|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$3.18
|
|
|
Service Code
|
NDC 68084-723-11
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna American Axle |
$2.07
|
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.07
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$2.23
|
| Rate for Payer: Cofinity Commercial |
$2.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.54
|
| Rate for Payer: Healthscope Commercial |
$2.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.70
|
| Rate for Payer: PHP Commercial |
$2.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.23
|
| Rate for Payer: Priority Health SBD |
$2.00
|
| Rate for Payer: UMR Bronson Commercial |
$1.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.38
|
|
|
OLOPATADINE 0.1 % EYE DROPS
|
Facility
|
IP
|
$21.88
|
|
|
Service Code
|
NDC 60505-0575-1
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna American Axle |
$14.22
|
| Rate for Payer: Aetna Commercial |
$18.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.22
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Cofinity Commercial |
$18.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.50
|
| Rate for Payer: Healthscope Commercial |
$19.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.60
|
| Rate for Payer: PHP Commercial |
$18.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.32
|
| Rate for Payer: Priority Health SBD |
$13.78
|
| Rate for Payer: UMR Bronson Commercial |
$9.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.41
|
|
|
OLOPATADINE 0.1 % EYE DROPS
|
Facility
|
IP
|
$21.81
|
|
|
Service Code
|
NDC 61314-271-05
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$19.63 |
| Rate for Payer: Aetna American Axle |
$14.18
|
| Rate for Payer: Aetna Commercial |
$18.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.18
|
| Rate for Payer: Cash Price |
$17.45
|
| Rate for Payer: Cofinity Commercial |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$18.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.45
|
| Rate for Payer: Healthscope Commercial |
$19.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.54
|
| Rate for Payer: PHP Commercial |
$18.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.27
|
| Rate for Payer: Priority Health SBD |
$13.74
|
| Rate for Payer: UMR Bronson Commercial |
$9.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.36
|
|
|
OLOPATADINE 0.1 % EYE DROPS
|
Facility
|
IP
|
$26.57
|
|
|
Service Code
|
NDC 70512-520-05
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$23.91 |
| Rate for Payer: Aetna American Axle |
$17.27
|
| Rate for Payer: Aetna Commercial |
$22.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.27
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cofinity Commercial |
$18.60
|
| Rate for Payer: Cofinity Commercial |
$22.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.26
|
| Rate for Payer: Healthscope Commercial |
$23.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.58
|
| Rate for Payer: PHP Commercial |
$22.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.60
|
| Rate for Payer: Priority Health SBD |
$16.74
|
| Rate for Payer: UMR Bronson Commercial |
$11.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.93
|
|
|
OLOPATADINE 0.1 % EYE DROPS
|
Facility
|
IP
|
$20.16
|
|
|
Service Code
|
NDC 17478-105-05
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$18.14 |
| Rate for Payer: Aetna American Axle |
$13.10
|
| Rate for Payer: Aetna Commercial |
$17.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.10
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Cofinity Commercial |
$14.11
|
| Rate for Payer: Cofinity Commercial |
$17.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.13
|
| Rate for Payer: Healthscope Commercial |
$18.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.14
|
| Rate for Payer: PHP Commercial |
$17.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.11
|
| Rate for Payer: Priority Health SBD |
$12.70
|
| Rate for Payer: UMR Bronson Commercial |
$8.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.12
|
|
|
OLOPATADINE 0.1 % EYE DROPS
|
Facility
|
IP
|
$42.67
|
|
|
Service Code
|
NDC 70069-007-01
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna American Axle |
$27.74
|
| Rate for Payer: Aetna Commercial |
$36.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.74
|
| Rate for Payer: Cash Price |
$34.14
|
| Rate for Payer: Cofinity Commercial |
$29.87
|
| Rate for Payer: Cofinity Commercial |
$36.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.14
|
| Rate for Payer: Healthscope Commercial |
$38.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.27
|
| Rate for Payer: PHP Commercial |
$36.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.87
|
| Rate for Payer: Priority Health SBD |
$26.88
|
| Rate for Payer: UMR Bronson Commercial |
$18.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.00
|
|
|
OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$4,431.88
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$3,988.69 |
| Rate for Payer: Aetna American Axle |
$2,880.72
|
| Rate for Payer: Aetna Commercial |
$3,767.10
|
| Rate for Payer: Aetna Medicare |
