|
ACETYLCYSTEINE 600 MG CAPSULE
|
Facility
|
IP
|
$176.25
|
|
|
Service Code
|
NDC 79854004097
|
| Hospital Charge Code |
116999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.55 |
| Max. Negotiated Rate |
$158.62 |
| Rate for Payer: Aetna American Axle |
$114.56
|
| Rate for Payer: Aetna Commercial |
$149.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.56
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$123.38
|
| Rate for Payer: Cofinity Commercial |
$151.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$158.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: PHP Commercial |
$149.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.56
|
| Rate for Payer: Priority Health SBD |
$111.04
|
| Rate for Payer: UMR Bronson Commercial |
$77.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.19
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE
|
Facility
|
IP
|
$249.57
|
|
|
Service Code
|
NDC 27434000211
|
| Hospital Charge Code |
116999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.81 |
| Max. Negotiated Rate |
$224.61 |
| Rate for Payer: Aetna American Axle |
$162.22
|
| Rate for Payer: Aetna Commercial |
$212.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.22
|
| Rate for Payer: Cash Price |
$199.66
|
| Rate for Payer: Cofinity Commercial |
$174.70
|
| Rate for Payer: Cofinity Commercial |
$214.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$174.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.66
|
| Rate for Payer: Healthscope Commercial |
$224.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.13
|
| Rate for Payer: PHP Commercial |
$212.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.22
|
| Rate for Payer: Priority Health SBD |
$157.23
|
| Rate for Payer: UMR Bronson Commercial |
$109.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.18
|
|
|
ACIDOPHILUS 25 MILLION CELL-PECTIN, CITRUS 100 MG TABLET
|
Facility
|
OP
|
$61.10
|
|
|
Service Code
|
NDC 80681002600
|
| Hospital Charge Code |
134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.61 |
| Max. Negotiated Rate |
$54.99 |
| Rate for Payer: Aetna American Axle |
$39.72
|
| Rate for Payer: Aetna Commercial |
$51.94
|
| Rate for Payer: Aetna Medicare |
$30.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.72
|
| Rate for Payer: BCBS Complete |
$24.44
|
| Rate for Payer: Cash Price |
$48.88
|
| Rate for Payer: Cofinity Commercial |
$42.77
|
| Rate for Payer: Cofinity Commercial |
$52.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.88
|
| Rate for Payer: Healthscope Commercial |
$54.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.94
|
| Rate for Payer: PHP Commercial |
$51.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.72
|
| Rate for Payer: Priority Health SBD |
$38.49
|
| Rate for Payer: UMR Bronson Commercial |
$22.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.82
|
|
|
ACIDOPHILUS 25 MILLION CELL-PECTIN, CITRUS 100 MG TABLET
|
Facility
|
IP
|
$61.10
|
|
|
Service Code
|
NDC 80681002600
|
| Hospital Charge Code |
134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$54.99 |
| Rate for Payer: Aetna American Axle |
$39.72
|
| Rate for Payer: Aetna Commercial |
$51.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.72
|
| Rate for Payer: Cash Price |
$48.88
|
| Rate for Payer: Cofinity Commercial |
$42.77
|
| Rate for Payer: Cofinity Commercial |
$52.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.88
|
| Rate for Payer: Healthscope Commercial |
$54.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.94
|
| Rate for Payer: PHP Commercial |
$51.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.72
|
| Rate for Payer: Priority Health SBD |
$38.49
|
| Rate for Payer: UMR Bronson Commercial |
$26.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.82
|
|
|
ACIDOPHILUS-SPOROGENES 35 MILLION-25 MILLION CELL TABLET
|
Facility
|
OP
|
$58.75
|
|
|
Service Code
|
NDC 00536718101
|
| Hospital Charge Code |
115719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.74 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna American Axle |
$38.19
|
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna Medicare |
$29.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: BCBS Complete |
$23.50
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
| Rate for Payer: UMR Bronson Commercial |
$21.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.06
|
|
|
ACIDOPHILUS-SPOROGENES 35 MILLION-25 MILLION CELL TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 00536718101
|
| Hospital Charge Code |
115719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.85 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna American Axle |
$38.19
|
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
| Rate for Payer: UMR Bronson Commercial |
$25.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.06
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$63.84
|
|
|
Service Code
|
NDC 00574052176
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.09 |
| Max. Negotiated Rate |
$57.46 |
| Rate for Payer: Aetna American Axle |
$41.50
|
| Rate for Payer: Aetna Commercial |
$54.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.50
|
| Rate for Payer: Cash Price |
$51.07
|
