|
GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$285.15
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
10100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.47 |
| Max. Negotiated Rate |
$256.63 |
| Rate for Payer: Aetna American Axle |
$185.35
|
| Rate for Payer: Aetna Commercial |
$242.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.35
|
| Rate for Payer: Cash Price |
$228.12
|
| Rate for Payer: Cofinity Commercial |
$199.60
|
| Rate for Payer: Cofinity Commercial |
$245.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.12
|
| Rate for Payer: Healthscope Commercial |
$256.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.38
|
| Rate for Payer: PHP Commercial |
$242.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.35
|
| Rate for Payer: Priority Health SBD |
$179.64
|
| Rate for Payer: UMR Bronson Commercial |
$125.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.86
|
|
|
GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$285.15
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
10100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.51 |
| Max. Negotiated Rate |
$256.63 |
| Rate for Payer: Aetna American Axle |
$185.35
|
| Rate for Payer: Aetna Commercial |
$242.38
|
| Rate for Payer: Aetna Medicare |
$142.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.35
|
| Rate for Payer: BCBS Complete |
$114.06
|
| Rate for Payer: Cash Price |
$228.12
|
| Rate for Payer: Cofinity Commercial |
$199.60
|
| Rate for Payer: Cofinity Commercial |
$245.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.12
|
| Rate for Payer: Healthscope Commercial |
$256.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.38
|
| Rate for Payer: PHP Commercial |
$242.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.35
|
| Rate for Payer: Priority Health SBD |
$179.64
|
| Rate for Payer: UMR Bronson Commercial |
$105.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.86
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.72 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna American Axle |
$410.59
|
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: Aetna Medicare |
$315.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$410.59
|
| Rate for Payer: BCBS Complete |
$252.67
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Commercial |
$442.18
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$442.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$442.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.59
|
| Rate for Payer: Priority Health SBD |
$397.96
|
| Rate for Payer: UMR Bronson Commercial |
$233.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.76
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$277.94 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna American Axle |
$410.59
|
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$410.59
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Commercial |
$442.18
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$442.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$442.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.59
|
| Rate for Payer: Priority Health SBD |
$397.96
|
| Rate for Payer: UMR Bronson Commercial |
$277.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.76
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$238.83
|
|
|
Service Code
|
NDC 70436000406
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.09 |
| Max. Negotiated Rate |
$214.95 |
| Rate for Payer: Aetna American Axle |
$155.24
|
| Rate for Payer: Aetna Commercial |
$203.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.24
|
| Rate for Payer: Cash Price |
$191.06
|
| Rate for Payer: Cofinity Commercial |
$167.18
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.06
|
| Rate for Payer: Healthscope Commercial |
$214.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.01
|
| Rate for Payer: PHP Commercial |
$203.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.24
|
| Rate for Payer: Priority Health SBD |
$150.46
|
| Rate for Payer: UMR Bronson Commercial |
$105.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.12
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$175.11
|
|
|
Service Code
|
NDC 57237004960
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.05 |
| Max. Negotiated Rate |
$157.60 |
| Rate for Payer: Aetna American Axle |
$113.82
|
| Rate for Payer: Aetna Commercial |
$148.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.82
|
| Rate for Payer: Cash Price |
$140.09
|
| Rate for Payer: Cofinity Commercial |
$122.58
|
| Rate for Payer: Cofinity Commercial |
$150.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$122.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.09
|
| Rate for Payer: Healthscope Commercial |
$157.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.84
|
| Rate for Payer: PHP Commercial |
$148.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.82
|
| Rate for Payer: Priority Health SBD |
$110.32
|
| Rate for Payer: UMR Bronson Commercial |
$77.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.33
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$238.83
|
|
|
Service Code
|
NDC 24979072204
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.09 |
| Max. Negotiated Rate |
$214.95 |
| Rate for Payer: Aetna American Axle |
$155.24
|
| Rate for Payer: Aetna Commercial |