$41.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,880.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$49.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$49.32
|
| Rate for Payer: BCBS Complete |
$22.67
|
| Rate for Payer: BCBS MAPPO |
$39.46
|
| Rate for Payer: BCBS Trust/PPO |
$127.50
|
| Rate for Payer: BCN Medicare Advantage |
$39.46
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cofinity Commercial |
$3,102.32
|
| Rate for Payer: Cofinity Commercial |
$3,811.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,545.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.46
|
| Rate for Payer: Healthscope Commercial |
$3,988.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,102.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,323.91
|
| Rate for Payer: Mclaren Medicaid |
$21.58
|
| Rate for Payer: Mclaren Medicare |
$39.46
|
| Rate for Payer: Meridian Medicaid |
$22.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$41.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,767.10
|
| Rate for Payer: PACE Medicare |
$37.49
|
| Rate for Payer: PACE SWMI |
$39.46
|
| Rate for Payer: PHP Commercial |
$3,767.10
|
| Rate for Payer: PHP Medicare Advantage |
$39.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,102.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.79
|
| Rate for Payer: Priority Health Medicare |
$39.46
|
| Rate for Payer: Priority Health Narrow Network |
$91.83
|
| Rate for Payer: Priority Health SBD |
$2,792.08
|
| Rate for Payer: Railroad Medicare Medicare |
$39.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.46
|
| Rate for Payer: UHC Medicare Advantage |
$40.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,639.80
|
| Rate for Payer: VA VA |
$39.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,323.91
|
|
|
OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$4,431.88
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,950.03 |
| Max. Negotiated Rate |
$3,988.69 |
| Rate for Payer: Aetna American Axle |
$2,880.72
|
| Rate for Payer: Aetna Commercial |
$3,767.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,880.72
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cofinity Commercial |
$3,102.32
|
| Rate for Payer: Cofinity Commercial |
$3,811.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,545.50
|
| Rate for Payer: Healthscope Commercial |
$3,988.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,102.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,323.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,767.10
|
| Rate for Payer: PHP Commercial |
$3,767.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,102.32
|
| Rate for Payer: Priority Health SBD |
$2,792.08
|
| Rate for Payer: UMR Bronson Commercial |
$1,950.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,323.91
|
|
|
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$4,431.88
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
36151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,950.03 |
| Max. Negotiated Rate |
$3,988.69 |
| Rate for Payer: Aetna American Axle |
$2,880.72
|
| Rate for Payer: Aetna Commercial |
$3,767.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,880.72
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cofinity Commercial |
$3,102.32
|
| Rate for Payer: Cofinity Commercial |
$3,811.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,545.50
|
| Rate for Payer: Healthscope Commercial |
$3,988.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,102.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,323.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,767.10
|
| Rate for Payer: PHP Commercial |
$3,767.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,102.32
|
| Rate for Payer: Priority Health SBD |
$2,792.08
|
| Rate for Payer: UMR Bronson Commercial |
$1,950.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,323.91
|
|
|
OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$4,431.88
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
36151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$3,988.69 |
| Rate for Payer: Aetna American Axle |
$2,880.72
|
| Rate for Payer: Aetna Commercial |
$3,767.10
|
| Rate for Payer: Aetna Medicare |
$41.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,880.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$49.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$49.32
|
| Rate for Payer: BCBS Complete |
$22.67
|
| Rate for Payer: BCBS MAPPO |
$39.46
|
| Rate for Payer: BCBS Trust/PPO |
$127.50
|
| Rate for Payer: BCN Medicare Advantage |
$39.46
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cofinity Commercial |
$3,811.42
|
| Rate for Payer: Cofinity Commercial |
$3,102.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,545.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.46
|
| Rate for Payer: Healthscope Commercial |
$3,988.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,102.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,323.91
|
| Rate for Payer: Mclaren Medicaid |
$21.58
|
| Rate for Payer: Mclaren Medicare |
$39.46
|
| Rate for Payer: Meridian Medicaid |
$22.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$41.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,767.10