| Rate for Payer: Cofinity Commercial |
$44.69
|
| Rate for Payer: Cofinity Commercial |
$54.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.07
|
| Rate for Payer: Healthscope Commercial |
$57.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.26
|
| Rate for Payer: PHP Commercial |
$54.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.50
|
| Rate for Payer: Priority Health SBD |
$40.22
|
| Rate for Payer: UMR Bronson Commercial |
$28.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.88
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$97.44
|
|
|
Service Code
|
NDC 66689020108
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$87.70 |
| Rate for Payer: Aetna American Axle |
$63.34
|
| Rate for Payer: Aetna Commercial |
$82.82
|
| Rate for Payer: Aetna Medicare |
$48.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.34
|
| Rate for Payer: BCBS Complete |
$38.98
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cofinity Commercial |
$68.21
|
| Rate for Payer: Cofinity Commercial |
$83.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.95
|
| Rate for Payer: Healthscope Commercial |
$87.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.82
|
| Rate for Payer: PHP Commercial |
$82.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.34
|
| Rate for Payer: Priority Health SBD |
$61.39
|
| Rate for Payer: UMR Bronson Commercial |
$36.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.08
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$63.84
|
|
|
Service Code
|
NDC 00574052176
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.62 |
| Max. Negotiated Rate |
$57.46 |
| Rate for Payer: Aetna American Axle |
$41.50
|
| Rate for Payer: Aetna Commercial |
$54.26
|
| Rate for Payer: Aetna Medicare |
$31.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.50
|
| Rate for Payer: BCBS Complete |
$25.54
|
| Rate for Payer: Cash Price |
$51.07
|
| Rate for Payer: Cofinity Commercial |
$44.69
|
| Rate for Payer: Cofinity Commercial |
$54.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.07
|
| Rate for Payer: Healthscope Commercial |
$57.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.26
|
| Rate for Payer: PHP Commercial |
$54.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.50
|
| Rate for Payer: Priority Health SBD |
$40.22
|
| Rate for Payer: UMR Bronson Commercial |
$23.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.88
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$97.44
|
|
|
Service Code
|
NDC 66689020108
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.87 |
| Max. Negotiated Rate |
$87.70 |
| Rate for Payer: Aetna American Axle |
$63.34
|
| Rate for Payer: Aetna Commercial |
$82.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.34
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cofinity Commercial |
$68.21
|
| Rate for Payer: Cofinity Commercial |
$83.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.95
|
| Rate for Payer: Healthscope Commercial |
$87.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.82
|
| Rate for Payer: PHP Commercial |
$82.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.34
|
| Rate for Payer: Priority Health SBD |
$61.39
|
| Rate for Payer: UMR Bronson Commercial |
$42.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.08
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,367.21
|
|
|
Service Code
|
NDC 50383081016
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$601.57 |
| Max. Negotiated Rate |
$1,230.49 |
| Rate for Payer: Aetna American Axle |
$888.69
|
| Rate for Payer: Aetna Commercial |
$1,162.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$888.69
|
| Rate for Payer: Cash Price |
$1,093.77
|
| Rate for Payer: Cofinity Commercial |
$1,175.80
|
| Rate for Payer: Cofinity Commercial |
$957.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$957.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,093.77
|
| Rate for Payer: Healthscope Commercial |
$1,230.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$957.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,025.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,162.13
|
| Rate for Payer: PHP Commercial |
$1,162.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$888.69
|
| Rate for Payer: Priority Health SBD |
$861.34
|
| Rate for Payer: UMR Bronson Commercial |
$601.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,025.41
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,367.21
|
|
|
Service Code
|
NDC 50383081016
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$505.87 |
| Max. Negotiated Rate |
$1,230.49 |
| Rate for Payer: Aetna American Axle |
$888.69
|
| Rate for Payer: Aetna Commercial |
$1,162.13
|
| Rate for Payer: Aetna Medicare |
$683.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$888.69
|
| Rate for Payer: BCBS Complete |
$546.88
|
| Rate for Payer: Cash Price |
$1,093.77
|
| Rate for Payer: Cofinity Commercial |
$1,175.80
|
| Rate for Payer: Cofinity Commercial |
$957.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$957.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,093.77
|
| Rate for Payer: Healthscope Commercial |
$1,230.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$957.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,025.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,162.13
