|
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 51079077601
|
| Hospital Charge Code |
19146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Aetna American Axle |
$2.00
|
| Rate for Payer: Aetna Commercial |
$2.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.00
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$2.16
|
| Rate for Payer: Cofinity Commercial |
$2.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.46
|
| Rate for Payer: Healthscope Commercial |
$2.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.62
|
| Rate for Payer: PHP Commercial |
$2.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.00
|
| Rate for Payer: Priority Health SBD |
$1.94
|
| Rate for Payer: UMR Bronson Commercial |
$1.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.31
|
|
|
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 29300013001
|
| Hospital Charge Code |
19146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.23 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna American Axle |
$145.11
|
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: Priority Health SBD |
$140.65
|
| Rate for Payer: UMR Bronson Commercial |
$98.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.44
|
|
|
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE
|
Facility
|
IP
|
$282.15
|
|
|
Service Code
|
NDC 00172487000
|
| Hospital Charge Code |
19146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.15 |
| Max. Negotiated Rate |
$253.94 |
| Rate for Payer: Aetna American Axle |
$183.40
|
| Rate for Payer: Aetna Commercial |
$239.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.40
|
| Rate for Payer: Cash Price |
$225.72
|
| Rate for Payer: Cofinity Commercial |
$197.50
|
| Rate for Payer: Cofinity Commercial |
$242.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.72
|
| Rate for Payer: Healthscope Commercial |
$253.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.83
|
| Rate for Payer: PHP Commercial |
$239.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.40
|
| Rate for Payer: Priority Health SBD |
$177.75
|
| Rate for Payer: UMR Bronson Commercial |
$124.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.61
|
|
|
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE
|
Facility
|
OP
|
$282.15
|
|
|
Service Code
|
NDC 00172487000
|
| Hospital Charge Code |
19146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.40 |
| Max. Negotiated Rate |
$253.94 |
| Rate for Payer: Aetna American Axle |
$183.40
|
| Rate for Payer: Aetna Commercial |
$239.83
|
| Rate for Payer: Aetna Medicare |
$141.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.40
|
| Rate for Payer: BCBS Complete |
$112.86
|
| Rate for Payer: Cash Price |
$225.72
|
| Rate for Payer: Cofinity Commercial |
$197.50
|
| Rate for Payer: Cofinity Commercial |
$242.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.72
|
| Rate for Payer: Healthscope Commercial |
$253.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.83
|
| Rate for Payer: PHP Commercial |
$239.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.40
|
| Rate for Payer: Priority Health SBD |
$177.75
|
| Rate for Payer: UMR Bronson Commercial |
$104.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.61
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.32 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$192.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 60687059311
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Aetna American Axle |
$2.85
|
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Aetna Medicare |
$2.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.85
|
| Rate for Payer: BCBS Complete |
$1.75
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Cofinity Commercial |
$3.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$3.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.72
|
| Rate for Payer: PHP Commercial |
$3.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.85
|
| Rate for Payer: Priority Health SBD |
$2.76
|
| Rate for Payer: UMR Bronson Commercial |
$1.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.29
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 29300012801
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.05
|
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.05
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$39.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.97
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 60687059311
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Aetna American Axle |
$2.85
|
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.85
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Cofinity Commercial |
$3.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$3.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.72
|
| Rate for Payer: PHP Commercial |
$3.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.85
|
| Rate for Payer: Priority Health SBD |
$2.76
|
| Rate for Payer: UMR Bronson Commercial |
$1.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.29
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.73 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna Medicare |
$218.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: BCBS Complete |
$174.84
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$161.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$23.50
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$21.15 |
| Rate for Payer: Aetna American Axle |
$15.28
|
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna Medicare |
$11.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.28
|
| Rate for Payer: BCBS Complete |
$9.40
|
| Rate for Payer: Cash Price |
$18.80
|
| Rate for Payer: Cofinity Commercial |
$16.45
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.80
|
| Rate for Payer: Healthscope Commercial |
$21.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.98
|
| Rate for Payer: PHP Commercial |
$19.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.28
|
| Rate for Payer: Priority Health SBD |
$14.80
|
| Rate for Payer: UMR Bronson Commercial |
$8.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.62
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$23.50
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$21.15 |
| Rate for Payer: Aetna American Axle |
$15.28
|
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.28
|
| Rate for Payer: Cash Price |
$18.80
|
| Rate for Payer: Cofinity Commercial |
$16.45
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.80
|
