|
GIVOSIRAN 189 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$107,575.00
|
|
|
Service Code
|
HCPCS J0223
|
| Hospital Charge Code |
192158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47,333.00 |
| Max. Negotiated Rate |
$96,817.50 |
| Rate for Payer: Aetna American Axle |
$69,923.75
|
| Rate for Payer: Aetna Commercial |
$91,438.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69,923.75
|
| Rate for Payer: Cash Price |
$86,060.00
|
| Rate for Payer: Cofinity Commercial |
$75,302.50
|
| Rate for Payer: Cofinity Commercial |
$92,514.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$75,302.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86,060.00
|
| Rate for Payer: Healthscope Commercial |
$96,817.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75,302.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80,681.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91,438.75
|
| Rate for Payer: PHP Commercial |
$91,438.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69,923.75
|
| Rate for Payer: Priority Health SBD |
$67,772.25
|
| Rate for Payer: UMR Bronson Commercial |
$47,333.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80,681.25
|
|
|
GIVOSIRAN 189 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$107,575.00
|
|
|
Service Code
|
HCPCS J0223
|
| Hospital Charge Code |
192158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.89 |
| Max. Negotiated Rate |
$96,817.50 |
| Rate for Payer: Aetna American Axle |
$69,923.75
|
| Rate for Payer: Aetna Commercial |
$91,438.75
|
| Rate for Payer: Aetna Medicare |
$120.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69,923.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$144.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$144.34
|
| Rate for Payer: BCBS Complete |
$64.99
|
| Rate for Payer: BCBS MAPPO |
$115.47
|
| Rate for Payer: BCBS Trust/PPO |
$302.35
|
| Rate for Payer: BCN Commercial |
$302.35
|
| Rate for Payer: BCN Medicare Advantage |
$115.47
|
| Rate for Payer: Cash Price |
$86,060.00
|
| Rate for Payer: Cash Price |
$86,060.00
|
| Rate for Payer: Cofinity Commercial |
$92,514.50
|
| Rate for Payer: Cofinity Commercial |
$75,302.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$75,302.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86,060.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$115.47
|
| Rate for Payer: Healthscope Commercial |
$96,817.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75,302.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80,681.25
|
| Rate for Payer: Mclaren Medicaid |
$61.89
|
| Rate for Payer: Mclaren Medicare |
$115.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$121.24
|
| Rate for Payer: Meridian Medicaid |
$64.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$132.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91,438.75
|
| Rate for Payer: Nomi Health Commercial |
$346.41
|
| Rate for Payer: PACE Medicare |
$109.70
|
| Rate for Payer: PACE SWMI |
$115.47
|
| Rate for Payer: PHP Commercial |
$91,438.75
|
| Rate for Payer: PHP Medicare Advantage |
$115.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$61.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69,923.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$322.74
|
| Rate for Payer: Priority Health Medicare |
$115.47
|
| Rate for Payer: Priority Health Narrow Network |
$258.19
|
| Rate for Payer: Priority Health SBD |
$67,772.25
|
| Rate for Payer: Railroad Medicare Medicare |
$115.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$325.04
|
| Rate for Payer: UHC Dual Complete DSNP |
$115.47
|
| Rate for Payer: UHC Exchange |
$220.67
|
| Rate for Payer: UHC Medicare Advantage |
$115.47
|
| Rate for Payer: UHCCP Medicaid |
$61.89
|
| Rate for Payer: UMR Bronson Commercial |
$39,802.75
|
| Rate for Payer: VA VA |
$115.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80,681.25
|
|
|
GLASSIA (ALPHA-1-PROTEINASE INHIBITOR) 1 GRAM/50 ML(2 %) IV SOLN
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
HCPCS J0257
|
| Hospital Charge Code |
106274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$16.53 |
| Rate for Payer: Aetna American Axle |
$1.02
|
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna Medicare |
$5.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.89
|
| Rate for Payer: BCBS Complete |
$3.10
|
| Rate for Payer: BCBS MAPPO |
$5.51
|
| Rate for Payer: BCBS Trust/PPO |
$15.03
|
| Rate for Payer: BCN Commercial |
$15.03
|
| Rate for Payer: BCN Medicare Advantage |
$5.51
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.51
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.18
|
| Rate for Payer: Mclaren Medicaid |
$2.95
|
| Rate for Payer: Mclaren Medicare |
$5.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.79
|
| Rate for Payer: Meridian Medicaid |
$3.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.33
|
| Rate for Payer: Nomi Health Commercial |
$16.53
|
| Rate for Payer: PACE Medicare |
$5.23
|
| Rate for Payer: PACE SWMI |
$5.51
|
| Rate for Payer: PHP Commercial |
$1.33
|
| Rate for Payer: PHP Medicare Advantage |
$5.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.04
|
| Rate for Payer: Priority Health Medicare |
