|
HYDROMORPHONE VARIABLE DOSE
|
Facility
|
OP
|
$14.07
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
150712
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$12.66 |
| Rate for Payer: Aetna American Axle |
$9.15
|
| Rate for Payer: Aetna Commercial |
$11.96
|
| Rate for Payer: Aetna Medicare |
$7.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.15
|
| Rate for Payer: BCBS Complete |
$5.63
|
| Rate for Payer: BCBS Trust/PPO |
$0.45
|
| Rate for Payer: BCN Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: Cofinity Advantage |
$9.85
|
| Rate for Payer: Cofinity Commercial |
$12.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.26
|
| Rate for Payer: Healthscope Commercial |
$12.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.55
|
| Rate for Payer: PHP Commercial |
$11.96
|
| Rate for Payer: Priority Health SBD |
$8.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.23
|
| Rate for Payer: UHC Core |
$0.23
|
| Rate for Payer: UHC Exchange |
$0.23
|
| Rate for Payer: UMR Bronson Commercial |
$5.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.55
|
|
|
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$3,118.85
|
|
|
Service Code
|
HCPCS J3424
|
| Hospital Charge Code |
155400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$2,806.97 |
| Rate for Payer: Aetna American Axle |
$2,027.25
|
| Rate for Payer: Aetna Commercial |
$2,651.02
|
| Rate for Payer: Aetna Medicare |
$5.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,027.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.80
|
| Rate for Payer: BCBS Complete |
$2.99
|
| Rate for Payer: BCBS MAPPO |
$5.44
|
| Rate for Payer: BCBS Trust/PPO |
$16.96
|
| Rate for Payer: BCN Commercial |
$16.96
|
| Rate for Payer: BCN Medicare Advantage |
$5.44
|
| Rate for Payer: Cash Price |
$2,495.08
|
| Rate for Payer: Cash Price |
$2,495.08
|
| Rate for Payer: Cofinity Advantage |
$2,183.20
|
| Rate for Payer: Cofinity Commercial |
$2,682.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,495.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.44
|
| Rate for Payer: Healthscope Commercial |
$2,806.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,183.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,339.14
|
| Rate for Payer: Mclaren Medicaid |
$5.44
|
| Rate for Payer: Mclaren Medicare |
$5.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.71
|
| Rate for Payer: Meridian Medicaid |
$5.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,651.02
|
| Rate for Payer: Nomi Health Commercial |
$16.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,339.14
|
| Rate for Payer: PACE Medicare |
$5.17
|
| Rate for Payer: PACE SWMI |
$5.44
|
| Rate for Payer: PHP Commercial |
$2,651.02
|
| Rate for Payer: PHP Medicare Advantage |
$5.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$16.35
|
| Rate for Payer: Priority Health Medicare |
$5.44
|
| Rate for Payer: Priority Health SBD |
$1,964.88
|
| Rate for Payer: Priority Health Tiered Network |
$13.08
|
| Rate for Payer: Railroad Medicare Medicare |
$5.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.98
|
| Rate for Payer: UHC Core |
$8.98
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.44
|
| Rate for Payer: UHC Exchange |
$8.98
|
| Rate for Payer: UHC Medicaid |
$2.85
|
| Rate for Payer: UHCCP Medicaid |
$2.85
|
| Rate for Payer: UMR Bronson Commercial |
$1,153.97
|
| Rate for Payer: VA VA |
$5.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,339.14
|
|
|
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$3,118.85
|
|
|
Service Code
|
HCPCS J3424
|
| Hospital Charge Code |
155400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,372.29 |
| Max. Negotiated Rate |
$2,806.97 |
| Rate for Payer: Aetna American Axle |
$2,027.25
|
| Rate for Payer: Aetna Commercial |
$2,651.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,027.25
|
| Rate for Payer: Cash Price |
$2,495.08
|
| Rate for Payer: Cofinity Advantage |
$2,183.20
|
| Rate for Payer: Cofinity Commercial |
$2,682.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,495.08
|
| Rate for Payer: Healthscope Commercial |
$2,806.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,183.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,339.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,651.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,339.14
|
| Rate for Payer: PHP Commercial |
$2,651.02
|
| Rate for Payer: Priority Health SBD |
$1,964.88
|
| Rate for Payer: UMR Bronson Commercial |
$1,372.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,339.14
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$379.68
|
|
|
Service Code
|
NDC 00781599401
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.06 |
| Max. Negotiated Rate |
$341.71 |
| Rate for Payer: Aetna American Axle |
$246.79
|
| Rate for Payer: Aetna Commercial |
$322.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.79
|
| Rate for Payer: Cash Price |
$303.74
|
| Rate for Payer: Cofinity Advantage |
$265.78
|
| Rate for Payer: Cofinity Commercial |
$326.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.74
|
| Rate for Payer: Healthscope Commercial |
$341.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.76
|
| Rate for Payer: PHP Commercial |
$322.73
|
