|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$716.95
|
|
|
Service Code
|
NDC 55253-802-30
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.46 |
| Max. Negotiated Rate |
$645.26 |
| Rate for Payer: Aetna American Axle |
$466.02
|
| Rate for Payer: Aetna Commercial |
$609.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$466.02
|
| Rate for Payer: Cash Price |
$573.56
|
| Rate for Payer: Cofinity Commercial |
$501.86
|
| Rate for Payer: Cofinity Commercial |
$616.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$573.56
|
| Rate for Payer: Healthscope Commercial |
$645.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$501.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$537.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$609.41
|
| Rate for Payer: PHP Commercial |
$609.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$501.86
|
| Rate for Payer: Priority Health SBD |
$451.68
|
| Rate for Payer: UMR Bronson Commercial |
$315.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$537.71
|
|
|
MODAFINIL 200 MG TABLET
|
Facility
|
IP
|
$7,956.26
|
|
|
Service Code
|
NDC 63459-201-30
|
| Hospital Charge Code |
24703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,500.75 |
| Max. Negotiated Rate |
$7,160.63 |
| Rate for Payer: Aetna American Axle |
$5,171.57
|
| Rate for Payer: Aetna Commercial |
$6,762.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,171.57
|
| Rate for Payer: Cash Price |
$6,365.01
|
| Rate for Payer: Cofinity Commercial |
$5,569.38
|
| Rate for Payer: Cofinity Commercial |
$6,842.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,365.01
|
| Rate for Payer: Healthscope Commercial |
$7,160.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,569.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,967.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,762.82
|
| Rate for Payer: PHP Commercial |
$6,762.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,569.38
|
| Rate for Payer: Priority Health SBD |
$5,012.44
|
| Rate for Payer: UMR Bronson Commercial |
$3,500.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,967.20
|
|
|
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18,654.02
|
|
|
Service Code
|
HCPCS J9204
|
| Hospital Charge Code |
188111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.09 |
| Max. Negotiated Rate |
$16,788.62 |
| Rate for Payer: Aetna American Axle |
$12,125.11
|
| Rate for Payer: Aetna Commercial |
$15,855.92
|
| Rate for Payer: Aetna Medicare |
$243.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,125.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$292.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$292.71
|
| Rate for Payer: BCBS Complete |
$134.50
|
| Rate for Payer: BCBS MAPPO |
$234.16
|
| Rate for Payer: BCBS Trust/PPO |
$756.70
|
| Rate for Payer: BCN Medicare Advantage |
$234.16
|
| Rate for Payer: Cash Price |
$14,923.22
|
| Rate for Payer: Cash Price |
$14,923.22
|
| Rate for Payer: Cofinity Commercial |
$16,042.46
|
| Rate for Payer: Cofinity Commercial |
$13,057.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,923.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$234.16
|
| Rate for Payer: Healthscope Commercial |
$16,788.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,057.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,990.52
|
| Rate for Payer: Mclaren Medicaid |
$128.09
|
| Rate for Payer: Mclaren Medicare |
$234.16
|
| Rate for Payer: Meridian Medicaid |
$134.50
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$245.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15,855.92
|
| Rate for Payer: PACE Medicare |
$222.46
|
| Rate for Payer: PACE SWMI |
$234.16
|
| Rate for Payer: PHP Commercial |
$15,855.92
|
| Rate for Payer: PHP Medicare Advantage |
$234.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$128.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,057.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$667.67
|
| Rate for Payer: Priority Health Medicare |
$234.16
|
| Rate for Payer: Priority Health Narrow Network |
$534.14
|
| Rate for Payer: Priority Health SBD |
$11,752.03
|
| Rate for Payer: Railroad Medicare Medicare |
$234.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$234.16
|
| Rate for Payer: UHC Medicare Advantage |
$241.19
|
| Rate for Payer: UMR Bronson Commercial |
$6,901.99
|
| Rate for Payer: VA VA |
$234.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,990.52
|
|
|
MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18,654.02
|
|
|
Service Code
|
HCPCS J9204
|
| Hospital Charge Code |
188111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,207.77 |
| Max. Negotiated Rate |
$16,788.62 |
| Rate for Payer: Aetna American Axle |
$12,125.11
|
| Rate for Payer: Aetna Commercial |
$15,855.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,125.11
|
| Rate for Payer: Cash Price |
$14,923.22
|
| Rate for Payer: Cofinity Commercial |
$16,042.46
|
| Rate for Payer: Cofinity Commercial |
$13,057.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,923.22
|
| Rate for Payer: Healthscope Commercial |
$16,788.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,057.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,990.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15,855.92
|
| Rate for Payer: PHP Commercial |
$15,855.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,057.81
