|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.64 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna American Axle |
$273.42
|
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna Medicare |
$210.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.42
|
| Rate for Payer: BCBS Complete |
$168.26
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Advantage |
$294.45
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$336.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.49
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health SBD |
$265.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.42
|
| Rate for Payer: UHC Core |
$219.16
|
| Rate for Payer: UHC Exchange |
$165.32
|
| Rate for Payer: UMR Bronson Commercial |
$155.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$1,069.25
|
|
|
Service Code
|
NDC 68462030205
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$470.47 |
| Max. Negotiated Rate |
$962.33 |
| Rate for Payer: Aetna American Axle |
$695.01
|
| Rate for Payer: Aetna Commercial |
$908.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$695.01
|
| Rate for Payer: Cash Price |
$855.40
|
| Rate for Payer: Cofinity Advantage |
$748.48
|
| Rate for Payer: Cofinity Commercial |
$919.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$855.40
|
| Rate for Payer: Healthscope Commercial |
$962.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$748.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$801.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$908.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$801.94
|
| Rate for Payer: PHP Commercial |
$908.86
|
| Rate for Payer: Priority Health SBD |
$673.63
|
| Rate for Payer: UMR Bronson Commercial |
$470.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$801.94
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
OP
|
$120.18
|
|
|
Service Code
|
NDC 50268043115
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.47 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna American Axle |
$78.12
|
| Rate for Payer: Aetna Commercial |
$102.15
|
| Rate for Payer: Aetna Medicare |
$60.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.12
|
| Rate for Payer: BCBS Complete |
$48.07
|
| Rate for Payer: Cash Price |
$96.14
|
| Rate for Payer: Cofinity Advantage |
$84.13
|
| Rate for Payer: Cofinity Commercial |
$103.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.14
|
| Rate for Payer: Healthscope Commercial |
$108.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$96.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.14
|
| Rate for Payer: PHP Commercial |
$102.15
|
| Rate for Payer: Priority Health SBD |
$75.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$78.12
|
| Rate for Payer: UHC Core |
$62.61
|
| Rate for Payer: UHC Exchange |
$47.23
|
| Rate for Payer: UMR Bronson Commercial |
$44.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.14
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
OP
|
$293.75
|
|
|
Service Code
|
NDC 68462030201
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.69 |
| Max. Negotiated Rate |
$264.38 |
| Rate for Payer: Aetna American Axle |
$190.94
|
| Rate for Payer: Aetna Commercial |
$249.69
|
| Rate for Payer: Aetna Medicare |
$146.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.94
|
| Rate for Payer: BCBS Complete |
$117.50
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cofinity Advantage |
$205.62
|
| Rate for Payer: Cofinity Commercial |
$252.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.00
|
| Rate for Payer: Healthscope Commercial |
$264.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$205.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$235.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.31
|
| Rate for Payer: PHP Commercial |
$249.69
|
| Rate for Payer: Priority Health SBD |
$185.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.94
|
| Rate for Payer: UHC Core |
$153.04
|
| Rate for Payer: UHC Exchange |
$115.44
|
| Rate for Payer: UMR Bronson Commercial |
$108.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.31
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
NDC 50268043111
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna American Axle |
$1.57
|
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.57
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cofinity Advantage |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.93
|
| Rate for Payer: Healthscope Commercial |
$2.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.81
|
| Rate for Payer: PHP Commercial |
$2.05
|
| Rate for Payer: Priority Health SBD |
$1.52
|
| Rate for Payer: UMR Bronson Commercial |
$1.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$293.75
|
|
|
Service Code
|
NDC 68462030201
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.25 |
| Max. Negotiated Rate |
$264.38 |
| Rate for Payer: Aetna American Axle |
$190.94
|
| Rate for Payer: Aetna Commercial |
$249.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.94
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cofinity Advantage |
$205.62
|
| Rate for Payer: Cofinity Commercial |
$252.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.00
|
| Rate for Payer: Healthscope Commercial |
$264.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$205.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.31
|
| Rate for Payer: PHP Commercial |
$249.69
|
| Rate for Payer: Priority Health SBD |
$185.06
|
| Rate for Payer: UMR Bronson Commercial |
$129.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.31
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
OP
|
$1,069.25
|
|
|
Service Code
|
NDC 68462030205
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$395.62 |
| Max. Negotiated Rate |
$962.33 |
| Rate for Payer: Aetna American Axle |
$695.01
|
| Rate for Payer: Aetna Commercial |
$908.86
|
| Rate for Payer: Aetna Medicare |
$534.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$695.01
|
| Rate for Payer: BCBS Complete |
$427.70
|
| Rate for Payer: Cash Price |
$855.40
|
| Rate for Payer: Cofinity Advantage |
$748.48
|
| Rate for Payer: Cofinity Commercial |
$919.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$855.40
|
| Rate for Payer: Healthscope Commercial |
