|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE
|
Facility
|
OP
|
$15,904.88
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
161514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.32 |
| Max. Negotiated Rate |
$14,314.39 |
| Rate for Payer: Aetna American Axle |
$10,338.17
|
| Rate for Payer: Aetna Commercial |
$13,519.15
|
| Rate for Payer: Aetna Medicare |
$219.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,338.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$263.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$263.54
|
| Rate for Payer: BCBS Complete |
$121.10
|
| Rate for Payer: BCBS MAPPO |
$210.83
|
| Rate for Payer: BCBS Trust/PPO |
$681.28
|
| Rate for Payer: BCN Medicare Advantage |
$210.83
|
| Rate for Payer: Cash Price |
$12,723.90
|
| Rate for Payer: Cash Price |
$12,723.90
|
| Rate for Payer: Cofinity Commercial |
$13,678.20
|
| Rate for Payer: Cofinity Commercial |
$11,133.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,723.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$210.83
|
| Rate for Payer: Healthscope Commercial |
$14,314.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11,133.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11,928.66
|
| Rate for Payer: Mclaren Medicaid |
$115.32
|
| Rate for Payer: Mclaren Medicare |
$210.83
|
| Rate for Payer: Meridian Medicaid |
$121.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$221.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$242.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13,519.15
|
| Rate for Payer: PACE Medicare |
$200.29
|
| Rate for Payer: PACE SWMI |
$210.83
|
| Rate for Payer: PHP Commercial |
$13,519.15
|
| Rate for Payer: PHP Medicare Advantage |
$210.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$115.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,133.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$608.39
|
| Rate for Payer: Priority Health Medicare |
$210.83
|
| Rate for Payer: Priority Health Narrow Network |
$486.71
|
| Rate for Payer: Priority Health SBD |
$10,020.07
|
| Rate for Payer: Railroad Medicare Medicare |
$210.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$210.83
|
| Rate for Payer: UHC Medicare Advantage |
$217.15
|
| Rate for Payer: UMR Bronson Commercial |
$5,884.81
|
| Rate for Payer: VA VA |
$210.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11,928.66
|
|
|
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,641.40
|
|
|
Service Code
|
HCPCS J9302
|
| Hospital Charge Code |
100265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,162.22 |
| Max. Negotiated Rate |
$2,377.26 |
| Rate for Payer: Aetna American Axle |
$1,716.91
|
| Rate for Payer: Aetna Commercial |
$2,245.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,716.91
|
| Rate for Payer: Cash Price |
$2,113.12
|
| Rate for Payer: Cofinity Commercial |
$1,848.98
|
| Rate for Payer: Cofinity Commercial |
$2,271.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,113.12
|
| Rate for Payer: Healthscope Commercial |
$2,377.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,848.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,981.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,245.19
|
| Rate for Payer: PHP Commercial |
$2,245.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,848.98
|
| Rate for Payer: Priority Health SBD |
$1,664.08
|
| Rate for Payer: UMR Bronson Commercial |
$1,162.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,981.05
|
|
|
OFATUMUMAB 100 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,641.40
|
|
|
Service Code
|
HCPCS J9302
|
| Hospital Charge Code |
100265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.98 |
| Max. Negotiated Rate |
$2,377.26 |
| Rate for Payer: Aetna American Axle |
$1,716.91
|
| Rate for Payer: Aetna Commercial |
$2,245.19
|
| Rate for Payer: Aetna Medicare |
$66.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,716.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$79.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$79.95
|
| Rate for Payer: BCBS Complete |
$36.74
|
| Rate for Payer: BCBS MAPPO |
$63.96
|
| Rate for Payer: BCBS Trust/PPO |
$194.84
|
| Rate for Payer: BCN Medicare Advantage |
$63.96
|
| Rate for Payer: Cash Price |
$2,113.12
|
| Rate for Payer: Cash Price |
$2,113.12
|
| Rate for Payer: Cofinity Commercial |
$2,271.60
|
| Rate for Payer: Cofinity Commercial |
$1,848.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,113.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$63.96
|
| Rate for Payer: Healthscope Commercial |
$2,377.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,848.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,981.05
|
| Rate for Payer: Mclaren Medicaid |
$34.98
|
| Rate for Payer: Mclaren Medicare |
$63.96
|
| Rate for Payer: Meridian Medicaid |
$36.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$67.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,245.19
|
| Rate for Payer: PACE Medicare |
$60.76
|
| Rate for Payer: PACE SWMI |
$63.96
|
| Rate for Payer: PHP Commercial |
$2,245.19
|
| Rate for Payer: PHP Medicare Advantage |
$63.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$34.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,848.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$187.83
|
| Rate for Payer: Priority Health Medicare |
$63.96
|
| Rate for Payer: Priority Health Narrow Network |
$150.26
|
| Rate for Payer: Priority Health SBD |
$1,664.08
|
| Rate for Payer: Railroad Medicare Medicare |
$63.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$63.96