|
| Rate for Payer: PHP Commercial |
$1,162.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$888.69
|
| Rate for Payer: Priority Health SBD |
$861.34
|
| Rate for Payer: UMR Bronson Commercial |
$505.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,025.41
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,589.28
|
|
|
Service Code
|
NDC 00472008216
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$588.03 |
| Max. Negotiated Rate |
$1,430.35 |
| Rate for Payer: Aetna American Axle |
$1,033.03
|
| Rate for Payer: Aetna Commercial |
$1,350.89
|
| Rate for Payer: Aetna Medicare |
$794.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,033.03
|
| Rate for Payer: BCBS Complete |
$635.71
|
| Rate for Payer: Cash Price |
$1,271.42
|
| Rate for Payer: Cofinity Commercial |
$1,112.50
|
| Rate for Payer: Cofinity Commercial |
$1,366.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,112.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,271.42
|
| Rate for Payer: Healthscope Commercial |
$1,430.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,112.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,191.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,350.89
|
| Rate for Payer: PHP Commercial |
$1,350.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,033.03
|
| Rate for Payer: Priority Health SBD |
$1,001.25
|
| Rate for Payer: UMR Bronson Commercial |
$588.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,191.96
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,589.28
|
|
|
Service Code
|
NDC 00472008216
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$699.28 |
| Max. Negotiated Rate |
$1,430.35 |
| Rate for Payer: Aetna American Axle |
$1,033.03
|
| Rate for Payer: Aetna Commercial |
$1,350.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,033.03
|
| Rate for Payer: Cash Price |
$1,271.42
|
| Rate for Payer: Cofinity Commercial |
$1,112.50
|
| Rate for Payer: Cofinity Commercial |
$1,366.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,112.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,271.42
|
| Rate for Payer: Healthscope Commercial |
$1,430.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,112.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,191.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,350.89
|
| Rate for Payer: PHP Commercial |
$1,350.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,033.03
|
| Rate for Payer: Priority Health SBD |
$1,001.25
|
| Rate for Payer: UMR Bronson Commercial |
$699.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,191.96
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
OP
|
$239.70
|
|
|
Service Code
|
NDC 75834012401
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.69 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna Medicare |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| Rate for Payer: BCBS Complete |
$95.88
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.74
|
| Rate for Payer: PHP Commercial |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.80
|
| Rate for Payer: Priority Health SBD |
$151.01
|
| Rate for Payer: UMR Bronson Commercial |
$88.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$261.25
|
|
|
Service Code
|
NDC 68084010701
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.95 |
| Max. Negotiated Rate |
$235.12 |
| Rate for Payer: Aetna American Axle |
$169.81
|
| Rate for Payer: Aetna Commercial |
$222.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.81
|
| Rate for Payer: Cash Price |
$209.00
|
| Rate for Payer: Cofinity Commercial |
$182.88
|
| Rate for Payer: Cofinity Commercial |
$224.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.00
|
| Rate for Payer: Healthscope Commercial |
$235.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.06
|
| Rate for Payer: PHP Commercial |
$222.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.81
|
| Rate for Payer: Priority Health SBD |
$164.59
|
| Rate for Payer: UMR Bronson Commercial |
$114.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.94
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 72578000201
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.26 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna American Axle |
$146.64
|
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health SBD |
$142.13
|
| Rate for Payer: UMR Bronson Commercial |
$99.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.20
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
OP
|
$380.70
|
|
|
Service Code
|
NDC 69076014601
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.86 |
| Max. Negotiated Rate |
$342.63 |
| Rate for Payer: Aetna American Axle |
$247.46
|
| Rate for Payer: Aetna Commercial |
$323.60
|
| Rate for Payer: Aetna Medicare |
$190.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$247.46
|
| Rate for Payer: BCBS Complete |
$152.28
|
| Rate for Payer: Cash Price |
$304.56
|
| Rate for Payer: Cofinity Commercial |
$266.49
|
| Rate for Payer: Cofinity Commercial |
$327.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$266.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.56
|