$962.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$748.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$801.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$855.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$908.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$801.94
|
| Rate for Payer: PHP Commercial |
$908.86
|
| Rate for Payer: Priority Health SBD |
$673.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$695.01
|
| Rate for Payer: UHC Core |
$557.08
|
| Rate for Payer: UHC Exchange |
$420.22
|
| Rate for Payer: UMR Bronson Commercial |
$395.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$801.94
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
OP
|
$2.41
|
|
|
Service Code
|
NDC 50268043111
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna American Axle |
$1.57
|
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: Aetna Medicare |
$1.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.57
|
| Rate for Payer: BCBS Complete |
$0.96
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cofinity Advantage |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.93
|
| Rate for Payer: Healthscope Commercial |
$2.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.81
|
| Rate for Payer: PHP Commercial |
$2.05
|
| Rate for Payer: Priority Health SBD |
$1.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.57
|
| Rate for Payer: UHC Core |
$1.26
|
| Rate for Payer: UHC Exchange |
$0.95
|
| Rate for Payer: UMR Bronson Commercial |
$0.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$120.18
|
|
|
Service Code
|
NDC 50268043115
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.88 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna American Axle |
$78.12
|
| Rate for Payer: Aetna Commercial |
$102.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.12
|
| Rate for Payer: Cash Price |
$96.14
|
| Rate for Payer: Cofinity Advantage |
$84.13
|
| Rate for Payer: Cofinity Commercial |
$103.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.14
|
| Rate for Payer: Healthscope Commercial |
$108.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.14
|
| Rate for Payer: PHP Commercial |
$102.15
|
| Rate for Payer: Priority Health SBD |
$75.71
|
| Rate for Payer: UMR Bronson Commercial |
$52.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.14
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$22,239.41
|
|
|
Service Code
|
NDC 69238208603
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,228.58 |
| Max. Negotiated Rate |
$20,015.47 |
| Rate for Payer: Aetna American Axle |
$14,455.62
|
| Rate for Payer: Aetna Commercial |
$18,903.50
|
| Rate for Payer: Aetna Medicare |
$11,119.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14,455.62
|
| Rate for Payer: BCBS Complete |
$8,895.76
|
| Rate for Payer: Cash Price |
$17,791.53
|
| Rate for Payer: Cofinity Advantage |
$15,567.59
|
| Rate for Payer: Cofinity Commercial |
$19,125.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17,791.53
|
| Rate for Payer: Healthscope Commercial |
$20,015.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15,567.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16,679.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,791.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18,903.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16,679.56
|
| Rate for Payer: PHP Commercial |
$18,903.50
|
| Rate for Payer: Priority Health SBD |
$14,010.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,455.62
|
| Rate for Payer: UHC Core |
$11,586.73
|
| Rate for Payer: UHC Exchange |
$8,740.09
|
| Rate for Payer: UMR Bronson Commercial |
$8,228.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16,679.56
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$22,239.41
|
|
|
Service Code
|
NDC 69238208603
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,785.34 |
| Max. Negotiated Rate |
$20,015.47 |
| Rate for Payer: Aetna American Axle |
$14,455.62
|
| Rate for Payer: Aetna Commercial |
$18,903.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14,455.62
|
| Rate for Payer: Cash Price |
$17,791.53
|
| Rate for Payer: Cofinity Advantage |
$15,567.59
|
| Rate for Payer: Cofinity Commercial |
$19,125.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17,791.53
|
| Rate for Payer: Healthscope Commercial |
$20,015.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15,567.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16,679.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18,903.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16,679.56
|
| Rate for Payer: PHP Commercial |
$18,903.50
|
| Rate for Payer: Priority Health SBD |
$14,010.83
|
| Rate for Payer: UMR Bronson Commercial |
$9,785.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16,679.56
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$672.40
|
|
|
Service Code
|
NDC 31722005132
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$295.86 |
| Max. Negotiated Rate |
$605.16 |
| Rate for Payer: Aetna American Axle |
$437.06
|
| Rate for Payer: Aetna Commercial |
$571.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.06
|
| Rate for Payer: Cash Price |
$537.92
|
| Rate for Payer: Cofinity Advantage |
$470.68
|
| Rate for Payer: Cofinity Commercial |
$578.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$537.92
|
| Rate for Payer: Healthscope Commercial |
$605.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$470.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$504.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$571.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$504.30
|
| Rate for Payer: PHP Commercial |
$571.54
|
| Rate for Payer: Priority Health SBD |
$423.61
|
| Rate for Payer: UMR Bronson Commercial |
$295.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$504.30
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$17,872.56
|
|
|
Service Code
|
NDC 70710185207
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,863.93 |
| Max. Negotiated Rate |
$16,085.30 |
| Rate for Payer: Aetna American Axle |
$11,617.16
|
| Rate for Payer: Aetna Commercial |
$15,191.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,617.16
|
| Rate for Payer: Cash Price |
$14,298.05
|
| Rate for Payer: Cofinity Advantage |
$12,510.79
|
| Rate for Payer: Cofinity Commercial |
$15,370.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,298.05
|
| Rate for Payer: Healthscope Commercial |