| Rate for Payer: Priority Health SBD |
$239.20
|
| Rate for Payer: UMR Bronson Commercial |
$167.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.76
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$266.95
|
|
|
Service Code
|
NDC 43598072101
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.77 |
| Max. Negotiated Rate |
$240.25 |
| Rate for Payer: Aetna American Axle |
$173.52
|
| Rate for Payer: Aetna Commercial |
$226.91
|
| Rate for Payer: Aetna Medicare |
$133.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.52
|
| Rate for Payer: BCBS Complete |
$106.78
|
| Rate for Payer: Cash Price |
$213.56
|
| Rate for Payer: Cofinity Advantage |
$186.87
|
| Rate for Payer: Cofinity Commercial |
$229.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.56
|
| Rate for Payer: Healthscope Commercial |
$240.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$213.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.21
|
| Rate for Payer: PHP Commercial |
$226.91
|
| Rate for Payer: Priority Health SBD |
$168.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$173.52
|
| Rate for Payer: UHC Core |
$139.08
|
| Rate for Payer: UHC Exchange |
$104.91
|
| Rate for Payer: UMR Bronson Commercial |
$98.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.21
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$643.20
|
|
|
Service Code
|
NDC 68084026911
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$283.01 |
| Max. Negotiated Rate |
$578.88 |
| Rate for Payer: Aetna American Axle |
$418.08
|
| Rate for Payer: Aetna Commercial |
$546.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$418.08
|
| Rate for Payer: Cash Price |
$514.56
|
| Rate for Payer: Cofinity Advantage |
$450.24
|
| Rate for Payer: Cofinity Commercial |
$553.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$514.56
|
| Rate for Payer: Healthscope Commercial |
$578.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$450.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$482.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$546.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$482.40
|
| Rate for Payer: PHP Commercial |
$546.72
|
| Rate for Payer: Priority Health SBD |
$405.22
|
| Rate for Payer: UMR Bronson Commercial |
$283.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$482.40
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$190.08
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.33 |
| Max. Negotiated Rate |
$171.07 |
| Rate for Payer: Aetna American Axle |
$123.55
|
| Rate for Payer: Aetna Commercial |
$161.57
|
| Rate for Payer: Aetna Medicare |
$95.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.55
|
| Rate for Payer: BCBS Complete |
$76.03
|
| Rate for Payer: Cash Price |
$152.06
|
| Rate for Payer: Cofinity Advantage |
$133.06
|
| Rate for Payer: Cofinity Commercial |
$163.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.06
|
| Rate for Payer: Healthscope Commercial |
$171.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$152.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$142.56
|
| Rate for Payer: PHP Commercial |
$161.57
|
| Rate for Payer: Priority Health SBD |
$119.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.55
|
| Rate for Payer: UHC Core |
$99.03
|
| Rate for Payer: UHC Exchange |
$74.70
|
| Rate for Payer: UMR Bronson Commercial |
$70.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.56
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$306.72
|
|
|
Service Code
|
NDC 68382009601
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.49 |
| Max. Negotiated Rate |
$276.05 |
| Rate for Payer: Aetna American Axle |
$199.37
|
| Rate for Payer: Aetna Commercial |
$260.71
|
| Rate for Payer: Aetna Medicare |
$153.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.37
|
| Rate for Payer: BCBS Complete |
$122.69
|
| Rate for Payer: Cash Price |
$245.38
|
| Rate for Payer: Cofinity Advantage |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.38
|
| Rate for Payer: Healthscope Commercial |
$276.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$245.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.04
|
| Rate for Payer: PHP Commercial |
$260.71
|
| Rate for Payer: Priority Health SBD |
$193.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$199.37
|
| Rate for Payer: UHC Core |
$159.80
|
| Rate for Payer: UHC Exchange |
$120.54
|
| Rate for Payer: UMR Bronson Commercial |
$113.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.04
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$379.68
|
|
|
Service Code
|
NDC 00781599401
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.48 |
| Max. Negotiated Rate |
$341.71 |
| Rate for Payer: Aetna American Axle |
$246.79
|
| Rate for Payer: Aetna Commercial |
$322.73
|
| Rate for Payer: Aetna Medicare |
$189.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.79
|
| Rate for Payer: BCBS Complete |
$151.87
|
| Rate for Payer: Cash Price |
$303.74
|
| Rate for Payer: Cofinity Advantage |
$265.78
|
| Rate for Payer: Cofinity Commercial |
$326.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.74
|
| Rate for Payer: Healthscope Commercial |
$341.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$303.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.76