|
| Rate for Payer: UHC Medicare Advantage |
$65.88
|
| Rate for Payer: UMR Bronson Commercial |
$977.32
|
| Rate for Payer: VA VA |
$63.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,981.05
|
|
|
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL
|
Facility
|
OP
|
$56.49
|
|
|
Service Code
|
CPT 99211
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$56.49 |
| Rate for Payer: BCBS Trust/PPO |
$56.49
|
| Rate for Payer: BCCCP Commercial |
$22.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.36
|
| Rate for Payer: UHC Exchange |
$8.51
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.94
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.25
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UMR Bronson Commercial |
$10.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$44.77
|
|
|
Service Code
|
NDC 64980-515-01
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$40.29 |
| Rate for Payer: Aetna American Axle |
$29.10
|
| Rate for Payer: Aetna Commercial |
$38.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.10
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Cofinity Commercial |
$31.34
|
| Rate for Payer: Cofinity Commercial |
$38.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.82
|
| Rate for Payer: Healthscope Commercial |
$40.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.05
|
| Rate for Payer: PHP Commercial |
$38.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.34
|
| Rate for Payer: Priority Health SBD |
$28.21
|
| Rate for Payer: UMR Bronson Commercial |
$19.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.58
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$48.83
|
|
|
Service Code
|
NDC 70756-607-30
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.49 |
| Max. Negotiated Rate |
$43.95 |
| Rate for Payer: Aetna American Axle |
$31.74
|
| Rate for Payer: Aetna Commercial |
$41.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.74
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Cofinity Commercial |
$41.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.06
|
| Rate for Payer: Healthscope Commercial |
$43.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.51
|
| Rate for Payer: PHP Commercial |
$41.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.18
|
| Rate for Payer: Priority Health SBD |
$30.76
|
| Rate for Payer: UMR Bronson Commercial |
$21.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.62
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$105.14
|
|
|
Service Code
|
NDC 60505-0560-1
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.26 |
| Max. Negotiated Rate |
$94.63 |
| Rate for Payer: Aetna American Axle |
$68.34
|
| Rate for Payer: Aetna Commercial |
$89.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.34
|
| Rate for Payer: Cash Price |
$84.11
|
| Rate for Payer: Cofinity Commercial |
$73.60
|
| Rate for Payer: Cofinity Commercial |
$90.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.11
|
| Rate for Payer: Healthscope Commercial |
$94.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$73.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.37
|
| Rate for Payer: PHP Commercial |
$89.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$73.60
|
| Rate for Payer: Priority Health SBD |
$66.24
|
| Rate for Payer: UMR Bronson Commercial |
$46.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.86
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$5.65
|
|
|
Service Code
|
NDC 59746-307-12
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$5.08 |
| Rate for Payer: Aetna American Axle |
$3.67
|
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.67
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cofinity Commercial |
$3.96
|
| Rate for Payer: Cofinity Commercial |
$4.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.52
|
| Rate for Payer: Healthscope Commercial |
$5.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.80
|
| Rate for Payer: PHP Commercial |
$4.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.96
|
| Rate for Payer: Priority Health SBD |
$3.56
|
| Rate for Payer: UMR Bronson Commercial |
$2.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.24
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$7.87
|
|
|
Service Code
|
NDC 55111-263-79
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$7.08 |
| Rate for Payer: Aetna American Axle |
$5.12
|
| Rate for Payer: Aetna Commercial |
$6.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.12
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cofinity Commercial |
$5.51
|
| Rate for Payer: Cofinity Commercial |
$6.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.30
|
| Rate for Payer: Healthscope Commercial |
$7.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.69
|
| Rate for Payer: PHP Commercial |
$6.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.51
|
| Rate for Payer: Priority Health SBD |
$4.96
|
| Rate for Payer: UMR Bronson Commercial |
$3.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.90
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$85.03
|
|
|
Service Code
|
NDC 0002-4454-01
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.41 |
| Max. Negotiated Rate |
$76.53 |
| Rate for Payer: Aetna American Axle |
$55.27
|
| Rate for Payer: Aetna Commercial |
$72.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.27
|
| Rate for Payer: Cash Price |
$68.02
|
| Rate for Payer: Cofinity Commercial |
$59.52
|
| Rate for Payer: Cofinity Commercial |
$73.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.02
