|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.63
|
|
|
Service Code
|
NDC 60505-7062-0
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$7.77 |
| Rate for Payer: Aetna American Axle |
$5.61
|
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.61
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$6.04
|
| Rate for Payer: Cofinity Commercial |
$7.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.90
|
| Rate for Payer: Healthscope Commercial |
$7.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.34
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.04
|
| Rate for Payer: Priority Health SBD |
$5.44
|
| Rate for Payer: UMR Bronson Commercial |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.47
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$107.93
|
|
|
Service Code
|
NDC 4898500150
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.49 |
| Max. Negotiated Rate |
$97.14 |
| Rate for Payer: Aetna American Axle |
$70.15
|
| Rate for Payer: Aetna Commercial |
$91.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.15
|
| Rate for Payer: Cash Price |
$86.34
|
| Rate for Payer: Cofinity Commercial |
$75.55
|
| Rate for Payer: Cofinity Commercial |
$92.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.34
|
| Rate for Payer: Healthscope Commercial |
$97.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.74
|
| Rate for Payer: PHP Commercial |
$91.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.55
|
| Rate for Payer: Priority Health SBD |
$68.00
|
| Rate for Payer: UMR Bronson Commercial |
$47.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.95
|
|
|
NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$120.70
|
|
|
Service Code
|
NDC 60505-7089-0
|
| Hospital Charge Code |
27862
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.11 |
| Max. Negotiated Rate |
$108.63 |
| Rate for Payer: Aetna American Axle |
$78.46
|
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.46
|
| Rate for Payer: Cash Price |
$96.56
|
| Rate for Payer: Cofinity Commercial |
$103.80
|
| Rate for Payer: Cofinity Commercial |
$84.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.56
|
| Rate for Payer: Healthscope Commercial |
$108.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.60
|
| Rate for Payer: PHP Commercial |
$102.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.49
|
| Rate for Payer: Priority Health SBD |
$76.04
|
| Rate for Payer: UMR Bronson Commercial |
$53.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.52
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$6.48
|
|
|
Service Code
|
NDC 0135-0194-08
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: Aetna American Axle |
$4.21
|
| Rate for Payer: Aetna Commercial |
$5.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.21
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cofinity Commercial |
$4.54
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.18
|
| Rate for Payer: Healthscope Commercial |
$5.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.51
|
| Rate for Payer: PHP Commercial |
$5.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.54
|
| Rate for Payer: Priority Health SBD |
$4.08
|
| Rate for Payer: UMR Bronson Commercial |
$2.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.86
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$284.70
|
|
|
Service Code
|
NDC 0135-0194-03
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.27 |
| Max. Negotiated Rate |
$256.23 |
| Rate for Payer: Aetna American Axle |
$185.06
|
| Rate for Payer: Aetna Commercial |
$242.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.06
|
| Rate for Payer: Cash Price |
$227.76
|
| Rate for Payer: Cofinity Commercial |
$199.29
|
| Rate for Payer: Cofinity Commercial |
$244.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.76
|
| Rate for Payer: Healthscope Commercial |
$256.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$242.00
|
| Rate for Payer: PHP Commercial |
$242.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.29
|
| Rate for Payer: Priority Health SBD |
$179.36
|
| Rate for Payer: UMR Bronson Commercial |
$125.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.52
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$92.14
|
|
|
Service Code
|
NDC 0536-5896-88
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.54 |
| Max. Negotiated Rate |
$82.93 |
| Rate for Payer: Aetna American Axle |
$59.89
|
| Rate for Payer: Aetna Commercial |
$78.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.89
|
| Rate for Payer: Cash Price |
$73.71
|
| Rate for Payer: Cofinity Commercial |
$64.50
|
| Rate for Payer: Cofinity Commercial |
$79.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.71
|
| Rate for Payer: Healthscope Commercial |
$82.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$64.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$78.32
|
| Rate for Payer: PHP Commercial |
$78.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.50
|
| Rate for Payer: Priority Health SBD |
$58.05
|
| Rate for Payer: UMR Bronson Commercial |
$40.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69.10
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$121.91
|
|
|
Service Code
|
NDC 4898500152
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.64 |
| Max. Negotiated Rate |
$109.72 |
| Rate for Payer: Aetna American Axle |
$79.24
|
| Rate for Payer: Aetna Commercial |
$103.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.24
|
| Rate for Payer: Cash Price |
$97.53
|
| Rate for Payer: Cofinity Commercial |