|
| Rate for Payer: PHP Commercial |
$322.73
|
| Rate for Payer: Priority Health SBD |
$239.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$246.79
|
| Rate for Payer: UHC Core |
$197.81
|
| Rate for Payer: UHC Exchange |
$149.21
|
| Rate for Payer: UMR Bronson Commercial |
$140.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.76
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$1,456.80
|
|
|
Service Code
|
NDC 68382009605
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$640.99 |
| Max. Negotiated Rate |
$1,311.12 |
| Rate for Payer: Aetna American Axle |
$946.92
|
| Rate for Payer: Aetna Commercial |
$1,238.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$946.92
|
| Rate for Payer: Cash Price |
$1,165.44
|
| Rate for Payer: Cofinity Advantage |
$1,019.76
|
| Rate for Payer: Cofinity Commercial |
$1,252.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,165.44
|
| Rate for Payer: Healthscope Commercial |
$1,311.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,019.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,092.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,238.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,092.60
|
| Rate for Payer: PHP Commercial |
$1,238.28
|
| Rate for Payer: Priority Health SBD |
$917.78
|
| Rate for Payer: UMR Bronson Commercial |
$640.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,092.60
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$643.20
|
|
|
Service Code
|
NDC 68084026911
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.98 |
| Max. Negotiated Rate |
$578.88 |
| Rate for Payer: Aetna American Axle |
$418.08
|
| Rate for Payer: Aetna Commercial |
$546.72
|
| Rate for Payer: Aetna Medicare |
$321.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$418.08
|
| Rate for Payer: BCBS Complete |
$257.28
|
| Rate for Payer: Cash Price |
$514.56
|
| Rate for Payer: Cofinity Advantage |
$450.24
|
| Rate for Payer: Cofinity Commercial |
$553.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$514.56
|
| Rate for Payer: Healthscope Commercial |
$578.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$450.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$482.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$514.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$546.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$482.40
|
| Rate for Payer: PHP Commercial |
$546.72
|
| Rate for Payer: Priority Health SBD |
$405.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.08
|
| Rate for Payer: UHC Core |
$335.11
|
| Rate for Payer: UHC Exchange |
$252.78
|
| Rate for Payer: UMR Bronson Commercial |
$237.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$482.40
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$266.95
|
|
|
Service Code
|
NDC 43598072101
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.46 |
| Max. Negotiated Rate |
$240.25 |
| Rate for Payer: Aetna American Axle |
$173.52
|
| Rate for Payer: Aetna Commercial |
$226.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.52
|
| Rate for Payer: Cash Price |
$213.56
|
| Rate for Payer: Cofinity Advantage |
$186.87
|
| Rate for Payer: Cofinity Commercial |
$229.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.56
|
| Rate for Payer: Healthscope Commercial |
$240.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.21
|
| Rate for Payer: PHP Commercial |
$226.91
|
| Rate for Payer: Priority Health SBD |
$168.18
|
| Rate for Payer: UMR Bronson Commercial |
$117.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.21
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$1,456.80
|
|
|
Service Code
|
NDC 68382009605
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$539.02 |
| Max. Negotiated Rate |
$1,311.12 |
| Rate for Payer: Aetna American Axle |
$946.92
|
| Rate for Payer: Aetna Commercial |
$1,238.28
|
| Rate for Payer: Aetna Medicare |
$728.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$946.92
|
| Rate for Payer: BCBS Complete |
$582.72
|
| Rate for Payer: Cash Price |
$1,165.44
|
| Rate for Payer: Cofinity Advantage |
$1,019.76
|
| Rate for Payer: Cofinity Commercial |
$1,252.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,165.44
|
| Rate for Payer: Healthscope Commercial |
$1,311.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,019.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,092.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,165.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,238.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,092.60
|
| Rate for Payer: PHP Commercial |
$1,238.28
|
| Rate for Payer: Priority Health SBD |
$917.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$946.92
|
| Rate for Payer: UHC Core |
$758.99
|
| Rate for Payer: UHC Exchange |
$572.52
|
| Rate for Payer: UMR Bronson Commercial |
$539.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,092.60
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$306.72
|
|
|
Service Code
|
NDC 68382009601
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.96 |
| Max. Negotiated Rate |
$276.05 |
| Rate for Payer: Aetna American Axle |
$199.37
|
| Rate for Payer: Aetna Commercial |
$260.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.37
|
