|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$23.97
|
|
|
Service Code
|
NDC 38396052163
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$21.57 |
| Rate for Payer: Aetna American Axle |
$15.58
|
| Rate for Payer: Aetna Commercial |
$20.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.58
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cofinity Commercial |
$16.78
|
| Rate for Payer: Cofinity Commercial |
$20.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Healthscope Commercial |
$21.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.37
|
| Rate for Payer: PHP Commercial |
$20.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.58
|
| Rate for Payer: Priority Health SBD |
$15.10
|
| Rate for Payer: UMR Bronson Commercial |
$10.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.98
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$24.21
|
|
|
Service Code
|
NDC 38396050208
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$21.79 |
| Rate for Payer: Aetna American Axle |
$15.74
|
| Rate for Payer: Aetna Commercial |
$20.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.74
|
| Rate for Payer: Cash Price |
$19.37
|
| Rate for Payer: Cofinity Commercial |
$16.95
|
| Rate for Payer: Cofinity Commercial |
$20.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.37
|
| Rate for Payer: Healthscope Commercial |
$21.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.58
|
| Rate for Payer: PHP Commercial |
$20.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.74
|
| Rate for Payer: Priority Health SBD |
$15.25
|
| Rate for Payer: UMR Bronson Commercial |
$10.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.16
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
OP
|
$3.13
|
|
|
Service Code
|
NDC 38396050763
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: BCBS Complete |
$1.25
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.66
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$42.54
|
|
|
Service Code
|
NDC 56151161011
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$38.29 |
| Rate for Payer: Aetna American Axle |
$27.65
|
| Rate for Payer: Aetna Commercial |
$36.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.65
|
| Rate for Payer: Cash Price |
$34.03
|
| Rate for Payer: Cofinity Commercial |
$29.78
|
| Rate for Payer: Cofinity Commercial |
$36.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.03
|
| Rate for Payer: Healthscope Commercial |
$38.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.16
|
| Rate for Payer: PHP Commercial |
$36.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.65
|
| Rate for Payer: Priority Health SBD |
$26.80
|
| Rate for Payer: UMR Bronson Commercial |
$18.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.90
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$5.60
|
|
|
Service Code
|
NDC 43900028300
|
| Hospital Charge Code |
170096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna American Axle |
$3.64
|
| Rate for Payer: Aetna Commercial |
$4.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.64
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cofinity Commercial |
$3.92
|
| Rate for Payer: Cofinity Commercial |
$4.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.48
|
| Rate for Payer: Healthscope Commercial |
$5.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.76
|
| Rate for Payer: PHP Commercial |
$4.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.64
|
| Rate for Payer: Priority Health SBD |
$3.53
|
| Rate for Payer: UMR Bronson Commercial |
$2.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.20
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$5.60
|
|
|
Service Code
|
NDC 43900028300
|
| Hospital Charge Code |
170096
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna American Axle |
$3.64
|
| Rate for Payer: Aetna Commercial |
$4.76
|
| Rate for Payer: Aetna Medicare |
$2.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.64
|
| Rate for Payer: BCBS Complete |
$2.24
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cofinity Commercial |
$3.92
|
| Rate for Payer: Cofinity Commercial |
$4.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.48
|
| Rate for Payer: Healthscope Commercial |
$5.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.76
|
| Rate for Payer: PHP Commercial |
$4.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.64
|
| Rate for Payer: Priority Health SBD |
$3.53
|
| Rate for Payer: UMR Bronson Commercial |
$2.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.20
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
OP
|
$190.35
|
|
|
Service Code
|
NDC 00093943301
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.43 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna Medicare |
$95.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: BCBS Complete |
$76.14
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: Priority Health SBD |
$119.92
|
| Rate for Payer: UMR Bronson Commercial |
$70.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$317.25
|
|
|
Service Code
|
NDC 43353065960
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.59 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna American Axle |
$206.21
|
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.21
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$222.08
|
| Rate for Payer: Cofinity Commercial |
$272.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$222.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$222.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: Priority Health SBD |
$199.87
|
| Rate for Payer: UMR Bronson Commercial |
$139.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.94
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 00093943301
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.75 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: Priority Health SBD |
$119.92
|
| Rate for Payer: UMR Bronson Commercial |
$83.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 65862002901
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.07 |
| Max. Negotiated Rate |
$315.14 |
| Rate for Payer: Aetna American Axle |
$227.60
|
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.60
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$245.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$315.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$245.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health SBD |