$5.51
|
| Rate for Payer: Priority Health Narrow Network |
$12.83
|
| Rate for Payer: Priority Health SBD |
$0.99
|
| Rate for Payer: Railroad Medicare Medicare |
$5.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.51
|
| Rate for Payer: UHC Exchange |
$10.53
|
| Rate for Payer: UHC Medicare Advantage |
$5.51
|
| Rate for Payer: UHCCP Medicaid |
$2.95
|
| Rate for Payer: UMR Bronson Commercial |
$0.58
|
| Rate for Payer: VA VA |
$5.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.18
|
|
|
GLASSIA (ALPHA-1-PROTEINASE INHIBITOR) 1 GRAM/50 ML(2 %) IV SOLN
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
HCPCS J0257
|
| Hospital Charge Code |
106274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna American Axle |
$1.02
|
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.02
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.33
|
| Rate for Payer: PHP Commercial |
$1.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: Priority Health SBD |
$0.99
|
| Rate for Payer: UMR Bronson Commercial |
$0.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.18
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
OP
|
$63.45
|
|
|
Service Code
|
NDC 55111032001
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna Medicare |
$31.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: BCBS Complete |
$25.38
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.42
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$23.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 16729000101
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 16729000101
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.17 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna Medicare |
$97.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$63.45
|
|
|
Service Code
|
NDC 55111032001
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.42
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$27.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.92 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna American Axle |
$271.70
|
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.70
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$359.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Healthscope Commercial |
$376.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: PHP Commercial |
$355.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health SBD |
$263.34
|
| Rate for Payer: UMR Bronson Commercial |
$183.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.50
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$4.18
|
|
|
Service Code
|
NDC 68084032611
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: Aetna American Axle |
$2.72
|
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Aetna Medicare |
$2.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.72
|
| Rate for Payer: BCBS Complete |
$1.67
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Healthscope Commercial |
$3.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: PHP Commercial |
$3.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.63
|
| Rate for Payer: UMR Bronson Commercial |
$1.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.14
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$4.18
|
|
|
Service Code
|
NDC 68084032611
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: Aetna American Axle |
$2.72
|
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.72
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Healthscope Commercial |
$3.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: PHP Commercial |
$3.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.63
|
| Rate for Payer: UMR Bronson Commercial |
$1.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.14
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.66 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna American Axle |
$271.70
|
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: Aetna Medicare |
$209.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.70
|
| Rate for Payer: BCBS Complete |
$167.20
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$359.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Healthscope Commercial |
$376.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: PHP Commercial |
$355.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health SBD |
$263.34
|
| Rate for Payer: UMR Bronson Commercial |
$154.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.50
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 68084032711
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.48
|
| Rate for Payer: Healthscope Commercial |
$2.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.02
|
| Rate for Payer: Priority Health SBD |
$1.95
|
| Rate for Payer: UMR Bronson Commercial |
$1.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.32
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$309.60
|
|
|
Service Code
|
NDC 68084032701
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.22 |
| Max. Negotiated Rate |
$278.64 |
| Rate for Payer: Aetna American Axle |
$201.24
|
| Rate for Payer: Aetna Commercial |
$263.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.24
|