|
| Rate for Payer: PACE Medicare |
$37.49
|
| Rate for Payer: PACE SWMI |
$39.46
|
| Rate for Payer: PHP Commercial |
$3,767.10
|
| Rate for Payer: PHP Medicare Advantage |
$39.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,102.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.79
|
| Rate for Payer: Priority Health Medicare |
$39.46
|
| Rate for Payer: Priority Health Narrow Network |
$91.83
|
| Rate for Payer: Priority Health SBD |
$2,792.08
|
| Rate for Payer: Railroad Medicare Medicare |
$39.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.46
|
| Rate for Payer: UHC Medicare Advantage |
$40.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,639.80
|
| Rate for Payer: VA VA |
$39.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,323.91
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$2,215.94
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$1,994.35 |
| Rate for Payer: Aetna American Axle |
$1,440.36
|
| Rate for Payer: Aetna Commercial |
$1,883.55
|
| Rate for Payer: Aetna Medicare |
$41.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,440.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$49.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$49.32
|
| Rate for Payer: BCBS Complete |
$22.67
|
| Rate for Payer: BCBS MAPPO |
$39.46
|
| Rate for Payer: BCBS Trust/PPO |
$127.50
|
| Rate for Payer: BCN Medicare Advantage |
$39.46
|
| Rate for Payer: Cash Price |
$1,772.75
|
| Rate for Payer: Cash Price |
$1,772.75
|
| Rate for Payer: Cofinity Commercial |
$1,551.16
|
| Rate for Payer: Cofinity Commercial |
$1,905.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,772.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.46
|
| Rate for Payer: Healthscope Commercial |
$1,994.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,551.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,661.96
|
| Rate for Payer: Mclaren Medicaid |
$21.58
|
| Rate for Payer: Mclaren Medicare |
$39.46
|
| Rate for Payer: Meridian Medicaid |
$22.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$41.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,883.55
|
| Rate for Payer: PACE Medicare |
$37.49
|
| Rate for Payer: PACE SWMI |
$39.46
|
| Rate for Payer: PHP Commercial |
$1,883.55
|
| Rate for Payer: PHP Medicare Advantage |
$39.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,551.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.79
|
| Rate for Payer: Priority Health Medicare |
$39.46
|
| Rate for Payer: Priority Health Narrow Network |
$91.83
|
| Rate for Payer: Priority Health SBD |
$1,396.04
|
| Rate for Payer: Railroad Medicare Medicare |
$39.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.46
|
| Rate for Payer: UHC Medicare Advantage |
$40.64
|
| Rate for Payer: UMR Bronson Commercial |
$819.90
|
| Rate for Payer: VA VA |
$39.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,661.96
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$2,215.94
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$975.01 |
| Max. Negotiated Rate |
$1,994.35 |
| Rate for Payer: Aetna American Axle |
$1,440.36
|
| Rate for Payer: Aetna Commercial |
$1,883.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,440.36
|
| Rate for Payer: Cash Price |
$1,772.75
|
| Rate for Payer: Cofinity Commercial |
$1,551.16
|
| Rate for Payer: Cofinity Commercial |
$1,905.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,772.75
|
| Rate for Payer: Healthscope Commercial |
$1,994.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,551.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,661.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,883.55
|
| Rate for Payer: PHP Commercial |
$1,883.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,551.16
|
| Rate for Payer: Priority Health SBD |
$1,396.04
|
| Rate for Payer: UMR Bronson Commercial |
$975.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,661.96
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
IP
|
$547.08
|
|
|
Service Code
|
NDC 42806-552-12
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.72 |
| Max. Negotiated Rate |
$492.37 |
| Rate for Payer: Aetna American Axle |
$355.60
|
| Rate for Payer: Aetna Commercial |
$465.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.60
|
| Rate for Payer: Cash Price |
$437.66
|
| Rate for Payer: Cofinity Commercial |
$382.96
|
| Rate for Payer: Cofinity Commercial |
$470.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$437.66
|
| Rate for Payer: Healthscope Commercial |
$492.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$382.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$410.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$465.02
|
| Rate for Payer: PHP Commercial |
$465.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$382.96
|
| Rate for Payer: Priority Health SBD |
$344.66
|
| Rate for Payer: UMR Bronson Commercial |
$240.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$410.31
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
IP
|
$493.50
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$217.14 |
| Max. Negotiated Rate |
$444.15 |
| Rate for Payer: Aetna American Axle |