|
| Rate for Payer: Healthscope Commercial |
$76.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$72.28
|
| Rate for Payer: PHP Commercial |
$72.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.52
|
| Rate for Payer: Priority Health SBD |
$53.57
|
| Rate for Payer: UMR Bronson Commercial |
$37.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.77
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$169.35
|
|
|
Service Code
|
NDC 59746-307-32
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.51 |
| Max. Negotiated Rate |
$152.42 |
| Rate for Payer: Aetna American Axle |
$110.08
|
| Rate for Payer: Aetna Commercial |
$143.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.08
|
| Rate for Payer: Cash Price |
$135.48
|
| Rate for Payer: Cofinity Commercial |
$118.54
|
| Rate for Payer: Cofinity Commercial |
$145.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.48
|
| Rate for Payer: Healthscope Commercial |
$152.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$143.95
|
| Rate for Payer: PHP Commercial |
$143.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.54
|
| Rate for Payer: Priority Health SBD |
$106.69
|
| Rate for Payer: UMR Bronson Commercial |
$74.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.01
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$5.62
|
|
|
Service Code
|
NDC 49884-321-52
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Aetna American Axle |
$3.65
|
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.65
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cofinity Commercial |
$3.93
|
| Rate for Payer: Cofinity Commercial |
$4.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.50
|
| Rate for Payer: Healthscope Commercial |
$5.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.78
|
| Rate for Payer: PHP Commercial |
$4.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.93
|
| Rate for Payer: Priority Health SBD |
$3.54
|
| Rate for Payer: UMR Bronson Commercial |
$2.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.22
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$236.10
|
|
|
Service Code
|
NDC 55111-263-81
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.88 |
| Max. Negotiated Rate |
$212.49 |
| Rate for Payer: Aetna American Axle |
$153.46
|
| Rate for Payer: Aetna Commercial |
$200.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.46
|
| Rate for Payer: Cash Price |
$188.88
|
| Rate for Payer: Cofinity Commercial |
$165.27
|
| Rate for Payer: Cofinity Commercial |
$203.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.88
|
| Rate for Payer: Healthscope Commercial |
$212.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$200.68
|
| Rate for Payer: PHP Commercial |
$200.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.27
|
| Rate for Payer: Priority Health SBD |
$148.74
|
| Rate for Payer: UMR Bronson Commercial |
$103.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.08
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$117.14
|
|
|
Service Code
|
NDC 33342-084-07
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.54 |
| Max. Negotiated Rate |
$105.43 |
| Rate for Payer: Aetna American Axle |
$76.14
|
| Rate for Payer: Aetna Commercial |
$99.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.14
|
| Rate for Payer: Cash Price |
$93.71
|
| Rate for Payer: Cofinity Commercial |
$100.74
|
| Rate for Payer: Cofinity Commercial |
$82.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.71
|
| Rate for Payer: Healthscope Commercial |
$105.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.57
|
| Rate for Payer: PHP Commercial |
$99.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.00
|
| Rate for Payer: Priority Health SBD |
$73.80
|
| Rate for Payer: UMR Bronson Commercial |
$51.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.86
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$168.34
|
|
|
Service Code
|
NDC 49884-321-55
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.07 |
| Max. Negotiated Rate |
$151.51 |
| Rate for Payer: Aetna American Axle |
$109.42
|
| Rate for Payer: Aetna Commercial |
$143.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.42
|
| Rate for Payer: Cash Price |
$134.67
|
| Rate for Payer: Cofinity Commercial |
$117.84
|
| Rate for Payer: Cofinity Commercial |
$144.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.67
|
| Rate for Payer: Healthscope Commercial |
$151.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$143.09
|
| Rate for Payer: PHP Commercial |
$143.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$117.84
|
| Rate for Payer: Priority Health SBD |
$106.05
|
| Rate for Payer: UMR Bronson Commercial |
$74.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.26
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$77.08
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.92 |
| Max. Negotiated Rate |
$69.37 |
| Rate for Payer: Aetna American Axle |
$50.10
|
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.10
|
| Rate for Payer: Cash Price |
$61.66
|
| Rate for Payer: Cofinity Commercial |
$53.96
|
| Rate for Payer: Cofinity Commercial |
$66.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.66
|
| Rate for Payer: Healthscope Commercial |
$69.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.52
|
| Rate for Payer: PHP Commercial |
$65.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.96
|
| Rate for Payer: Priority Health SBD |
$48.56
|
| Rate for Payer: UMR Bronson Commercial |
$33.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.81