$220.59
|
| Rate for Payer: UMR Bronson Commercial |
$154.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.61
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
OP
|
$350.15
|
|
|
Service Code
|
NDC 65862002901
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.56 |
| Max. Negotiated Rate |
$315.14 |
| Rate for Payer: Aetna American Axle |
$227.60
|
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: Aetna Medicare |
$175.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.60
|
| Rate for Payer: BCBS Complete |
$140.06
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$245.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$315.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$245.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health SBD |
$220.59
|
| Rate for Payer: UMR Bronson Commercial |
$129.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.61
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
OP
|
$317.25
|
|
|
Service Code
|
NDC 43353065960
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.38 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna American Axle |
$206.21
|
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna Medicare |
$158.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.21
|
| Rate for Payer: BCBS Complete |
$126.90
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$222.08
|
| Rate for Payer: Cofinity Commercial |
$272.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$222.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$222.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: Priority Health SBD |
$199.87
|
| Rate for Payer: UMR Bronson Commercial |
$117.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.94
|
|
|
GLYBURIDE 5 MG TABLET
|
Facility
|
IP
|
$217.55
|
|
|
Service Code
|
NDC 65862003001
|
| Hospital Charge Code |
3489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.72 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna American Axle |
$141.41
|
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.41
|
| Rate for Payer: Priority Health SBD |
$137.06
|
| Rate for Payer: UMR Bronson Commercial |
$95.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.16
|
|
|
GLYBURIDE 5 MG TABLET
|
Facility
|
OP
|
$217.55
|
|
|
Service Code
|
NDC 65862003001
|
| Hospital Charge Code |
3489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.49 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna American Axle |
$141.41
|
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna Medicare |
$108.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: BCBS Complete |
$87.02
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.41
|
| Rate for Payer: Priority Health SBD |
$137.06
|
| Rate for Payer: UMR Bronson Commercial |
$80.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.16
|
|
|
GLYBURIDE MICRONIZED 3 MG TABLET
|
Facility
|
OP
|
$233.70
|
|
|
Service Code
|
NDC 00093803501
|
| Hospital Charge Code |
14778
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.47 |
| Max. Negotiated Rate |
$210.33 |
| Rate for Payer: Aetna American Axle |
$151.90
|
| Rate for Payer: Aetna Commercial |
$198.64
|
| Rate for Payer: Aetna Medicare |
$116.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.90
|
| Rate for Payer: BCBS Complete |
$93.48
|
| Rate for Payer: Cash Price |
$186.96
|
| Rate for Payer: Cofinity Commercial |
$163.59
|
| Rate for Payer: Cofinity Commercial |
$200.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$163.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.96
|
| Rate for Payer: Healthscope Commercial |
$210.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$163.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$198.64
|
| Rate for Payer: PHP Commercial |
$198.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.90
|
| Rate for Payer: Priority Health SBD |
$147.23
|
| Rate for Payer: UMR Bronson Commercial |
$86.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.28
|
|
|
GLYBURIDE MICRONIZED 3 MG TABLET
|
Facility
|
IP
|
$233.70
|
|
|
Service Code
|
NDC 00093803501
|
| Hospital Charge Code |
14778
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.83 |
| Max. Negotiated Rate |
$210.33 |
| Rate for Payer: Aetna American Axle |
$151.90
|
| Rate for Payer: Aetna Commercial |
$198.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.90
|
| Rate for Payer: Cash Price |
$186.96
|
| Rate for Payer: Cofinity Commercial |
$163.59
|
| Rate for Payer: Cofinity Commercial |
$200.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$163.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.96
|
| Rate for Payer: Healthscope Commercial |
$210.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$163.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$198.64
|
| Rate for Payer: PHP Commercial |
$198.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.90
|
| Rate for Payer: Priority Health SBD |
$147.23
|
| Rate for Payer: UMR Bronson Commercial |
$102.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.28
|
|
|
GLYBURIDE MICRONIZED 6 MG TABLET
|
Facility
|
OP
|
$336.05
|
|
|
Service Code
|
NDC 00093803601
|
| Hospital Charge Code |
22146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$302.44 |
| Rate for Payer: Aetna American Axle |
$218.43
|
| Rate for Payer: Aetna Commercial |
$285.64
|
| Rate for Payer: Aetna Medicare |
$168.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.43
|
| Rate for Payer: BCBS Complete |
$134.42
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Commercial |
$235.24
|
| Rate for Payer: Cofinity Commercial |
$289.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$302.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.43
|
| Rate for Payer: Priority Health SBD |
$211.71
|
| Rate for Payer: UMR Bronson Commercial |
$124.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.04
|
|
|
GLYBURIDE MICRONIZED 6 MG TABLET
|
Facility
|
IP
|
$336.05
|
|
|
Service Code
|
NDC 00093803601
|
| Hospital Charge Code |
22146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.86 |
| Max. Negotiated Rate |
$302.44 |
| Rate for Payer: Aetna American Axle |
$218.43
|
| Rate for Payer: Aetna Commercial |
$285.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.43
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Commercial |
$235.24
|
| Rate for Payer: Cofinity Commercial |