$320.78
|
| Rate for Payer: Aetna Commercial |
$419.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$320.78
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cofinity Commercial |
$345.45
|
| Rate for Payer: Cofinity Commercial |
$424.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$394.80
|
| Rate for Payer: Healthscope Commercial |
$444.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$345.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$370.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$419.48
|
| Rate for Payer: PHP Commercial |
$419.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$345.45
|
| Rate for Payer: Priority Health SBD |
$310.90
|
| Rate for Payer: UMR Bronson Commercial |
$217.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$370.12
|
|
|
OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$100.61
|
|
|
Service Code
|
NDC 67544-510-30
|
| Hospital Charge Code |
27694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.27 |
| Max. Negotiated Rate |
$90.55 |
| Rate for Payer: Aetna American Axle |
$65.40
|
| Rate for Payer: Aetna Commercial |
$85.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.40
|
| Rate for Payer: Cash Price |
$80.49
|
| Rate for Payer: Cofinity Commercial |
$70.43
|
| Rate for Payer: Cofinity Commercial |
$86.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.49
|
| Rate for Payer: Healthscope Commercial |
$90.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.52
|
| Rate for Payer: PHP Commercial |
$85.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.43
|
| Rate for Payer: Priority Health SBD |
$63.38
|
| Rate for Payer: UMR Bronson Commercial |
$44.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.46
|
|
|
OMEPRAZOLE 2 MG-SODIUM BICARBONATE 84 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$742.18
|
|
|
Service Code
|
NDC 65628-272-03
|
| Hospital Charge Code |
203260
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$326.56 |
| Max. Negotiated Rate |
$667.96 |
| Rate for Payer: Aetna American Axle |
$482.42
|
| Rate for Payer: Aetna Commercial |
$630.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$482.42
|
| Rate for Payer: Cash Price |
$593.74
|
| Rate for Payer: Cofinity Commercial |
$519.53
|
| Rate for Payer: Cofinity Commercial |
$638.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$593.74
|
| Rate for Payer: Healthscope Commercial |
$667.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$519.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$556.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$630.85
|
| Rate for Payer: PHP Commercial |
$630.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$519.53
|
| Rate for Payer: Priority Health SBD |
$467.57
|
| Rate for Payer: UMR Bronson Commercial |
$326.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$556.64
|
|
|
ONABOTULINUMTOXINA 100 UNIT/3 ML INJECTION CUSTOM
|
Facility
|
IP
|
$1,923.20
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
180907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$846.21 |
| Max. Negotiated Rate |
$1,730.88 |
| Rate for Payer: Aetna American Axle |
$1,250.08
|
| Rate for Payer: Aetna Commercial |
$1,634.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,250.08
|
| Rate for Payer: Cash Price |
$1,538.56
|
| Rate for Payer: Cofinity Commercial |
$1,346.24
|
| Rate for Payer: Cofinity Commercial |
$1,653.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,538.56
|
| Rate for Payer: Healthscope Commercial |
$1,730.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,346.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,442.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,634.72
|
| Rate for Payer: PHP Commercial |
$1,634.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,346.24
|
| Rate for Payer: Priority Health SBD |
$1,211.62
|
| Rate for Payer: UMR Bronson Commercial |
$846.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,442.40
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$2,028.80
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
32700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$892.67 |
| Max. Negotiated Rate |
$1,825.92 |
| Rate for Payer: Aetna American Axle |
$1,318.72
|
| Rate for Payer: Aetna Commercial |
$1,724.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,318.72
|
| Rate for Payer: Cash Price |
$1,623.04
|
| Rate for Payer: Cofinity Commercial |
$1,420.16
|
| Rate for Payer: Cofinity Commercial |
$1,744.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,623.04
|
| Rate for Payer: Healthscope Commercial |
$1,825.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,420.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,521.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,724.48
|
| Rate for Payer: PHP Commercial |
$1,724.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,420.16
|
| Rate for Payer: Priority Health SBD |
$1,278.14
|
| Rate for Payer: UMR Bronson Commercial |
$892.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,521.60
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$85.68
|
|
|
Service Code
|
NDC 0781-5238-64
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.70 |
| Max. Negotiated Rate |
