|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$300.80
|
|
|
Service Code
|
NDC 62559-511-01
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.35 |
| Max. Negotiated Rate |
$270.72 |
| Rate for Payer: Aetna American Axle |
$195.52
|
| Rate for Payer: Aetna Commercial |
$255.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.52
|
| Rate for Payer: Cash Price |
$240.64
|
| Rate for Payer: Cofinity Commercial |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$258.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.64
|
| Rate for Payer: Healthscope Commercial |
$270.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.68
|
| Rate for Payer: PHP Commercial |
$255.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.56
|
| Rate for Payer: Priority Health SBD |
$189.50
|
| Rate for Payer: UMR Bronson Commercial |
$132.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,190.34
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.75 |
| Max. Negotiated Rate |
$1,071.31 |
| Rate for Payer: Aetna American Axle |
$773.72
|
| Rate for Payer: Aetna Commercial |
$1,011.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$773.72
|
| Rate for Payer: Cash Price |
$952.27
|
| Rate for Payer: Cofinity Commercial |
$1,023.69
|
| Rate for Payer: Cofinity Commercial |
$833.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$952.27
|
| Rate for Payer: Healthscope Commercial |
$1,071.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$833.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$892.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,011.79
|
| Rate for Payer: PHP Commercial |
$1,011.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$833.24
|
| Rate for Payer: Priority Health SBD |
$749.91
|
| Rate for Payer: UMR Bronson Commercial |
$523.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$892.76
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,190.34
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.75 |
| Max. Negotiated Rate |
$1,071.31 |
| Rate for Payer: Aetna American Axle |
$773.72
|
| Rate for Payer: Aetna Commercial |
$1,011.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$773.72
|
| Rate for Payer: Cash Price |
$952.27
|
| Rate for Payer: Cofinity Commercial |
$1,023.69
|
| Rate for Payer: Cofinity Commercial |
$833.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$952.27
|
| Rate for Payer: Healthscope Commercial |
$1,071.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$833.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$892.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,011.79
|
| Rate for Payer: PHP Commercial |
$1,011.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$833.24
|
| Rate for Payer: Priority Health SBD |
$749.91
|
| Rate for Payer: UMR Bronson Commercial |
$523.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$892.76
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 0517-0375-10
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$209.07 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.62
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: UMR Bronson Commercial |
$209.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,190.34
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.75 |
| Max. Negotiated Rate |
$1,071.31 |
| Rate for Payer: Aetna American Axle |
$773.72
|
| Rate for Payer: Aetna Commercial |
$1,011.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$773.72
|
| Rate for Payer: Cash Price |
$952.27
|
| Rate for Payer: Cofinity Commercial |
$1,023.69
|
| Rate for Payer: Cofinity Commercial |
$833.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$952.27
|
| Rate for Payer: Healthscope Commercial |
$1,071.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$833.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$892.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,011.79
|
| Rate for Payer: PHP Commercial |
$1,011.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$833.24
|
| Rate for Payer: Priority Health SBD |
$749.91
|
| Rate for Payer: UMR Bronson Commercial |
$523.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$892.76
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,190.34
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.75 |
| Max. Negotiated Rate |
$1,071.31 |
| Rate for Payer: Aetna American Axle |
$773.72
|
| Rate for Payer: Aetna Commercial |
$1,011.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$773.72
|
| Rate for Payer: Cash Price |
$952.27
|
| Rate for Payer: Cofinity Commercial |
$833.24
|
| Rate for Payer: Cofinity Commercial |
$1,023.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$952.27
|
| Rate for Payer: Healthscope Commercial |
$1,071.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$833.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$892.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,011.79
|
| Rate for Payer: PHP Commercial |
$1,011.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$833.24
|
| Rate for Payer: Priority Health SBD |
$749.91
|
| Rate for Payer: UMR Bronson Commercial |
$523.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$892.76
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.95
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.95
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$403.05
|
|
|
Service Code
|
NDC 70100-424-02
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.34 |
| Max. Negotiated Rate |
$362.74 |
| Rate for Payer: Aetna American Axle |
$261.98
|
| Rate for Payer: Aetna Commercial |
$342.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.98
|
| Rate for Payer: Cash Price |
$322.44
|
| Rate for Payer: Cofinity Commercial |
$282.14
|
| Rate for Payer: Cofinity Commercial |
$346.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.44
|
| Rate for Payer: Healthscope Commercial |
$362.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$302.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$342.59
|
| Rate for Payer: PHP Commercial |
$342.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.14
|
| Rate for Payer: Priority Health SBD |
$253.92
|
| Rate for Payer: UMR Bronson Commercial |
$177.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$302.29
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$403.05
|
|
|
Service Code
|