$104.84
|
| Rate for Payer: Cofinity Commercial |
$85.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.53
|
| Rate for Payer: Healthscope Commercial |
$109.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.62
|
| Rate for Payer: PHP Commercial |
$103.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.34
|
| Rate for Payer: Priority Health SBD |
$76.80
|
| Rate for Payer: UMR Bronson Commercial |
$53.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.43
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.86
|
|
|
Service Code
|
NDC 60505-7090-0
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.98 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Aetna American Axle |
$75.31
|
| Rate for Payer: Aetna Commercial |
$98.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.31
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cofinity Commercial |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$99.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.69
|
| Rate for Payer: Healthscope Commercial |
$104.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.48
|
| Rate for Payer: PHP Commercial |
$98.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.10
|
| Rate for Payer: Priority Health SBD |
$72.99
|
| Rate for Payer: UMR Bronson Commercial |
$50.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.90
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.28
|
|
|
Service Code
|
NDC 60505-7063-0
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna American Axle |
$5.38
|
| Rate for Payer: Aetna Commercial |
$7.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.38
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$5.80
|
| Rate for Payer: Cofinity Commercial |
$7.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$7.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.04
|
| Rate for Payer: PHP Commercial |
$7.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.80
|
| Rate for Payer: Priority Health SBD |
$5.22
|
| Rate for Payer: UMR Bronson Commercial |
$3.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.21
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$186.48
|
|
|
Service Code
|
NDC 0135-0194-02
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.05 |
| Max. Negotiated Rate |
$167.83 |
| Rate for Payer: Aetna American Axle |
$121.21
|
| Rate for Payer: Aetna Commercial |
$158.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.21
|
| Rate for Payer: Cash Price |
$149.18
|
| Rate for Payer: Cofinity Commercial |
$130.54
|
| Rate for Payer: Cofinity Commercial |
$160.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$149.18
|
| Rate for Payer: Healthscope Commercial |
$167.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$130.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$158.51
|
| Rate for Payer: PHP Commercial |
$158.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.54
|
| Rate for Payer: Priority Health SBD |
$117.48
|
| Rate for Payer: UMR Bronson Commercial |
$82.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.86
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$189.80
|
|
|
Service Code
|
NDC 766145020
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.51 |
| Max. Negotiated Rate |
$170.82 |
| Rate for Payer: Aetna American Axle |
$123.37
|
| Rate for Payer: Aetna Commercial |
$161.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.37
|
| Rate for Payer: Cash Price |
$151.84
|
| Rate for Payer: Cofinity Commercial |
$132.86
|
| Rate for Payer: Cofinity Commercial |
$163.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.84
|
| Rate for Payer: Healthscope Commercial |
$170.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.33
|
| Rate for Payer: PHP Commercial |
$161.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.86
|
| Rate for Payer: Priority Health SBD |
$119.57
|
| Rate for Payer: UMR Bronson Commercial |
$83.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.35
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$170.53
|
|
|
Service Code
|
NDC 766142020
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.03 |
| Max. Negotiated Rate |
$153.48 |
| Rate for Payer: Aetna American Axle |
$110.84
|
| Rate for Payer: Aetna Commercial |
$144.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.84
|
| Rate for Payer: Cash Price |
$136.42
|
| Rate for Payer: Cofinity Commercial |
$119.37
|
| Rate for Payer: Cofinity Commercial |
$146.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.42
|
| Rate for Payer: Healthscope Commercial |
$153.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$144.95
|
| Rate for Payer: PHP Commercial |
$144.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.37
|
| Rate for Payer: Priority Health SBD |
$107.43
|
| Rate for Payer: UMR Bronson Commercial |
$75.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.90
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$90.66
|
|
|
Service Code
|
NDC 0135-0194-05
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.89 |
| Max. Negotiated Rate |
$81.59 |
| Rate for Payer: Aetna American Axle |
$58.93
|
| Rate for Payer: Aetna Commercial |
$77.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.93
|
| Rate for Payer: Cash Price |
$72.53
|
| Rate for Payer: Cofinity Commercial |
$63.46
|
| Rate for Payer: Cofinity Commercial |
$77.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.53
|
| Rate for Payer: Healthscope Commercial |
$81.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.06
|
| Rate for Payer: PHP Commercial |