$77.11 |
| Rate for Payer: Aetna American Axle |
$55.69
|
| Rate for Payer: Aetna Commercial |
$72.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.69
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cofinity Commercial |
$59.98
|
| Rate for Payer: Cofinity Commercial |
$73.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.54
|
| Rate for Payer: Healthscope Commercial |
$77.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$72.83
|
| Rate for Payer: PHP Commercial |
$72.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.98
|
| Rate for Payer: Priority Health SBD |
$53.98
|
| Rate for Payer: UMR Bronson Commercial |
$37.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.26
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$83.67
|
|
|
Service Code
|
NDC 65862-390-10
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.96 |
| Max. Negotiated Rate |
$75.30 |
| Rate for Payer: Aetna American Axle |
$54.39
|
| Rate for Payer: Aetna Commercial |
$71.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.39
|
| Rate for Payer: BCBS Complete |
$33.47
|
| Rate for Payer: Cash Price |
$66.94
|
| Rate for Payer: Cofinity Commercial |
$58.57
|
| Rate for Payer: Cofinity Commercial |
$71.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.94
|
| Rate for Payer: Healthscope Commercial |
$75.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.12
|
| Rate for Payer: PHP Commercial |
$71.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.57
|
| Rate for Payer: Priority Health SBD |
$52.71
|
| Rate for Payer: UMR Bronson Commercial |
$30.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.75
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 0781-5238-06
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Aetna American Axle |
$1.86
|
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.86
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.00
|
| Rate for Payer: Cofinity Commercial |
$2.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.29
|
| Rate for Payer: Healthscope Commercial |
$2.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.43
|
| Rate for Payer: PHP Commercial |
$2.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.00
|
| Rate for Payer: Priority Health SBD |
$1.80
|
| Rate for Payer: UMR Bronson Commercial |
$1.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.14
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$135.36
|
|
|
Service Code
|
NDC 68462-157-13
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.56 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna American Axle |
$87.98
|
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.98
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.75
|
| Rate for Payer: Priority Health SBD |
$85.28
|
| Rate for Payer: UMR Bronson Commercial |
$59.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.52
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$66.41
|
|
|
Service Code
|
NDC 57237-077-10
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$59.77 |
| Rate for Payer: Aetna American Axle |
$43.17
|
| Rate for Payer: Aetna Commercial |
$56.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.17
|
| Rate for Payer: BCBS Complete |
$26.56
|
| Rate for Payer: Cash Price |
$53.13
|
| Rate for Payer: Cofinity Commercial |
$46.49
|
| Rate for Payer: Cofinity Commercial |
$57.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.13
|
| Rate for Payer: Healthscope Commercial |
$59.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.45
|
| Rate for Payer: PHP Commercial |
$56.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.49
|
| Rate for Payer: Priority Health SBD |
$41.84
|
| Rate for Payer: UMR Bronson Commercial |
$24.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.81
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$81.94
|
|
|
Service Code
|
NDC 62756-240-64
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.32 |
| Max. Negotiated Rate |
$73.75 |
| Rate for Payer: Aetna American Axle |
$53.26
|
| Rate for Payer: Aetna Commercial |
$69.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.26
|
| Rate for Payer: BCBS Complete |
$32.78
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cofinity Commercial |
$57.36
|
| Rate for Payer: Cofinity Commercial |
$70.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.55
|
| Rate for Payer: Healthscope Commercial |
$73.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.65
|
| Rate for Payer: PHP Commercial |
$69.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.36
|
| Rate for Payer: Priority Health SBD |
$51.62
|
| Rate for Payer: UMR Bronson Commercial |
$30.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.46
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 62756-240-60
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna American Axle |
$1.78
|
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.78
|
| Rate for Payer: BCBS Complete |
$1.10
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$1.92
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.92
|
| Rate for Payer: Priority Health SBD |
$1.73
|
| Rate for Payer: UMR Bronson Commercial |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