|
|
|
OLANZAPINE 10 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
NDC 0002-7597-01
|
| Hospital Charge Code |
200122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.52 |
| Max. Negotiated Rate |
$187.20 |
| Rate for Payer: Aetna American Axle |
$135.20
|
| Rate for Payer: Aetna Commercial |
$176.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.20
|
| Rate for Payer: Cash Price |
$166.40
|
| Rate for Payer: Cofinity Commercial |
$145.60
|
| Rate for Payer: Cofinity Commercial |
$178.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$187.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.80
|
| Rate for Payer: PHP Commercial |
$176.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.60
|
| Rate for Payer: Priority Health SBD |
$131.04
|
| Rate for Payer: UMR Bronson Commercial |
$91.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.00
|
|
|
OLANZAPINE 10 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$155.89
|
|
|
Service Code
|
NDC 0517-0955-01
|
| Hospital Charge Code |
200122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.59 |
| Max. Negotiated Rate |
$140.30 |
| Rate for Payer: Aetna American Axle |
$101.33
|
| Rate for Payer: Aetna Commercial |
$132.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.33
|
| Rate for Payer: Cash Price |
$124.71
|
| Rate for Payer: Cofinity Commercial |
$109.12
|
| Rate for Payer: Cofinity Commercial |
$134.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.71
|
| Rate for Payer: Healthscope Commercial |
$140.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$132.51
|
| Rate for Payer: PHP Commercial |
$132.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.12
|
| Rate for Payer: Priority Health SBD |
$98.21
|
| Rate for Payer: UMR Bronson Commercial |
$68.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.92
|
|
|
OLANZAPINE 10 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$77.08
|
|
|
Service Code
|
NDC 0781-3159-72
|
| Hospital Charge Code |
200122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.92 |
| Max. Negotiated Rate |
$69.37 |
| Rate for Payer: Aetna American Axle |
$50.10
|
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.10
|
| Rate for Payer: Cash Price |
$61.66
|
| Rate for Payer: Cofinity Commercial |
$53.96
|
| Rate for Payer: Cofinity Commercial |
$66.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.66
|
| Rate for Payer: Healthscope Commercial |
$69.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.52
|
| Rate for Payer: PHP Commercial |
$65.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.96
|
| Rate for Payer: Priority Health SBD |
$48.56
|
| Rate for Payer: UMR Bronson Commercial |
$33.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.81
|
|
|
OLANZAPINE 10 MG TABLET
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 60505-3113-0
|
| Hospital Charge Code |
17937
|
|
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
|
|
|
OLANZAPINE 10 MG TABLET
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 0904-6376-61
|
| Hospital Charge Code |
17937
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.58 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna American Axle |
$250.51
|
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.78
|
| Rate for Payer: Priority Health SBD |
$242.80
|
| Rate for Payer: UMR Bronson Commercial |
$169.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
OLANZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$8.28
|
|
|
Service Code
|
NDC 49884-322-52
|
| Hospital Charge Code |
28161
|
|
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
|
|
|
OLANZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$248.26
|
|
|
Service Code
|
NDC 59746-308-32
|
| Hospital Charge Code |
28161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.23 |
| Max. Negotiated Rate |
$223.43 |
| Rate for Payer: Aetna American Axle |
$161.37
|
| Rate for Payer: Aetna Commercial |
$211.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.37
|
| Rate for Payer: Cash Price |
$198.61
|
| Rate for Payer: Cofinity Commercial |
$173.78
|
| Rate for Payer: Cofinity Commercial |
$213.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.61
|
| Rate for Payer: Healthscope Commercial |
$223.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$211.02
|
| Rate for Payer: PHP Commercial |
$211.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$173.78
|
| Rate for Payer: Priority Health SBD |
$156.40
|
| Rate for Payer: UMR Bronson Commercial |
$109.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.20
|
|
|
OLANZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$348.10
|
|
|
Service Code
|
NDC 55111-264-81
|
| Hospital Charge Code |
28161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.16 |
| Max. Negotiated Rate |
$313.29 |
| Rate for Payer: Aetna American Axle |
$226.26
|
| Rate for Payer: Aetna Commercial |
$295.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.26
|
| Rate for Payer: Cash Price |
$278.48
|
| Rate for Payer: Cofinity Commercial |
$243.67
|
| Rate for Payer: Cofinity Commercial |
$299.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$278.48
|
| Rate for Payer: Healthscope Commercial |
$313.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$243.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$295.88
|
| Rate for Payer: PHP Commercial |
$295.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.67
|
| Rate for Payer: Priority Health SBD |
$219.30
|
| Rate for Payer: UMR Bronson Commercial |
$153.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.08
|
|