| Rate for Payer: Cash Price |
$245.38
|
| Rate for Payer: Cofinity Advantage |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.38
|
| Rate for Payer: Healthscope Commercial |
$276.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.04
|
| Rate for Payer: PHP Commercial |
$260.71
|
| Rate for Payer: Priority Health SBD |
$193.23
|
| Rate for Payer: UMR Bronson Commercial |
$134.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.04
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$244.80
|
|
|
Service Code
|
NDC 63304029601
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.71 |
| Max. Negotiated Rate |
$220.32 |
| Rate for Payer: Aetna American Axle |
$159.12
|
| Rate for Payer: Aetna Commercial |
$208.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.12
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cofinity Advantage |
$171.36
|
| Rate for Payer: Cofinity Commercial |
$210.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.84
|
| Rate for Payer: Healthscope Commercial |
$220.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.60
|
| Rate for Payer: PHP Commercial |
$208.08
|
| Rate for Payer: Priority Health SBD |
$154.22
|
| Rate for Payer: UMR Bronson Commercial |
$107.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.60
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$244.80
|
|
|
Service Code
|
NDC 63304029601
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.58 |
| Max. Negotiated Rate |
$220.32 |
| Rate for Payer: Aetna American Axle |
$159.12
|
| Rate for Payer: Aetna Commercial |
$208.08
|
| Rate for Payer: Aetna Medicare |
$122.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.12
|
| Rate for Payer: BCBS Complete |
$97.92
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cofinity Advantage |
$171.36
|
| Rate for Payer: Cofinity Commercial |
$210.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.84
|
| Rate for Payer: Healthscope Commercial |
$220.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$195.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.60
|
| Rate for Payer: PHP Commercial |
$208.08
|
| Rate for Payer: Priority Health SBD |
$154.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$159.12
|
| Rate for Payer: UHC Core |
$127.54
|
| Rate for Payer: UHC Exchange |
$96.21
|
| Rate for Payer: UMR Bronson Commercial |
$90.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.60
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$190.08
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.64 |
| Max. Negotiated Rate |
$171.07 |
| Rate for Payer: Aetna American Axle |
$123.55
|
| Rate for Payer: Aetna Commercial |
$161.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.55
|
| Rate for Payer: Cash Price |
$152.06
|
| Rate for Payer: Cofinity Advantage |
$133.06
|
| Rate for Payer: Cofinity Commercial |
$163.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.06
|
| Rate for Payer: Healthscope Commercial |
$171.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$142.56
|
| Rate for Payer: PHP Commercial |
$161.57
|
| Rate for Payer: Priority Health SBD |
$119.75
|
| Rate for Payer: UMR Bronson Commercial |
$83.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.56
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$250.08
|
|
|
Service Code
|
NDC 69315016401
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$225.07 |
| Rate for Payer: Aetna American Axle |
$162.55
|
| Rate for Payer: Aetna Commercial |
$212.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.55
|
| Rate for Payer: Cash Price |
$200.06
|
| Rate for Payer: Cofinity Advantage |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.06
|
| Rate for Payer: Healthscope Commercial |
$225.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$187.56
|
| Rate for Payer: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health SBD |
$157.55
|
| Rate for Payer: UMR Bronson Commercial |
$110.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.56
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
OP
|
$407.04
|
|
|
Service Code
|
NDC 00904693961
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.60 |
| Max. Negotiated Rate |
$366.34 |
| Rate for Payer: Aetna American Axle |
$264.58
|
| Rate for Payer: Aetna Commercial |
$345.98
|
| Rate for Payer: Aetna Medicare |
$203.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.58
|
| Rate for Payer: BCBS Complete |
$162.82
|
| Rate for Payer: Cash Price |
$325.63
|
| Rate for Payer: Cofinity Advantage |
$284.93
|
| Rate for Payer: Cofinity Commercial |
$350.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.63
|
| Rate for Payer: Healthscope Commercial |
$366.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$325.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$305.28
|
| Rate for Payer: PHP Commercial |
$345.98
|
| Rate for Payer: Priority Health SBD |
$256.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.58
|
| Rate for Payer: UHC Core |
$212.07
|
| Rate for Payer: UHC Exchange |
$159.97
|
| Rate for Payer: UMR Bronson Commercial |
$150.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.28
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$353.40
|
|
|
Service Code
|
NDC 49884072401
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna American Axle |