|
| Rate for Payer: Priority Health SBD |
$11,752.03
|
| Rate for Payer: UMR Bronson Commercial |
$8,207.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,990.52
|
|
|
MOLASSES
|
Facility
|
IP
|
$23.94
|
|
|
Service Code
|
NDC 0990-0000-75
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna American Axle |
$15.56
|
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.56
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.15
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.35
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.76
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.96
|
|
|
MOMETASONE 0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$56.97
|
|
|
Service Code
|
NDC 45802-257-35
|
| Hospital Charge Code |
10646
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$51.27 |
| Rate for Payer: Aetna American Axle |
$37.03
|
| Rate for Payer: Aetna Commercial |
$48.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.03
|
| Rate for Payer: Cash Price |
$45.58
|
| Rate for Payer: Cofinity Commercial |
$39.88
|
| Rate for Payer: Cofinity Commercial |
$48.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.58
|
| Rate for Payer: Healthscope Commercial |
$51.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.42
|
| Rate for Payer: PHP Commercial |
$48.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.88
|
| Rate for Payer: Priority Health SBD |
$35.89
|
| Rate for Payer: UMR Bronson Commercial |
$25.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.73
|
|
|
MOMETASONE 0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$56.97
|
|
|
Service Code
|
NDC 68462-192-17
|
| Hospital Charge Code |
10646
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$51.27 |
| Rate for Payer: Aetna American Axle |
$37.03
|
| Rate for Payer: Aetna Commercial |
$48.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.03
|
| Rate for Payer: Cash Price |
$45.58
|
| Rate for Payer: Cofinity Commercial |
$39.88
|
| Rate for Payer: Cofinity Commercial |
$48.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.58
|
| Rate for Payer: Healthscope Commercial |
$51.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.42
|
| Rate for Payer: PHP Commercial |
$48.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.88
|
| Rate for Payer: Priority Health SBD |
$35.89
|
| Rate for Payer: UMR Bronson Commercial |
$25.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.73
|
|
|
MOMETASONE 110 MCG/ACTUATION(30 DOSES) BREATH ACTIVATED POWDER INHALER
|
Facility
|
IP
|
$432.53
|
|
|
Service Code
|
NDC 0085-1461-02
|
| Hospital Charge Code |
91877
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.31 |
| Max. Negotiated Rate |
$389.28 |
| Rate for Payer: Aetna American Axle |
$281.14
|
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$281.14
|
| Rate for Payer: Cash Price |
$346.02
|
| Rate for Payer: Cofinity Commercial |
$302.77
|
| Rate for Payer: Cofinity Commercial |
$371.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$346.02
|
| Rate for Payer: Healthscope Commercial |
$389.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$302.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$324.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$367.65
|
| Rate for Payer: PHP Commercial |
$367.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.77
|
| Rate for Payer: Priority Health SBD |
$272.49
|
| Rate for Payer: UMR Bronson Commercial |
$190.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$324.40
|
|
|
MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
IP
|
$526.35
|
|
|
Service Code
|
NDC 0085-4610-01
|
| Hospital Charge Code |
105699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.59 |
| Max. Negotiated Rate |
$473.72 |
| Rate for Payer: Aetna American Axle |
$342.13
|
| Rate for Payer: Aetna Commercial |
$447.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$342.13
|
| Rate for Payer: Cash Price |
$421.08
|
| Rate for Payer: Cofinity Commercial |
$368.44
|
| Rate for Payer: Cofinity Commercial |
$452.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$421.08
|
| Rate for Payer: Healthscope Commercial |
$473.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$368.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$394.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$447.40
|
| Rate for Payer: PHP Commercial |
$447.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$368.44
|
| Rate for Payer: Priority Health SBD |
$331.60
|
| Rate for Payer: UMR Bronson Commercial |
$231.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$394.76
|
|
|
MONALISA TOUCH, SERIES, UP TO 3 VISITS
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 00561
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$1,260.00 |
| Rate for Payer: BCBS Complete |
$720.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,260.00
|
| Rate for Payer: UMR Bronson Commercial |
$828.00
|
|
|
MONALISA TOUCH, SINGLE TREATMENT FOLLOWING A SERIES
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 00562
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: BCBS Complete |
$240.00
|
| Rate for Payer: Cash Price |
$480.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$420.00
|
| Rate for Payer: UMR Bronson Commercial |
$276.00
|
|
|
MONOCHLOROACETIC ACID (BULK) 99 % POWDER
|
Facility
|
IP
|
$156.48
|
|
|
Service Code
|
NDC 9900-0009-63
|