NDC 70100-424-01
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.34 |
| Max. Negotiated Rate |
$362.74 |
| Rate for Payer: Aetna American Axle |
$261.98
|
| Rate for Payer: Aetna Commercial |
$342.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.98
|
| Rate for Payer: Cash Price |
$322.44
|
| Rate for Payer: Cofinity Commercial |
$282.14
|
| Rate for Payer: Cofinity Commercial |
$346.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.44
|
| Rate for Payer: Healthscope Commercial |
$362.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$302.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$342.59
|
| Rate for Payer: PHP Commercial |
$342.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.14
|
| Rate for Payer: Priority Health SBD |
$253.92
|
| Rate for Payer: UMR Bronson Commercial |
$177.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$302.29
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238-424-06
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.25 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.67
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$102.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238-424-25
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.25 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.67
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$102.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$957.40
|
|
|
Service Code
|
NDC 63323-659-03
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$421.26 |
| Max. Negotiated Rate |
$861.66 |
| Rate for Payer: Aetna American Axle |
$622.31
|
| Rate for Payer: Aetna Commercial |
$813.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.31
|
| Rate for Payer: Cash Price |
$765.92
|
| Rate for Payer: Cofinity Commercial |
$670.18
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$765.92
|
| Rate for Payer: Healthscope Commercial |
$861.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$813.79
|
| Rate for Payer: PHP Commercial |
$813.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$670.18
|
| Rate for Payer: Priority Health SBD |
$603.16
|
| Rate for Payer: UMR Bronson Commercial |
$421.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.05
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$957.40
|
|
|
Service Code
|
NDC 63323-659-09
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$421.26 |
| Max. Negotiated Rate |
$861.66 |
| Rate for Payer: Aetna American Axle |
$622.31
|
| Rate for Payer: Aetna Commercial |
$813.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.31
|
| Rate for Payer: Cash Price |
$765.92
|
| Rate for Payer: Cofinity Commercial |
$670.18
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$765.92
|
| Rate for Payer: Healthscope Commercial |
$861.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$813.79
|
| Rate for Payer: PHP Commercial |
$813.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$670.18
|
| Rate for Payer: Priority Health SBD |
$603.16
|
| Rate for Payer: UMR Bronson Commercial |
$421.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.05
|
|
|
INDOMETHACIN 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$7,707.72
|
|
|
Service Code
|
NDC 69344-101-01
|
| Hospital Charge Code |
3900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,391.40 |
| Max. Negotiated Rate |
$6,936.95 |
| Rate for Payer: Aetna American Axle |
$5,010.02
|
| Rate for Payer: Aetna Commercial |
$6,551.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,010.02
|
| Rate for Payer: Cash Price |
$6,166.18
|
| Rate for Payer: Cofinity Commercial |
$5,395.40
|
| Rate for Payer: Cofinity Commercial |
$6,628.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,166.18
|
| Rate for Payer: Healthscope Commercial |
$6,936.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,395.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,780.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,551.56
|
| Rate for Payer: PHP Commercial |
$6,551.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,395.40
|
| Rate for Payer: Priority Health SBD |
$4,855.86
|
| Rate for Payer: UMR Bronson Commercial |
$3,391.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,780.79
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$117.33
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.63 |
| Max. Negotiated Rate |
$105.60 |
| Rate for Payer: Aetna American Axle |
$76.26
|
| Rate for Payer: Aetna Commercial |
$99.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.26
|
| Rate for Payer: Cash Price |
$93.86
|
| Rate for Payer: Cofinity Commercial |
$100.90
|
| Rate for Payer: Cofinity Commercial |
$82.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.86
|
| Rate for Payer: Healthscope Commercial |
$105.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.73
|
| Rate for Payer: PHP Commercial |
$99.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.13
|
| Rate for Payer: Priority Health SBD |
$73.92
|
| Rate for Payer: UMR Bronson Commercial |
$51.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.00
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna American Axle |
$1.53
|
| Rate for Payer: Aetna Commercial |
$2.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.53
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$1.64
|
| Rate for Payer: Cofinity Commercial |
$2.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.88
|
| Rate for Payer: Healthscope Commercial |
$2.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.00
|
| Rate for Payer: PHP Commercial |
$2.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.48
|
| Rate for Payer: UMR Bronson Commercial |
$1.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.76
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155-010-01
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.09 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna American Axle |
$273.42
|
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.42
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$294.46
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$357.55
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$294.46
|
| Rate for Payer: Priority Health SBD |
$265.01
|
| Rate for Payer: UMR Bronson Commercial |
$185.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$1,163.25
|
|