| Rate for Payer: Cash Price |
$247.68
|
| Rate for Payer: Cofinity Commercial |
$216.72
|
| Rate for Payer: Cofinity Commercial |
$266.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.68
|
| Rate for Payer: Healthscope Commercial |
$278.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.16
|
| Rate for Payer: PHP Commercial |
$263.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.24
|
| Rate for Payer: Priority Health SBD |
$195.05
|
| Rate for Payer: UMR Bronson Commercial |
$136.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.20
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
OP
|
$309.60
|
|
|
Service Code
|
NDC 68084032701
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.55 |
| Max. Negotiated Rate |
$278.64 |
| Rate for Payer: Aetna American Axle |
$201.24
|
| Rate for Payer: Aetna Commercial |
$263.16
|
| Rate for Payer: Aetna Medicare |
$154.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.24
|
| Rate for Payer: BCBS Complete |
$123.84
|
| Rate for Payer: Cash Price |
$247.68
|
| Rate for Payer: Cofinity Commercial |
$216.72
|
| Rate for Payer: Cofinity Commercial |
$266.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.68
|
| Rate for Payer: Healthscope Commercial |
$278.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.16
|
| Rate for Payer: PHP Commercial |
$263.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.24
|
| Rate for Payer: Priority Health SBD |
$195.05
|
| Rate for Payer: UMR Bronson Commercial |
$114.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.20
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 68084032711
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: Aetna Medicare |
$1.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: BCBS Complete |
$1.24
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.48
|
| Rate for Payer: Healthscope Commercial |
$2.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.02
|
| Rate for Payer: Priority Health SBD |
$1.95
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.32
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 250 MG TABLET
|
Facility
|
IP
|
$277.44
|
|
|
Service Code
|
NDC 00093745501
|
| Hospital Charge Code |
34092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.07 |
| Max. Negotiated Rate |
$249.70 |
| Rate for Payer: Aetna American Axle |
$180.34
|
| Rate for Payer: Aetna Commercial |
$235.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.34
|
| Rate for Payer: Cash Price |
$221.95
|
| Rate for Payer: Cofinity Commercial |
$194.21
|
| Rate for Payer: Cofinity Commercial |
$238.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.95
|
| Rate for Payer: Healthscope Commercial |
$249.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.82
|
| Rate for Payer: PHP Commercial |
$235.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.34
|
| Rate for Payer: Priority Health SBD |
$174.79
|
| Rate for Payer: UMR Bronson Commercial |
$122.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.08
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 250 MG TABLET
|
Facility
|
OP
|
$277.44
|
|
|
Service Code
|
NDC 00093745501
|
| Hospital Charge Code |
34092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.65 |
| Max. Negotiated Rate |
$249.70 |
| Rate for Payer: Aetna American Axle |
$180.34
|
| Rate for Payer: Aetna Commercial |
$235.82
|
| Rate for Payer: Aetna Medicare |
$138.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.34
|
| Rate for Payer: BCBS Complete |
$110.98
|
| Rate for Payer: Cash Price |
$221.95
|
| Rate for Payer: Cofinity Commercial |
$194.21
|
| Rate for Payer: Cofinity Commercial |
$238.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.95
|
| Rate for Payer: Healthscope Commercial |
$249.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.82
|
| Rate for Payer: PHP Commercial |
$235.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.34
|
| Rate for Payer: Priority Health SBD |
$174.79
|
| Rate for Payer: UMR Bronson Commercial |
$102.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.08
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 250 MG TABLET
|
Facility
|
IP
|
$300.20
|
|
|
Service Code
|
NDC 23155011501
|
| Hospital Charge Code |
34092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.09 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna American Axle |
$195.13
|
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.13
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$210.14
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.13
|
| Rate for Payer: Priority Health SBD |
$189.13
|
| Rate for Payer: UMR Bronson Commercial |
$132.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 250 MG TABLET
|
Facility
|
OP
|
$300.20
|
|
|
Service Code
|
NDC 23155011501
|
| Hospital Charge Code |
34092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.07 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna American Axle |
$195.13
|
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: Aetna Medicare |
$150.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.13
|
| Rate for Payer: BCBS Complete |
$120.08
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$210.14
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.13