$77.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.46
|
| Rate for Payer: Priority Health SBD |
$57.12
|
| Rate for Payer: UMR Bronson Commercial |
$39.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.00
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$106.99
|
|
|
Service Code
|
NDC 0536-5894-88
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$96.29 |
| Rate for Payer: Aetna American Axle |
$69.54
|
| Rate for Payer: Aetna Commercial |
$90.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.54
|
| Rate for Payer: Cash Price |
$85.59
|
| Rate for Payer: Cofinity Commercial |
$74.89
|
| Rate for Payer: Cofinity Commercial |
$92.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.59
|
| Rate for Payer: Healthscope Commercial |
$96.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.94
|
| Rate for Payer: PHP Commercial |
$90.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.89
|
| Rate for Payer: Priority Health SBD |
$67.40
|
| Rate for Payer: UMR Bronson Commercial |
$47.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.24
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.28
|
|
|
Service Code
|
NDC 60505-7061-0
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna American Axle |
$5.38
|
| Rate for Payer: Aetna Commercial |
$7.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.38
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$5.80
|
| Rate for Payer: Cofinity Commercial |
$7.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$7.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.04
|
| Rate for Payer: PHP Commercial |
$7.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.80
|
| Rate for Payer: Priority Health SBD |
$5.22
|
| Rate for Payer: UMR Bronson Commercial |
$3.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.21
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.86
|
|
|
Service Code
|
NDC 60505-7088-0
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.98 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Aetna American Axle |
$75.31
|
| Rate for Payer: Aetna Commercial |
$98.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.31
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cofinity Commercial |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$99.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.69
|
| Rate for Payer: Healthscope Commercial |
$104.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.48
|
| Rate for Payer: PHP Commercial |
$98.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.10
|
| Rate for Payer: Priority Health SBD |
$72.99
|
| Rate for Payer: UMR Bronson Commercial |
$50.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.90
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$112.50
|
|
|
Service Code
|
NDC 0536-1106-88
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$101.25 |
| Rate for Payer: Aetna American Axle |
$73.12
|
| Rate for Payer: Aetna Commercial |
$95.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.12
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cofinity Commercial |
$78.75
|
| Rate for Payer: Cofinity Commercial |
$96.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.00
|
| Rate for Payer: Healthscope Commercial |
$101.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$95.62
|
| Rate for Payer: PHP Commercial |
$95.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.75
|
| Rate for Payer: Priority Health SBD |
$70.88
|
| Rate for Payer: UMR Bronson Commercial |
$49.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.38
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE
|
Facility
|
IP
|
$250.35
|
|
|
Service Code
|
NDC 45802-344-05
|
| Hospital Charge Code |
34769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.15 |
| Max. Negotiated Rate |
$225.32 |
| Rate for Payer: Aetna American Axle |
$162.73
|
| Rate for Payer: Aetna Commercial |
$212.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.73
|
| Rate for Payer: Cash Price |
$200.28
|
| Rate for Payer: Cofinity Commercial |
$175.24
|
| Rate for Payer: Cofinity Commercial |
$215.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.28
|
| Rate for Payer: Healthscope Commercial |
$225.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.80
|
| Rate for Payer: PHP Commercial |
$212.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.24
|
| Rate for Payer: Priority Health SBD |
$157.72
|
| Rate for Payer: UMR Bronson Commercial |
$110.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.76
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$267.02
|
|
|
Service Code
|
NDC 45802-089-02
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.49 |
| Max. Negotiated Rate |
$240.32 |
| Rate for Payer: Aetna American Axle |
$173.56
|
| Rate for Payer: Aetna Commercial |
$226.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.56
|
| Rate for Payer: Cash Price |
$213.62
|
| Rate for Payer: Cofinity Commercial |
$186.91
|
| Rate for Payer: Cofinity Commercial |
$229.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.62
|
| Rate for Payer: Healthscope Commercial |
$240.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$226.97
|
| Rate for Payer: PHP Commercial |
$226.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.91
|
| Rate for Payer: Priority Health SBD |
$168.22
|
| Rate for Payer: UMR Bronson Commercial |
$117.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.26
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$89.01
|
|
|
Service Code
|
NDC 45802-089-01
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$80.11 |