| Hospital Charge Code |
119702
|
| Min. Negotiated Rate |
$68.85 |
| Max. Negotiated Rate |
$140.83 |
| Rate for Payer: Aetna American Axle |
$101.71
|
| Rate for Payer: Aetna Commercial |
$133.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.71
|
| Rate for Payer: Cash Price |
$125.18
|
| Rate for Payer: Cofinity Commercial |
$109.54
|
| Rate for Payer: Cofinity Commercial |
$134.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.18
|
| Rate for Payer: Healthscope Commercial |
$140.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.01
|
| Rate for Payer: PHP Commercial |
$133.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.54
|
| Rate for Payer: Priority Health SBD |
$98.58
|
| Rate for Payer: UMR Bronson Commercial |
$68.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.36
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 68084-875-11
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna American Axle |
$1.98
|
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.98
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1.92
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 68084-875-01
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.18 |
| Max. Negotiated Rate |
$274.46 |
| Rate for Payer: Aetna American Axle |
$198.22
|
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.22
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$213.46
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.21
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.46
|
| Rate for Payer: Priority Health SBD |
$192.12
|
| Rate for Payer: UMR Bronson Commercial |
$134.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$236.55
|
|
|
Service Code
|
NDC 0904-6808-61
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.08 |
| Max. Negotiated Rate |
$212.90 |
| Rate for Payer: Aetna American Axle |
$153.76
|
| Rate for Payer: Aetna Commercial |
$201.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.76
|
| Rate for Payer: Cash Price |
$189.24
|
| Rate for Payer: Cofinity Commercial |
$203.43
|
| Rate for Payer: Cofinity Commercial |
$165.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.24
|
| Rate for Payer: Healthscope Commercial |
$212.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.07
|
| Rate for Payer: PHP Commercial |
$201.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.58
|
| Rate for Payer: Priority Health SBD |
$149.03
|
| Rate for Payer: UMR Bronson Commercial |
$104.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.41
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$118.28
|
|
|
Service Code
|
NDC 0904-6808-06
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$106.45 |
| Rate for Payer: Aetna American Axle |
$76.88
|
| Rate for Payer: Aetna Commercial |
$100.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.88
|
| Rate for Payer: BCBS Complete |
$47.31
|
| Rate for Payer: Cash Price |
$94.62
|
| Rate for Payer: Cofinity Commercial |
$101.72
|
| Rate for Payer: Cofinity Commercial |
$82.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.62
|
| Rate for Payer: Healthscope Commercial |
$106.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.54
|
| Rate for Payer: PHP Commercial |
$100.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.80
|
| Rate for Payer: Priority Health SBD |
$74.52
|
| Rate for Payer: UMR Bronson Commercial |
$43.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.71
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$67.55
|
|
|
Service Code
|
NDC 29300-220-13
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.72 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Aetna American Axle |
$43.91
|
| Rate for Payer: Aetna Commercial |
$57.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.91
|
| Rate for Payer: Cash Price |
$54.04
|
| Rate for Payer: Cofinity Commercial |
$47.28
|
| Rate for Payer: Cofinity Commercial |
$58.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.04
|
| Rate for Payer: Healthscope Commercial |
$60.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.42
|
| Rate for Payer: PHP Commercial |
$57.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.28
|
| Rate for Payer: Priority Health SBD |
$42.56
|
| Rate for Payer: UMR Bronson Commercial |
$29.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.66
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
IP
|
$100.08
|
|
|
Service Code
|
NDC 0781-5554-31
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.04 |
| Max. Negotiated Rate |
$90.07 |
| Rate for Payer: Aetna American Axle |
$65.05
|
| Rate for Payer: Aetna Commercial |
$85.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.05
|
| Rate for Payer: Cash Price |
$80.06
|
| Rate for Payer: Cofinity Commercial |
$70.06
|
| Rate for Payer: Cofinity Commercial |
$86.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.06
|
| Rate for Payer: Healthscope Commercial |
$90.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.07
|
| Rate for Payer: PHP Commercial |
$85.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.06
|
| Rate for Payer: Priority Health SBD |
$63.05
|
| Rate for Payer: UMR Bronson Commercial |
$44.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.06
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$3.31
|
|
|
Service Code
|
NDC 50268-573-11
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna American Axle |
$2.15
|