| Rate for Payer: Healthscope Commercial |
$342.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$266.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$323.60
|
| Rate for Payer: PHP Commercial |
$323.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.46
|
| Rate for Payer: Priority Health SBD |
$239.84
|
| Rate for Payer: UMR Bronson Commercial |
$140.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.52
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$394.80
|
|
|
Service Code
|
NDC 60505004206
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.71 |
| Max. Negotiated Rate |
$355.32 |
| Rate for Payer: Aetna American Axle |
$256.62
|
| Rate for Payer: Aetna Commercial |
$335.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$256.62
|
| Rate for Payer: Cash Price |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$276.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$315.84
|
| Rate for Payer: Healthscope Commercial |
$355.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$276.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$335.58
|
| Rate for Payer: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.62
|
| Rate for Payer: Priority Health SBD |
$248.72
|
| Rate for Payer: UMR Bronson Commercial |
$173.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.10
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 75834012401
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.47 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.74
|
| Rate for Payer: PHP Commercial |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.80
|
| Rate for Payer: Priority Health SBD |
$151.01
|
| Rate for Payer: UMR Bronson Commercial |
$105.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 68084010711
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
OP
|
$394.80
|
|
|
Service Code
|
NDC 60505004206
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.08 |
| Max. Negotiated Rate |
$355.32 |
| Rate for Payer: Aetna American Axle |
$256.62
|
| Rate for Payer: Aetna Commercial |
$335.58
|
| Rate for Payer: Aetna Medicare |
$197.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$256.62
|
| Rate for Payer: BCBS Complete |
$157.92
|
| Rate for Payer: Cash Price |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$276.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$315.84
|
| Rate for Payer: Healthscope Commercial |
$355.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$276.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$335.58
|
| Rate for Payer: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.62
|
| Rate for Payer: Priority Health SBD |
$248.72
|
| Rate for Payer: UMR Bronson Commercial |
$146.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.10
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 72578000201
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.47 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna American Axle |
$146.64
|
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health SBD |
$142.13
|
| Rate for Payer: UMR Bronson Commercial |
$83.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.20
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$380.70
|
|
|
Service Code
|
NDC 69076014601
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.51 |
| Max. Negotiated Rate |
$342.63 |
| Rate for Payer: Aetna American Axle |
$247.46
|
| Rate for Payer: Aetna Commercial |
$323.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$247.46
|
| Rate for Payer: Cash Price |
$304.56
|
| Rate for Payer: Cofinity Commercial |
$266.49
|
| Rate for Payer: Cofinity Commercial |
$327.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$266.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.56
|
| Rate for Payer: Healthscope Commercial |
$342.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$266.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$323.60
|
| Rate for Payer: PHP Commercial |
$323.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.46
|
| Rate for Payer: Priority Health SBD |
$239.84
|
| Rate for Payer: UMR Bronson Commercial |
$167.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.52
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$392.45
|
|
|
Service Code
|
NDC 23155022901
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.68 |
| Max. Negotiated Rate |
$353.20 |
| Rate for Payer: Aetna American Axle |
$255.09
|
| Rate for Payer: Aetna Commercial |
$333.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.09
|
| Rate for Payer: Cash Price |
$313.96
|
| Rate for Payer: Cofinity Commercial |
$274.72
|
| Rate for Payer: Cofinity Commercial |
$337.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$274.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.96
|
| Rate for Payer: Healthscope Commercial |
$353.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$274.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$294.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$333.58
|
| Rate for Payer: PHP Commercial |
$333.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.09
|
| Rate for Payer: Priority Health SBD |
$247.24
|
| Rate for Payer: UMR Bronson Commercial |
$172.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$294.34
|
|