$229.71
|
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Advantage |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$247.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$265.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$265.05
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health SBD |
$222.64
|
| Rate for Payer: UMR Bronson Commercial |
$155.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$265.05
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$407.04
|
|
|
Service Code
|
NDC 00904693961
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.10 |
| Max. Negotiated Rate |
$366.34 |
| Rate for Payer: Aetna American Axle |
$264.58
|
| Rate for Payer: Aetna Commercial |
$345.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.58
|
| Rate for Payer: Cash Price |
$325.63
|
| Rate for Payer: Cofinity Advantage |
$284.93
|
| Rate for Payer: Cofinity Commercial |
$350.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.63
|
| Rate for Payer: Healthscope Commercial |
$366.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$305.28
|
| Rate for Payer: PHP Commercial |
$345.98
|
| Rate for Payer: Priority Health SBD |
$256.44
|
| Rate for Payer: UMR Bronson Commercial |
$179.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.28
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
OP
|
$250.08
|
|
|
Service Code
|
NDC 69315016401
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.53 |
| Max. Negotiated Rate |
$225.07 |
| Rate for Payer: Aetna American Axle |
$162.55
|
| Rate for Payer: Aetna Commercial |
$212.57
|
| Rate for Payer: Aetna Medicare |
$125.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.55
|
| Rate for Payer: BCBS Complete |
$100.03
|
| Rate for Payer: Cash Price |
$200.06
|
| Rate for Payer: Cofinity Advantage |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.06
|
| Rate for Payer: Healthscope Commercial |
$225.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$200.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$187.56
|
| Rate for Payer: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health SBD |
$157.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$162.55
|
| Rate for Payer: UHC Core |
$130.29
|
| Rate for Payer: UHC Exchange |
$98.28
|
| Rate for Payer: UMR Bronson Commercial |
$92.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.56
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
OP
|
$353.40
|
|
|
Service Code
|
NDC 49884072401
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.76 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna American Axle |
$229.71
|
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna Medicare |
$176.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: BCBS Complete |
$141.36
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Advantage |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$247.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$265.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$282.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$265.05
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health SBD |
$222.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$229.71
|
| Rate for Payer: UHC Core |
$184.12
|
| Rate for Payer: UHC Exchange |
$138.89
|
| Rate for Payer: UMR Bronson Commercial |
$130.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$265.05
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
NDC 51552085109
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.20 |
| Max. Negotiated Rate |
$297.00 |
| Rate for Payer: Aetna American Axle |
$214.50
|
| Rate for Payer: Aetna Commercial |
$280.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.50
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cofinity Advantage |
$231.00
|
| Rate for Payer: Cofinity Commercial |
$283.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.00
|
| Rate for Payer: Healthscope Commercial |
$297.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$247.50
|
| Rate for Payer: PHP Commercial |
$280.50
|
| Rate for Payer: Priority Health SBD |
$207.90
|
| Rate for Payer: UMR Bronson Commercial |
$145.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.50
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
IP
|
$1,272.00
|
|
|
Service Code
|
NDC 51552085104
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$559.68 |
| Max. Negotiated Rate |
$1,144.80 |
| Rate for Payer: Aetna American Axle |
$826.80
|
| Rate for Payer: Aetna Commercial |
$1,081.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$826.80
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cofinity Advantage |
$890.40
|
| Rate for Payer: Cofinity Commercial |
$1,093.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,017.60
|
| Rate for Payer: Healthscope Commercial |
$1,144.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$890.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$954.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,081.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$954.00
|
| Rate for Payer: PHP Commercial |
$1,081.20
|
| Rate for Payer: Priority Health SBD |
$801.36
|
| Rate for Payer: UMR Bronson Commercial |
$559.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$954.00
|
|