$289.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$302.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.43
|
| Rate for Payer: Priority Health SBD |
$211.71
|
| Rate for Payer: UMR Bronson Commercial |
$147.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.04
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION
|
Facility
|
OP
|
$44.61
|
|
|
Service Code
|
NDC 87701040072
|
| Hospital Charge Code |
116359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$40.15 |
| Rate for Payer: Aetna American Axle |
$29.00
|
| Rate for Payer: Aetna Commercial |
$37.92
|
| Rate for Payer: Aetna Medicare |
$22.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.00
|
| Rate for Payer: BCBS Complete |
$17.84
|
| Rate for Payer: Cash Price |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$31.23
|
| Rate for Payer: Cofinity Commercial |
$38.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.69
|
| Rate for Payer: Healthscope Commercial |
$40.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.92
|
| Rate for Payer: PHP Commercial |
$37.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.00
|
| Rate for Payer: Priority Health SBD |
$28.10
|
| Rate for Payer: UMR Bronson Commercial |
$16.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.46
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION
|
Facility
|
IP
|
$44.61
|
|
|
Service Code
|
NDC 87701040072
|
| Hospital Charge Code |
116359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.63 |
| Max. Negotiated Rate |
$40.15 |
| Rate for Payer: Aetna American Axle |
$29.00
|
| Rate for Payer: Aetna Commercial |
$37.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.00
|
| Rate for Payer: Cash Price |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$31.23
|
| Rate for Payer: Cofinity Commercial |
$38.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.69
|
| Rate for Payer: Healthscope Commercial |
$40.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.92
|
| Rate for Payer: PHP Commercial |
$37.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.00
|
| Rate for Payer: Priority Health SBD |
$28.10
|
| Rate for Payer: UMR Bronson Commercial |
$19.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.46
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION
|
Facility
|
IP
|
$244.07
|
|
|
Service Code
|
NDC 00395103116
|
| Hospital Charge Code |
116359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.39 |
| Max. Negotiated Rate |
$219.66 |
| Rate for Payer: Aetna American Axle |
$158.65
|
| Rate for Payer: Aetna Commercial |
$207.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.65
|
| Rate for Payer: Cash Price |
$195.26
|
| Rate for Payer: Cofinity Commercial |
$170.85
|
| Rate for Payer: Cofinity Commercial |
$209.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$170.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.26
|
| Rate for Payer: Healthscope Commercial |
$219.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.46
|
| Rate for Payer: PHP Commercial |
$207.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.65
|
| Rate for Payer: Priority Health SBD |
$153.76
|
| Rate for Payer: UMR Bronson Commercial |
$107.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.05
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION
|
Facility
|
OP
|
$244.07
|
|
|
Service Code
|
NDC 00395103116
|
| Hospital Charge Code |
116359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.31 |
| Max. Negotiated Rate |
$219.66 |
| Rate for Payer: Aetna American Axle |
$158.65
|
| Rate for Payer: Aetna Commercial |
$207.46
|
| Rate for Payer: Aetna Medicare |
$122.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.65
|
| Rate for Payer: BCBS Complete |
$97.63
|
| Rate for Payer: Cash Price |
$195.26
|
| Rate for Payer: Cofinity Commercial |
$170.85
|
| Rate for Payer: Cofinity Commercial |
$209.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$170.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.26
|
| Rate for Payer: Healthscope Commercial |
$219.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.46
|
| Rate for Payer: PHP Commercial |
$207.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.65
|
| Rate for Payer: Priority Health SBD |
$153.76
|
| Rate for Payer: UMR Bronson Commercial |
$90.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.05
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$41.74
|
|
|
Service Code
|
NDC 58980041012
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$37.57 |
| Rate for Payer: Aetna American Axle |
$27.13
|
| Rate for Payer: Aetna Commercial |
$35.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.13
|
| Rate for Payer: Cash Price |
$33.39
|
| Rate for Payer: Cofinity Commercial |
$29.22
|
| Rate for Payer: Cofinity Commercial |
$35.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.39
|
| Rate for Payer: Healthscope Commercial |
$37.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.48
|
| Rate for Payer: PHP Commercial |
$35.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.13
|
| Rate for Payer: Priority Health SBD |
$26.30
|
| Rate for Payer: UMR Bronson Commercial |
$18.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.30
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 09900001155
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna American Axle |
$1.64
|
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna Medicare |
$1.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: BCBS Complete |
$1.01
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
OP
|
$60.35
|
|
|
Service Code
|
NDC 00132007924
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.33 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Aetna American Axle |
$39.23
|
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Medicare |
$30.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.23
|
| Rate for Payer: BCBS Complete |
$24.14
|
| Rate for Payer: Cash Price |
$48.28
|
| Rate for Payer: Cofinity Commercial |
$42.24
|
| Rate for Payer: Cofinity Commercial |
$51.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.28
|
| Rate for Payer: Healthscope Commercial |
$54.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.30
|
| Rate for Payer: PHP Commercial |
$51.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.23
|
| Rate for Payer: Priority Health SBD |
$38.02
|
| Rate for Payer: UMR Bronson Commercial |
$22.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.26
|
|