$203.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.24
|
| Rate for Payer: Cash Price |
$191.06
|
| Rate for Payer: Cofinity Commercial |
$167.18
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.06
|
| Rate for Payer: Healthscope Commercial |
$214.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.01
|
| Rate for Payer: PHP Commercial |
$203.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.24
|
| Rate for Payer: Priority Health SBD |
$150.46
|
| Rate for Payer: UMR Bronson Commercial |
$105.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.12
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$175.11
|
|
|
Service Code
|
NDC 57237004960
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.79 |
| Max. Negotiated Rate |
$157.60 |
| Rate for Payer: Aetna American Axle |
$113.82
|
| Rate for Payer: Aetna Commercial |
$148.84
|
| Rate for Payer: Aetna Medicare |
$87.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.82
|
| Rate for Payer: BCBS Complete |
$70.04
|
| Rate for Payer: Cash Price |
$140.09
|
| Rate for Payer: Cofinity Commercial |
$122.58
|
| Rate for Payer: Cofinity Commercial |
$150.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$122.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.09
|
| Rate for Payer: Healthscope Commercial |
$157.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.84
|
| Rate for Payer: PHP Commercial |
$148.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.82
|
| Rate for Payer: Priority Health SBD |
$110.32
|
| Rate for Payer: UMR Bronson Commercial |
$64.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.33
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$238.83
|
|
|
Service Code
|
NDC 24979072204
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.37 |
| Max. Negotiated Rate |
$214.95 |
| Rate for Payer: Aetna American Axle |
$155.24
|
| Rate for Payer: Aetna Commercial |
$203.01
|
| Rate for Payer: Aetna Medicare |
$119.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.24
|
| Rate for Payer: BCBS Complete |
$95.53
|
| Rate for Payer: Cash Price |
$191.06
|
| Rate for Payer: Cofinity Commercial |
$167.18
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.06
|
| Rate for Payer: Healthscope Commercial |
$214.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.01
|
| Rate for Payer: PHP Commercial |
$203.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.24
|
| Rate for Payer: Priority Health SBD |
$150.46
|
| Rate for Payer: UMR Bronson Commercial |
$88.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.12
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$238.83
|
|
|
Service Code
|
NDC 70436000406
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.37 |
| Max. Negotiated Rate |
$214.95 |
| Rate for Payer: Aetna American Axle |
$155.24
|
| Rate for Payer: Aetna Commercial |
$203.01
|
| Rate for Payer: Aetna Medicare |
$119.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.24
|
| Rate for Payer: BCBS Complete |
$95.53
|
| Rate for Payer: Cash Price |
$191.06
|
| Rate for Payer: Cofinity Commercial |
$167.18
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.06
|
| Rate for Payer: Healthscope Commercial |
$214.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.01
|
| Rate for Payer: PHP Commercial |
$203.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.24
|
| Rate for Payer: Priority Health SBD |
$150.46
|
| Rate for Payer: UMR Bronson Commercial |
$88.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.12
|
|
|
GALANTAMINE ER 24 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$473.09
|
|
|
Service Code
|
NDC 00591349830
|
| Hospital Charge Code |
41140
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.04 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna American Axle |
$307.51
|
| Rate for Payer: Aetna Commercial |
$402.13
|
| Rate for Payer: Aetna Medicare |
$236.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.51
|
| Rate for Payer: BCBS Complete |
$189.24
|
| Rate for Payer: Cash Price |
$378.47
|
| Rate for Payer: Cofinity Commercial |
$331.16
|
| Rate for Payer: Cofinity Commercial |
$406.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$331.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.47
|
| Rate for Payer: Healthscope Commercial |
$425.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$354.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.13
|
| Rate for Payer: PHP Commercial |
$402.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.51
|
| Rate for Payer: Priority Health SBD |
$298.05
|
| Rate for Payer: UMR Bronson Commercial |
$175.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$354.82
|
|
|
GALANTAMINE ER 24 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$473.09
|
|
|
Service Code
|
NDC 00591349830
|
| Hospital Charge Code |
41140
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.16 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna American Axle |
$307.51
|
| Rate for Payer: Aetna Commercial |
$402.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.51
|
| Rate for Payer: Cash Price |
$378.47
|
| Rate for Payer: Cofinity Commercial |
$331.16
|
| Rate for Payer: Cofinity Commercial |
$406.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$331.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.47
|
| Rate for Payer: Healthscope Commercial |
$425.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$354.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.13
