
|
| Rate for Payer: Priority Health SBD |
$150.57
|
| Rate for Payer: UMR Bronson Commercial |
$105.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.25
|
|
|
FOLIC ACID-VIT B6-VIT B12 2.5 MG-25 MG-2 MG TABLET
|
Facility
|
OP
|
$239.00
|
|
|
Service Code
|
NDC 69367022409
|
| Hospital Charge Code |
38624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.43 |
| Max. Negotiated Rate |
$215.10 |
| Rate for Payer: Aetna American Axle |
$155.35
|
| Rate for Payer: Aetna Commercial |
$203.15
|
| Rate for Payer: Aetna Medicare |
$119.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.35
|
| Rate for Payer: BCBS Complete |
$95.60
|
| Rate for Payer: Cash Price |
$191.20
|
| Rate for Payer: Cofinity Commercial |
$167.30
|
| Rate for Payer: Cofinity Commercial |
$205.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.20
|
| Rate for Payer: Healthscope Commercial |
$215.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.15
|
| Rate for Payer: PHP Commercial |
$203.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.35
|
| Rate for Payer: Priority Health SBD |
$150.57
|
| Rate for Payer: UMR Bronson Commercial |
$88.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.25
|
|