| Rate for Payer: Healthscope Commercial |
$21.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.98
|
| Rate for Payer: PHP Commercial |
$19.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.28
|
| Rate for Payer: Priority Health SBD |
$14.80
|
| Rate for Payer: UMR Bronson Commercial |
$10.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.62
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$49.35
|
|
|
Service Code
|
NDC 69584036110
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.26 |
| Max. Negotiated Rate |
$44.41 |
| Rate for Payer: Aetna American Axle |
$32.08
|
| Rate for Payer: Aetna Commercial |
$41.95
|
| Rate for Payer: Aetna Medicare |
$24.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.08
|
| Rate for Payer: BCBS Complete |
$19.74
|
| Rate for Payer: Cash Price |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$34.55
|
| Rate for Payer: Cofinity Commercial |
$42.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.48
|
| Rate for Payer: Healthscope Commercial |
$44.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.95
|
| Rate for Payer: PHP Commercial |
$41.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.08
|
| Rate for Payer: Priority Health SBD |
$31.09
|
| Rate for Payer: UMR Bronson Commercial |
$18.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.01
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$49.35
|
|
|
Service Code
|
NDC 69584036110
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$44.41 |
| Rate for Payer: Aetna American Axle |
$32.08
|
| Rate for Payer: Aetna Commercial |
$41.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.08
|
| Rate for Payer: Cash Price |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$34.55
|
| Rate for Payer: Cofinity Commercial |
$42.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.48
|
| Rate for Payer: Healthscope Commercial |
$44.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.95
|
| Rate for Payer: PHP Commercial |
$41.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.08
|
| Rate for Payer: Priority Health SBD |
$31.09
|
| Rate for Payer: UMR Bronson Commercial |
$21.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.01
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$89.30
|
|
|
Service Code
|
NDC 29300012801
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.04 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.05
|
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna Medicare |
$44.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: BCBS Complete |
$35.72
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.05
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$33.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.97
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$995.75
|
|
|
Service Code
|
NDC 60687041801
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$438.13 |
| Max. Negotiated Rate |
$896.17 |
| Rate for Payer: Aetna American Axle |
$647.24
|
| Rate for Payer: Aetna Commercial |
$846.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$647.24
|
| Rate for Payer: Cash Price |
$796.60
|
| Rate for Payer: Cofinity Commercial |
$697.02
|
| Rate for Payer: Cofinity Commercial |
$856.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$697.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$796.60
|
| Rate for Payer: Healthscope Commercial |
$896.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$697.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$746.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$846.39
|
| Rate for Payer: PHP Commercial |
$846.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$647.24
|
| Rate for Payer: Priority Health SBD |
$627.32
|
| Rate for Payer: UMR Bronson Commercial |
$438.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$746.81
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
NDC 60687041811
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna American Axle |
$6.47
|
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.47
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cofinity Commercial |
$6.97
|
| Rate for Payer: Cofinity Commercial |
$8.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.97
|
| Rate for Payer: Healthscope Commercial |
$8.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.47
|
| Rate for Payer: PHP Commercial |
$8.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.47
|
| Rate for Payer: Priority Health SBD |
$6.27
|
| Rate for Payer: UMR Bronson Commercial |
$4.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.47
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
NDC 60687041811
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna American Axle |
$6.47
|
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Aetna Medicare |
$4.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.47
|
| Rate for Payer: BCBS Complete |
$3.98
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cofinity Commercial |
$6.97
|
| Rate for Payer: Cofinity Commercial |
$8.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.97
|
| Rate for Payer: Healthscope Commercial |
$8.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.47
|
| Rate for Payer: PHP Commercial |
$8.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.47
|
| Rate for Payer: Priority Health SBD |
$6.27
|
| Rate for Payer: UMR Bronson Commercial |
$3.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.47
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
NDC 27808003701
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna American Axle |
$113.75
|
| Rate for Payer: Aetna Commercial |
$148.75
|
| Rate for Payer: Aetna Medicare |
$87.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.75
|
| Rate for Payer: BCBS Complete |
$70.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Cofinity Commercial |
$150.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.00
|
| Rate for Payer: Healthscope Commercial |
$157.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.75
|
| Rate for Payer: PHP Commercial |
$148.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.75
|
| Rate for Payer: Priority Health SBD |
$110.25
|
| Rate for Payer: UMR Bronson Commercial |
$64.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.25
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$995.75
|
|
|
Service Code
|
NDC 60687041801
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$368.43 |
| Max. Negotiated Rate |
$896.17 |
| Rate for Payer: Aetna American Axle |
$647.24
|
| Rate for Payer: Aetna Commercial |
$846.39
|