|
| Rate for Payer: PHP Commercial |
$402.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.51
|
| Rate for Payer: Priority Health SBD |
$298.05
|
| Rate for Payer: UMR Bronson Commercial |
$208.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$354.82
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$200.88
|
|
|
Service Code
|
NDC 65862074430
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.33 |
| Max. Negotiated Rate |
$180.79 |
| Rate for Payer: Aetna American Axle |
$130.57
|
| Rate for Payer: Aetna Commercial |
$170.75
|
| Rate for Payer: Aetna Medicare |
$100.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.57
|
| Rate for Payer: BCBS Complete |
$80.35
|
| Rate for Payer: Cash Price |
$160.70
|
| Rate for Payer: Cofinity Commercial |
$140.62
|
| Rate for Payer: Cofinity Commercial |
$172.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.70
|
| Rate for Payer: Healthscope Commercial |
$180.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.75
|
| Rate for Payer: PHP Commercial |
$170.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.57
|
| Rate for Payer: Priority Health SBD |
$126.55
|
| Rate for Payer: UMR Bronson Commercial |
$74.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.66
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$200.88
|
|
|
Service Code
|
NDC 65862074430
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.39 |
| Max. Negotiated Rate |
$180.79 |
| Rate for Payer: Aetna American Axle |
$130.57
|
| Rate for Payer: Aetna Commercial |
$170.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.57
|
| Rate for Payer: Cash Price |
$160.70
|
| Rate for Payer: Cofinity Commercial |
$140.62
|
| Rate for Payer: Cofinity Commercial |
$172.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.70
|
| Rate for Payer: Healthscope Commercial |
$180.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.75
|
| Rate for Payer: PHP Commercial |
$170.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.57
|
| Rate for Payer: Priority Health SBD |
$126.55
|
| Rate for Payer: UMR Bronson Commercial |
$88.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.66
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$476.08
|
|
|
Service Code
|
NDC 00591349630
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.15 |
| Max. Negotiated Rate |
$428.47 |
| Rate for Payer: Aetna American Axle |
$309.45
|
| Rate for Payer: Aetna Commercial |
$404.67
|
| Rate for Payer: Aetna Medicare |
$238.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$309.45
|
| Rate for Payer: BCBS Complete |
$190.43
|
| Rate for Payer: Cash Price |
$380.86
|
| Rate for Payer: Cofinity Commercial |
$333.26
|
| Rate for Payer: Cofinity Commercial |
$409.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$333.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.86
|
| Rate for Payer: Healthscope Commercial |
$428.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$333.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$357.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$404.67
|
| Rate for Payer: PHP Commercial |
$404.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$309.45
|
| Rate for Payer: Priority Health SBD |
$299.93
|
| Rate for Payer: UMR Bronson Commercial |
$176.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$357.06
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$528.14
|
|
|
Service Code
|
NDC 10147089103
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.41 |
| Max. Negotiated Rate |
$475.33 |
| Rate for Payer: Aetna American Axle |
$343.29
|
| Rate for Payer: Aetna Commercial |
$448.92
|
| Rate for Payer: Aetna Medicare |
$264.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$343.29
|
| Rate for Payer: BCBS Complete |
$211.26
|
| Rate for Payer: Cash Price |
$422.51
|
| Rate for Payer: Cofinity Commercial |
$369.70
|
| Rate for Payer: Cofinity Commercial |
$454.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$369.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$422.51
|
| Rate for Payer: Healthscope Commercial |
$475.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$369.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$396.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$448.92
|
| Rate for Payer: PHP Commercial |
$448.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$343.29
|
| Rate for Payer: Priority Health SBD |
$332.73
|
| Rate for Payer: UMR Bronson Commercial |
$195.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$396.11
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$130.04
|
|
|
Service Code
|
NDC 47335083583
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.22 |
| Max. Negotiated Rate |
$117.04 |
| Rate for Payer: Aetna American Axle |
$84.53
|
| Rate for Payer: Aetna Commercial |
$110.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.53
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cofinity Commercial |
$111.83
|
| Rate for Payer: Cofinity Commercial |
$91.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.03
|
| Rate for Payer: Healthscope Commercial |
$117.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.53
|
| Rate for Payer: PHP Commercial |
$110.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.53
|
| Rate for Payer: Priority Health SBD |
$81.93
|
| Rate for Payer: UMR Bronson Commercial |