| Rate for Payer: Aetna American Axle |
$57.86
|
| Rate for Payer: Aetna Commercial |
$75.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.86
|
| Rate for Payer: Cash Price |
$71.21
|
| Rate for Payer: Cofinity Commercial |
$62.31
|
| Rate for Payer: Cofinity Commercial |
$76.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.21
|
| Rate for Payer: Healthscope Commercial |
$80.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.66
|
| Rate for Payer: PHP Commercial |
$75.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.31
|
| Rate for Payer: Priority Health SBD |
$56.08
|
| Rate for Payer: UMR Bronson Commercial |
$39.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.76
|
|
|
NICU DEXTROSE 10 % AND PROTEIN 3.5 % INFUSION 500 ML (IV PREMIX)
|
Facility
|
IP
|
$192.02
|
|
|
Service Code
|
NDC 9900-0011-81
|
| Hospital Charge Code |
300737
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.49 |
| Max. Negotiated Rate |
$172.82 |
| Rate for Payer: Aetna American Axle |
$124.81
|
| Rate for Payer: Aetna Commercial |
$163.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$124.81
|
| Rate for Payer: Cash Price |
$153.62
|
| Rate for Payer: Cofinity Commercial |
$134.41
|
| Rate for Payer: Cofinity Commercial |
$165.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.62
|
| Rate for Payer: Healthscope Commercial |
$172.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$163.22
|
| Rate for Payer: PHP Commercial |
$163.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.41
|
| Rate for Payer: Priority Health SBD |
$120.97
|
| Rate for Payer: UMR Bronson Commercial |
$84.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.02
|
|
|
NICU DEXTROSE 3.5 % AND PROTEIN 3.5 % INFUSION 250 ML
|
Facility
|
IP
|
$95.03
|
|
|
Service Code
|
NDC 9900-0019-69
|
| Hospital Charge Code |
301638
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$85.53 |
| Rate for Payer: Aetna American Axle |
$61.77
|
| Rate for Payer: Aetna Commercial |
$80.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.77
|
| Rate for Payer: Cash Price |
$76.02
|
| Rate for Payer: Cofinity Commercial |
$66.52
|
| Rate for Payer: Cofinity Commercial |
$81.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.02
|
| Rate for Payer: Healthscope Commercial |
$85.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$80.78
|
| Rate for Payer: PHP Commercial |
$80.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.52
|
| Rate for Payer: Priority Health SBD |
$59.87
|
| Rate for Payer: UMR Bronson Commercial |
$41.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.27
|
|
|
NICU DEXTROSE 5 % AND PROTEIN 3.5 % INFUSION 500 ML (IV PREMIX)
|
Facility
|
IP
|
$190.06
|
|
|
Service Code
|
NDC 9900-0011-82
|
| Hospital Charge Code |
300739
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.63 |
| Max. Negotiated Rate |
$171.05 |
| Rate for Payer: Aetna American Axle |
$123.54
|
| Rate for Payer: Aetna Commercial |
$161.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.54
|
| Rate for Payer: Cash Price |
$152.05
|
| Rate for Payer: Cofinity Commercial |
$133.04
|
| Rate for Payer: Cofinity Commercial |
$163.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.05
|
| Rate for Payer: Healthscope Commercial |
$171.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.55
|
| Rate for Payer: PHP Commercial |
$161.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.04
|
| Rate for Payer: Priority Health SBD |
$119.74
|
| Rate for Payer: UMR Bronson Commercial |
$83.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.54
|
|
|
NIFEDIPINE 10 MG CAPSULE
|
Facility
|
IP
|
$376.80
|
|
|
Service Code
|
NDC 0904-7229-61
|
| Hospital Charge Code |
5558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.79 |
| Max. Negotiated Rate |
$339.12 |
| Rate for Payer: Aetna American Axle |
$244.92
|
| Rate for Payer: Aetna Commercial |
$320.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.92
|
| Rate for Payer: Cash Price |
$301.44
|
| Rate for Payer: Cofinity Commercial |
$263.76
|
| Rate for Payer: Cofinity Commercial |
$324.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$301.44
|
| Rate for Payer: Healthscope Commercial |
$339.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$263.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$282.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$320.28
|
| Rate for Payer: PHP Commercial |
$320.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.76
|
| Rate for Payer: Priority Health SBD |
$237.38
|
| Rate for Payer: UMR Bronson Commercial |
$165.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$282.60
|
|
|
NIFEDIPINE 10 MG CAPSULE
|
Facility
|
IP
|
$272.65
|
|
|
Service Code
|
NDC 23155-194-01
|
| Hospital Charge Code |
5558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.97 |
| Max. Negotiated Rate |
$245.38 |
| Rate for Payer: Aetna American Axle |
$177.22
|
| Rate for Payer: Aetna Commercial |
$231.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.22
|
| Rate for Payer: Cash Price |
$218.12
|
| Rate for Payer: Cofinity Commercial |
$190.86
|
| Rate for Payer: Cofinity Commercial |
$234.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.12
|
| Rate for Payer: Healthscope Commercial |
$245.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$231.75
|
| Rate for Payer: PHP Commercial |
$231.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.86
|
| Rate for Payer: Priority Health SBD |
$171.77
|
| Rate for Payer: UMR Bronson Commercial |
$119.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.49
|
|