|
Service Code
|
NDC 68462-302-05
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$511.83 |
| Max. Negotiated Rate |
$1,046.92 |
| Rate for Payer: Aetna American Axle |
$756.11
|
| Rate for Payer: Aetna Commercial |
$988.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$756.11
|
| Rate for Payer: Cash Price |
$930.60
|
| Rate for Payer: Cofinity Commercial |
$1,000.40
|
| Rate for Payer: Cofinity Commercial |
$814.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$930.60
|
| Rate for Payer: Healthscope Commercial |
$1,046.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$814.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$872.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$988.76
|
| Rate for Payer: PHP Commercial |
$988.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$814.28
|
| Rate for Payer: Priority Health SBD |
$732.85
|
| Rate for Payer: UMR Bronson Commercial |
$511.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$872.44
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna American Axle |
$1.44
|
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$1.55
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
| Rate for Payer: PHP Commercial |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health SBD |
$1.39
|
| Rate for Payer: UMR Bronson Commercial |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.66
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$289.05
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.18 |
| Max. Negotiated Rate |
$260.14 |
| Rate for Payer: Aetna American Axle |
$187.88
|
| Rate for Payer: Aetna Commercial |
$245.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.88
|
| Rate for Payer: Cash Price |
$231.24
|
| Rate for Payer: Cofinity Commercial |
$202.34
|
| Rate for Payer: Cofinity Commercial |
$248.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.24
|
| Rate for Payer: Healthscope Commercial |
$260.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$245.69
|
| Rate for Payer: PHP Commercial |
$245.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.34
|
| Rate for Payer: Priority Health SBD |
$182.10
|
| Rate for Payer: UMR Bronson Commercial |
$127.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.79
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$110.20
|
|
|
Service Code
|
NDC 50268-431-15
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.49 |
| Max. Negotiated Rate |
$99.18 |
| Rate for Payer: Aetna American Axle |
$71.63
|
| Rate for Payer: Aetna Commercial |
$93.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.63
|
| Rate for Payer: Cash Price |
$88.16
|
| Rate for Payer: Cofinity Commercial |
$77.14
|
| Rate for Payer: Cofinity Commercial |
$94.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.16
|
| Rate for Payer: Healthscope Commercial |
$99.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.67
|
| Rate for Payer: PHP Commercial |
$93.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.14
|
| Rate for Payer: Priority Health SBD |
$69.43
|
| Rate for Payer: UMR Bronson Commercial |
$48.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.65
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$37,359.50
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16,438.18 |
| Max. Negotiated Rate |
$33,623.55 |
| Rate for Payer: Aetna American Axle |
$24,283.68
|
| Rate for Payer: Aetna Commercial |
$31,755.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24,283.68
|
| Rate for Payer: Cash Price |
$29,887.60
|
| Rate for Payer: Cofinity Commercial |
$26,151.65
|
| Rate for Payer: Cofinity Commercial |
$32,129.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29,887.60
|
| Rate for Payer: Healthscope Commercial |
$33,623.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26,151.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28,019.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31,755.58
|
| Rate for Payer: PHP Commercial |
$31,755.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26,151.65
|
| Rate for Payer: Priority Health SBD |
$23,536.48
|
| Rate for Payer: UMR Bronson Commercial |
$16,438.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28,019.62
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$21,919.17
|
|
|
Service Code
|
NDC 70710-1852-7
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9,644.43 |
| Max. Negotiated Rate |
$19,727.25 |
| Rate for Payer: Aetna American Axle |
$14,247.46
|
| Rate for Payer: Aetna Commercial |
$18,631.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14,247.46
|
| Rate for Payer: Cash Price |
$17,535.34
|
| Rate for Payer: Cofinity Commercial |
$15,343.42
|
| Rate for Payer: Cofinity Commercial |
$18,850.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17,535.34
|
| Rate for Payer: Healthscope Commercial |
$19,727.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15,343.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16,439.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18,631.29
|
| Rate for Payer: PHP Commercial |
$18,631.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,343.42
|
| Rate for Payer: Priority Health SBD |
$13,809.08
|
| Rate for Payer: UMR Bronson Commercial |
$9,644.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16,439.38
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$730.64
|
|
|
Service Code
|
NDC 70710-1852-6
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.48 |
| Max. Negotiated Rate |
$657.58 |
| Rate for Payer: Aetna American Axle |
$474.92
|
| Rate for Payer: Aetna Commercial |
$621.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$474.92
|
| Rate for Payer: Cash Price |
$584.51
|
| Rate for Payer: Cofinity Commercial |
$511.45
|
| Rate for Payer: Cofinity Commercial |
$628.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$584.51
|
| Rate for Payer: Healthscope Commercial |
$657.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$511.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$547.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$621.04
|
| Rate for Payer: PHP Commercial |
$621.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$511.45
|
| Rate for Payer: Priority Health SBD |
$460.30
|
| Rate for Payer: UMR Bronson Commercial |
$321.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$547.98
|
|