$57.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.53
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$487.52
|
|
|
Service Code
|
NDC 00378810593
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.51 |
| Max. Negotiated Rate |
$438.77 |
| Rate for Payer: Aetna American Axle |
$316.89
|
| Rate for Payer: Aetna Commercial |
$414.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$316.89
|
| Rate for Payer: Cash Price |
$390.02
|
| Rate for Payer: Cofinity Commercial |
$341.26
|
| Rate for Payer: Cofinity Commercial |
$419.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$341.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.02
|
| Rate for Payer: Healthscope Commercial |
$438.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$341.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$365.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$414.39
|
| Rate for Payer: PHP Commercial |
$414.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.89
|
| Rate for Payer: Priority Health SBD |
$307.14
|
| Rate for Payer: UMR Bronson Commercial |
$214.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$365.64
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$487.52
|
|
|
Service Code
|
NDC 00378810593
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.38 |
| Max. Negotiated Rate |
$438.77 |
| Rate for Payer: Aetna American Axle |
$316.89
|
| Rate for Payer: Aetna Commercial |
$414.39
|
| Rate for Payer: Aetna Medicare |
$243.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$316.89
|
| Rate for Payer: BCBS Complete |
$195.01
|
| Rate for Payer: Cash Price |
$390.02
|
| Rate for Payer: Cofinity Commercial |
$341.26
|
| Rate for Payer: Cofinity Commercial |
$419.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$341.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$390.02
|
| Rate for Payer: Healthscope Commercial |
$438.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$341.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$365.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$414.39
|
| Rate for Payer: PHP Commercial |
$414.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.89
|
| Rate for Payer: Priority Health SBD |
$307.14
|
| Rate for Payer: UMR Bronson Commercial |
$180.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$365.64
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$476.08
|
|
|
Service Code
|
NDC 00591349630
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.48 |
| Max. Negotiated Rate |
$428.47 |
| Rate for Payer: Aetna American Axle |
$309.45
|
| Rate for Payer: Aetna Commercial |
$404.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$309.45
|
| Rate for Payer: Cash Price |
$380.86
|
| Rate for Payer: Cofinity Commercial |
$333.26
|
| Rate for Payer: Cofinity Commercial |
$409.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$333.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.86
|
| Rate for Payer: Healthscope Commercial |
$428.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$333.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$357.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$404.67
|
| Rate for Payer: PHP Commercial |
$404.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$309.45
|
| Rate for Payer: Priority Health SBD |
$299.93
|
| Rate for Payer: UMR Bronson Commercial |
$209.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$357.06
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$528.14
|
|
|
Service Code
|
NDC 10147089103
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$475.33 |
| Rate for Payer: Aetna American Axle |
$343.29
|
| Rate for Payer: Aetna Commercial |
$448.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$343.29
|
| Rate for Payer: Cash Price |
$422.51
|
| Rate for Payer: Cofinity Commercial |
$369.70
|
| Rate for Payer: Cofinity Commercial |
$454.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$369.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$422.51
|
| Rate for Payer: Healthscope Commercial |
$475.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$369.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$396.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$448.92
|
| Rate for Payer: PHP Commercial |
$448.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$343.29
|
| Rate for Payer: Priority Health SBD |
$332.73
|
| Rate for Payer: UMR Bronson Commercial |
$232.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$396.11
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$130.04
|
|
|
Service Code
|
NDC 47335083583
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.11 |
| Max. Negotiated Rate |
$117.04 |
| Rate for Payer: Aetna American Axle |
$84.53
|
| Rate for Payer: Aetna Commercial |
$110.53
|
| Rate for Payer: Aetna Medicare |
$65.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.53
|
| Rate for Payer: BCBS Complete |
$52.02
|
| Rate for Payer: Cash Price |
$104.03
|
| Rate for Payer: Cofinity Commercial |
$111.83
|
| Rate for Payer: Cofinity Commercial |
$91.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.03
|
| Rate for Payer: Healthscope Commercial |
$117.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.53
|
| Rate for Payer: PHP Commercial |
$110.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.53
|
| Rate for Payer: Priority Health SBD |
$81.93
|
| Rate for Payer: UMR Bronson Commercial |