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.15
|
| Rate for Payer: BCBS Complete |
$1.32
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.65
|
| Rate for Payer: Healthscope Commercial |
$2.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.81
|
| Rate for Payer: PHP Commercial |
$2.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.48
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
IP
|
$138.89
|
|
|
Service Code
|
NDC 69452-106-13
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.11 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna American Axle |
$90.28
|
| Rate for Payer: Aetna Commercial |
$118.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.28
|
| Rate for Payer: Cash Price |
$111.11
|
| Rate for Payer: Cofinity Commercial |
$119.45
|
| Rate for Payer: Cofinity Commercial |
$97.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.11
|
| Rate for Payer: Healthscope Commercial |
$125.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$118.06
|
| Rate for Payer: PHP Commercial |
$118.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.22
|
| Rate for Payer: Priority Health SBD |
$87.50
|
| Rate for Payer: UMR Bronson Commercial |
$61.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.17
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$165.12
|
|
|
Service Code
|
NDC 50268-573-15
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.09 |
| Max. Negotiated Rate |
$148.61 |
| Rate for Payer: Aetna American Axle |
$107.33
|
| Rate for Payer: Aetna Commercial |
$140.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.33
|
| Rate for Payer: BCBS Complete |
$66.05
|
| Rate for Payer: Cash Price |
$132.10
|
| Rate for Payer: Cofinity Commercial |
$115.58
|
| Rate for Payer: Cofinity Commercial |
$142.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.10
|
| Rate for Payer: Healthscope Commercial |
$148.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$140.35
|
| Rate for Payer: PHP Commercial |
$140.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.58
|
| Rate for Payer: Priority Health SBD |
$104.03
|
| Rate for Payer: UMR Bronson Commercial |
$61.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.84
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 33342-110-07
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.22 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna American Axle |
$54.99
|
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
| Rate for Payer: Priority Health SBD |
$53.30
|
| Rate for Payer: UMR Bronson Commercial |
$37.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$151.92
|
|
|
Service Code
|
NDC 27241-015-31
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.84 |
| Max. Negotiated Rate |
$136.73 |
| Rate for Payer: Aetna American Axle |
$98.75
|
| Rate for Payer: Aetna Commercial |
$129.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.75
|
| Rate for Payer: Cash Price |
$121.54
|
| Rate for Payer: Cofinity Commercial |
$106.34
|
| Rate for Payer: Cofinity Commercial |
$130.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.54
|
| Rate for Payer: Healthscope Commercial |
$136.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$113.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.13
|
| Rate for Payer: PHP Commercial |
$129.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.34
|
| Rate for Payer: Priority Health SBD |
$95.71
|
| Rate for Payer: UMR Bronson Commercial |
$66.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$113.94
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$784.66
|
|
|
Service Code
|
NDC 0006-3841-30
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$345.25 |
| Max. Negotiated Rate |
$706.19 |
| Rate for Payer: Aetna American Axle |
$510.03
|
| Rate for Payer: Aetna Commercial |
$666.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$510.03
|
| Rate for Payer: Cash Price |
$627.73
|
| Rate for Payer: Cofinity Commercial |
$549.26
|
| Rate for Payer: Cofinity Commercial |
$674.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$627.73
|
| Rate for Payer: Healthscope Commercial |
$706.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$549.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$588.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$666.96
|
| Rate for Payer: PHP Commercial |
$666.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$549.26
|
| Rate for Payer: Priority Health SBD |
$494.34
|
| Rate for Payer: UMR Bronson Commercial |
$345.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$588.50
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$15.68
|
|
|
Service Code
|
NDC 55111-763-07
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$14.11 |
| Rate for Payer: Aetna American Axle |
$10.19
|
| Rate for Payer: Aetna Commercial |
$13.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.19
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: Cofinity Commercial |
$10.98
|
| Rate for Payer: Cofinity Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.54
|
| Rate for Payer: Healthscope Commercial |
$14.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.33
|
| Rate for Payer: PHP Commercial |
$13.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.98
|
| Rate for Payer: Priority Health SBD |
$9.88
|
| Rate for Payer: UMR Bronson Commercial |
$6.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.76
|
|