| Rate for Payer: Aetna Medicare |
$497.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$647.24
|
| Rate for Payer: BCBS Complete |
$398.30
|
| Rate for Payer: Cash Price |
$796.60
|
| Rate for Payer: Cofinity Commercial |
$697.02
|
| Rate for Payer: Cofinity Commercial |
$856.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$697.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$796.60
|
| Rate for Payer: Healthscope Commercial |
$896.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$697.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$746.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$846.39
|
| Rate for Payer: PHP Commercial |
$846.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$647.24
|
| Rate for Payer: Priority Health SBD |
$627.32
|
| Rate for Payer: UMR Bronson Commercial |
$368.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$746.81
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$8.04
|
|
|
Service Code
|
NDC 00406012523
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$7.24 |
| Rate for Payer: Aetna American Axle |
$5.23
|
| Rate for Payer: Aetna Commercial |
$6.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.23
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$5.63
|
| Rate for Payer: Cofinity Commercial |
$6.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.43
|
| Rate for Payer: Healthscope Commercial |
$7.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.83
|
| Rate for Payer: PHP Commercial |
$6.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.23
|
| Rate for Payer: Priority Health SBD |
$5.07
|
| Rate for Payer: UMR Bronson Commercial |
$3.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.03
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$8.04
|
|
|
Service Code
|
NDC 00406012523
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$7.24 |
| Rate for Payer: Aetna American Axle |
$5.23
|
| Rate for Payer: Aetna Commercial |
$6.83
|
| Rate for Payer: Aetna Medicare |
$4.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.23
|
| Rate for Payer: BCBS Complete |
$3.22
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$5.63
|
| Rate for Payer: Cofinity Commercial |
$6.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.43
|
| Rate for Payer: Healthscope Commercial |
$7.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.83
|
| Rate for Payer: PHP Commercial |
$6.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.23
|
| Rate for Payer: Priority Health SBD |
$5.07
|
| Rate for Payer: UMR Bronson Commercial |
$2.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.03
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$686.00
|
|
|
Service Code
|
NDC 00904682561
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.84 |
| Max. Negotiated Rate |
$617.40 |
| Rate for Payer: Aetna American Axle |
$445.90
|
| Rate for Payer: Aetna Commercial |
$583.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$445.90
|
| Rate for Payer: Cash Price |
$548.80
|
| Rate for Payer: Cofinity Commercial |
$480.20
|
| Rate for Payer: Cofinity Commercial |
$589.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$480.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$548.80
|
| Rate for Payer: Healthscope Commercial |
$617.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$480.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$514.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$583.10
|
| Rate for Payer: PHP Commercial |
$583.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$445.90
|
| Rate for Payer: Priority Health SBD |
$432.18
|
| Rate for Payer: UMR Bronson Commercial |
$301.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$514.50
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$686.00
|
|
|
Service Code
|
NDC 00904682561
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.82 |
| Max. Negotiated Rate |
$617.40 |
| Rate for Payer: Aetna American Axle |
$445.90
|
| Rate for Payer: Aetna Commercial |
$583.10
|
| Rate for Payer: Aetna Medicare |
$343.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$445.90
|
| Rate for Payer: BCBS Complete |
$274.40
|
| Rate for Payer: Cash Price |
$548.80
|
| Rate for Payer: Cofinity Commercial |
$480.20
|
| Rate for Payer: Cofinity Commercial |
$589.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$480.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$548.80
|
| Rate for Payer: Healthscope Commercial |
$617.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$480.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$514.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$583.10
|
| Rate for Payer: PHP Commercial |
$583.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$445.90
|
| Rate for Payer: Priority Health SBD |
$432.18
|
| Rate for Payer: UMR Bronson Commercial |
$253.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$514.50
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$241.50
|
|
|
Service Code
|
NDC 53746011001
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.26 |
| Max. Negotiated Rate |
$217.35 |
| Rate for Payer: Aetna American Axle |
$156.97
|
| Rate for Payer: Aetna Commercial |
$205.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.97
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$169.05
|
| Rate for Payer: Cofinity Commercial |
$207.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$169.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.20
|
| Rate for Payer: Healthscope Commercial |
$217.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.28
|
| Rate for Payer: PHP Commercial |
$205.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.97
|
| Rate for Payer: Priority Health SBD |
$152.15
|
| Rate for Payer: UMR Bronson Commercial |
$106.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.12
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
NDC 27808003701
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna American Axle |
$113.75
|
| Rate for Payer: Aetna Commercial |
$148.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.75
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Cofinity Commercial |
$150.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.00
|
| Rate for Payer: Healthscope Commercial |
$157.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.75
|
| Rate for Payer: PHP Commercial |
$148.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.75
|
| Rate for Payer: Priority Health SBD |
$110.25
|
| Rate for Payer: UMR Bronson Commercial |
$77.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.25
|
|