$48.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.53
|
|
|
GAMMAKED 10 GRAM/100 ML (10 %) INJECTION SOLUTION
|
Facility
|
IP
|
$3,921.16
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
153286
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,725.31 |
| Max. Negotiated Rate |
$3,529.04 |
| Rate for Payer: Aetna American Axle |
$2,548.75
|
| Rate for Payer: Aetna Commercial |
$3,332.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,548.75
|
| Rate for Payer: Cash Price |
$3,136.93
|
| Rate for Payer: Cofinity Commercial |
$2,744.81
|
| Rate for Payer: Cofinity Commercial |
$3,372.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,744.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,136.93
|
| Rate for Payer: Healthscope Commercial |
$3,529.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,744.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,940.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,332.99
|
| Rate for Payer: PHP Commercial |
$3,332.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,548.75
|
| Rate for Payer: Priority Health SBD |
$2,470.33
|
| Rate for Payer: UMR Bronson Commercial |
$1,725.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,940.87
|
|
|
GAMMAKED 10 GRAM/100 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$3,921.16
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
153286
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$3,529.04 |
| Rate for Payer: Aetna American Axle |
$2,548.75
|
| Rate for Payer: Aetna Commercial |
$3,332.99
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,548.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.20
|
| Rate for Payer: BCBS Complete |
$27.55
|
| Rate for Payer: BCBS MAPPO |
$48.96
|
| Rate for Payer: BCN Medicare Advantage |
$48.96
|
| Rate for Payer: Cash Price |
$3,136.93
|
| Rate for Payer: Cash Price |
$3,136.93
|
| Rate for Payer: Cofinity Commercial |
$3,372.20
|
| Rate for Payer: Cofinity Commercial |
$2,744.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,744.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,136.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.96
|
| Rate for Payer: Healthscope Commercial |
$3,529.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,744.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,940.87
|
| Rate for Payer: Mclaren Medicaid |
$26.24
|
| Rate for Payer: Mclaren Medicare |
$48.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.41
|
| Rate for Payer: Meridian Medicaid |
$27.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,332.99
|
| Rate for Payer: PACE Medicare |
$46.51
|
| Rate for Payer: PACE SWMI |
$48.96
|
| Rate for Payer: PHP Commercial |
$3,332.99
|
| Rate for Payer: PHP Medicare Advantage |
$48.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,548.75
|
| Rate for Payer: Priority Health Medicare |
$48.96
|
| Rate for Payer: Priority Health SBD |
$2,470.33
|
| Rate for Payer: Railroad Medicare Medicare |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.96
|
| Rate for Payer: UHC Exchange |
$93.57
|
| Rate for Payer: UHC Medicare Advantage |
$48.96
|
| Rate for Payer: UHCCP Medicaid |
$26.24
|
| Rate for Payer: UMR Bronson Commercial |
$1,450.83
|
| Rate for Payer: VA VA |
$48.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,940.87
|
|
|
GAMMAKED 20 GRAM/200 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$7,842.31
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
153287
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$7,058.08 |
| Rate for Payer: Aetna American Axle |
$5,097.50
|
| Rate for Payer: Aetna Commercial |
$6,665.96
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,097.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.20
|
| Rate for Payer: BCBS Complete |
$27.55
|
| Rate for Payer: BCBS MAPPO |
$48.96
|
| Rate for Payer: BCN Medicare Advantage |
$48.96
|
| Rate for Payer: Cash Price |
$6,273.85
|
| Rate for Payer: Cash Price |
$6,273.85
|
| Rate for Payer: Cofinity Commercial |
$5,489.62
|
| Rate for Payer: Cofinity Commercial |
$6,744.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,489.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,273.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.96
|
| Rate for Payer: Healthscope Commercial |
$7,058.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,489.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,881.73
|
| Rate for Payer: Mclaren Medicaid |
$26.24
|
| Rate for Payer: Mclaren Medicare |
$48.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.41
|
| Rate for Payer: Meridian Medicaid |
$27.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,665.96
|
| Rate for Payer: PACE Medicare |
$46.51
|
| Rate for Payer: PACE SWMI |
$48.96
|
| Rate for Payer: PHP Commercial |
$6,665.96
|
| Rate for Payer: PHP Medicare Advantage |
$48.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,097.50
|
| Rate for Payer: Priority Health Medicare |
$48.96
|
| Rate for Payer: Priority Health SBD |
$4,940.66
|
| Rate for Payer: Railroad Medicare Medicare |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.96
|
| Rate for Payer: UHC Exchange |
$93.57
|
| Rate for Payer: UHC Medicare Advantage |
$48.96
|
| Rate for Payer: UHCCP Medicaid |
$26.24
|
| Rate for Payer: UMR Bronson Commercial |
$2,901.65
|
| Rate for Payer: VA VA |
$48.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,881.73
|
|