|
| Rate for Payer: Priority Health SBD |
$189.13
|
| Rate for Payer: UMR Bronson Commercial |
$111.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 500 MG TABLET
|
Facility
|
OP
|
$295.45
|
|
|
Service Code
|
NDC 23155011601
|
| Hospital Charge Code |
34093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.32 |
| Max. Negotiated Rate |
$265.90 |
| Rate for Payer: Aetna American Axle |
$192.04
|
| Rate for Payer: Aetna Commercial |
$251.13
|
| Rate for Payer: Aetna Medicare |
$147.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.04
|
| Rate for Payer: BCBS Complete |
$118.18
|
| Rate for Payer: Cash Price |
$236.36
|
| Rate for Payer: Cofinity Commercial |
$206.82
|
| Rate for Payer: Cofinity Commercial |
$254.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.36
|
| Rate for Payer: Healthscope Commercial |
$265.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$221.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$251.13
|
| Rate for Payer: PHP Commercial |
$251.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.04
|
| Rate for Payer: Priority Health SBD |
$186.13
|
| Rate for Payer: UMR Bronson Commercial |
$109.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$221.59
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 500 MG TABLET
|
Facility
|
OP
|
$331.20
|
|
|
Service Code
|
NDC 00093745601
|
| Hospital Charge Code |
34093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.54 |
| Max. Negotiated Rate |
$298.08 |
| Rate for Payer: Aetna American Axle |
$215.28
|
| Rate for Payer: Aetna Commercial |
$281.52
|
| Rate for Payer: Aetna Medicare |
$165.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.28
|
| Rate for Payer: BCBS Complete |
$132.48
|
| Rate for Payer: Cash Price |
$264.96
|
| Rate for Payer: Cofinity Commercial |
$231.84
|
| Rate for Payer: Cofinity Commercial |
$284.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.96
|
| Rate for Payer: Healthscope Commercial |
$298.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.52
|
| Rate for Payer: PHP Commercial |
$281.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.28
|
| Rate for Payer: Priority Health SBD |
$208.66
|
| Rate for Payer: UMR Bronson Commercial |
$122.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.40
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 500 MG TABLET
|
Facility
|
IP
|
$295.45
|
|
|
Service Code
|
NDC 23155011601
|
| Hospital Charge Code |
34093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$265.90 |
| Rate for Payer: Aetna American Axle |
$192.04
|
| Rate for Payer: Aetna Commercial |
$251.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.04
|
| Rate for Payer: Cash Price |
$236.36
|
| Rate for Payer: Cofinity Commercial |
$206.82
|
| Rate for Payer: Cofinity Commercial |
$254.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.36
|
| Rate for Payer: Healthscope Commercial |
$265.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$221.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$251.13
|
| Rate for Payer: PHP Commercial |
$251.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.04
|
| Rate for Payer: Priority Health SBD |
$186.13
|
| Rate for Payer: UMR Bronson Commercial |
$130.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$221.59
|
|
|
GLIPIZIDE 2.5 MG-METFORMIN 500 MG TABLET
|
Facility
|
IP
|
$331.20
|
|
|
Service Code
|
NDC 00093745601
|
| Hospital Charge Code |
34093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.73 |
| Max. Negotiated Rate |
$298.08 |
| Rate for Payer: Aetna American Axle |
$215.28
|
| Rate for Payer: Aetna Commercial |
$281.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.28
|
| Rate for Payer: Cash Price |
$264.96
|
| Rate for Payer: Cofinity Commercial |
$231.84
|
| Rate for Payer: Cofinity Commercial |
$284.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.96
|
| Rate for Payer: Healthscope Commercial |
$298.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.52
|
| Rate for Payer: PHP Commercial |
$281.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.28
|
| Rate for Payer: Priority Health SBD |
$208.66
|
| Rate for Payer: UMR Bronson Commercial |
$145.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.40
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
OP
|
$206.15
|
|
|
Service Code
|
NDC 51079081020
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.28 |
| Max. Negotiated Rate |
$185.54 |
| Rate for Payer: Aetna American Axle |
$134.00
|
| Rate for Payer: Aetna Commercial |
$175.23
|
| Rate for Payer: Aetna Medicare |
$103.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.00
|
| Rate for Payer: BCBS Complete |
$82.46
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$144.30
|
| Rate for Payer: Cofinity Commercial |
$177.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.92
|
| Rate for Payer: Healthscope Commercial |
$185.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.23
|
| Rate for Payer: PHP Commercial |
$175.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.00
|
| Rate for Payer: Priority Health SBD |
$129.87
|
| Rate for Payer: UMR Bronson Commercial |
$76.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.61
|
|