$16,085.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,510.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,404.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,191.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,404.42
|
| Rate for Payer: PHP Commercial |
$15,191.68
|
| Rate for Payer: Priority Health SBD |
$11,259.71
|
| Rate for Payer: UMR Bronson Commercial |
$7,863.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,404.42
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$18,935.61
|
|
|
Service Code
|
NDC 0054195030
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,006.18 |
| Max. Negotiated Rate |
$17,042.05 |
| Rate for Payer: Aetna American Axle |
$12,308.15
|
| Rate for Payer: Aetna Commercial |
$16,095.27
|
| Rate for Payer: Aetna Medicare |
$9,467.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,308.15
|
| Rate for Payer: BCBS Complete |
$7,574.24
|
| Rate for Payer: Cash Price |
$15,148.49
|
| Rate for Payer: Cofinity Advantage |
$13,254.93
|
| Rate for Payer: Cofinity Commercial |
$16,284.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,148.49
|
| Rate for Payer: Healthscope Commercial |
$17,042.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,254.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,201.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,148.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,095.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,201.71
|
| Rate for Payer: PHP Commercial |
$16,095.27
|
| Rate for Payer: Priority Health SBD |
$11,929.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,308.15
|
| Rate for Payer: UHC Core |
$9,865.45
|
| Rate for Payer: UHC Exchange |
$7,441.69
|
| Rate for Payer: UMR Bronson Commercial |
$7,006.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,201.71
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$20,171.81
|
|
|
Service Code
|
NDC 31722005131
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,875.60 |
| Max. Negotiated Rate |
$18,154.63 |
| Rate for Payer: Aetna American Axle |
$13,111.68
|
| Rate for Payer: Aetna Commercial |
$17,146.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,111.68
|
| Rate for Payer: Cash Price |
$16,137.45
|
| Rate for Payer: Cofinity Advantage |
$14,120.27
|
| Rate for Payer: Cofinity Commercial |
$17,347.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,137.45
|
| Rate for Payer: Healthscope Commercial |
$18,154.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,120.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,128.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,146.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,128.86
|
| Rate for Payer: PHP Commercial |
$17,146.04
|
| Rate for Payer: Priority Health SBD |
$12,708.24
|
| Rate for Payer: UMR Bronson Commercial |
$8,875.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,128.86
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$18,935.61
|
|
|
Service Code
|
NDC 0054195030
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,331.67 |
| Max. Negotiated Rate |
$17,042.05 |
| Rate for Payer: Aetna American Axle |
$12,308.15
|
| Rate for Payer: Aetna Commercial |
$16,095.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,308.15
|
| Rate for Payer: Cash Price |
$15,148.49
|
| Rate for Payer: Cofinity Advantage |
$13,254.93
|
| Rate for Payer: Cofinity Commercial |
$16,284.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,148.49
|
| Rate for Payer: Healthscope Commercial |
$17,042.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,254.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,201.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,095.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,201.71
|
| Rate for Payer: PHP Commercial |
$16,095.27
|
| Rate for Payer: Priority Health SBD |
$11,929.43
|
| Rate for Payer: UMR Bronson Commercial |
$8,331.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,201.71
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$672.40
|
|
|
Service Code
|
NDC 31722005132
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$248.79 |
| Max. Negotiated Rate |
$605.16 |
| Rate for Payer: Aetna American Axle |
$437.06
|
| Rate for Payer: Aetna Commercial |
$571.54
|
| Rate for Payer: Aetna Medicare |
$336.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.06
|
| Rate for Payer: BCBS Complete |
$268.96
|
| Rate for Payer: Cash Price |
$537.92
|
| Rate for Payer: Cofinity Advantage |
$470.68
|
| Rate for Payer: Cofinity Commercial |
$578.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$537.92
|
| Rate for Payer: Healthscope Commercial |
$605.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$470.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$504.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$537.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$571.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$504.30
|
| Rate for Payer: PHP Commercial |
$571.54
|
| Rate for Payer: Priority Health SBD |
$423.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$437.06
|
| Rate for Payer: UHC Core |
$350.32
|
| Rate for Payer: UHC Exchange |
$264.25
|
| Rate for Payer: UMR Bronson Commercial |
$248.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$504.30
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$20,171.81
|
|
|
Service Code
|
NDC 31722005131
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,463.57 |
| Max. Negotiated Rate |
$18,154.63 |
| Rate for Payer: Aetna American Axle |
$13,111.68
|
| Rate for Payer: Aetna Commercial |
$17,146.04
|
| Rate for Payer: Aetna Medicare |
$10,085.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,111.68
|
| Rate for Payer: BCBS Complete |
$8,068.72
|
| Rate for Payer: Cash Price |
$16,137.45
|
| Rate for Payer: Cofinity Advantage |
$14,120.27
|
| Rate for Payer: Cofinity Commercial |
$17,347.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,137.45
|
| Rate for Payer: Healthscope Commercial |
$18,154.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,120.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,128.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,137.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,146.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,128.86
|
| Rate for Payer: PHP Commercial |
$17,146.04
|
| Rate for Payer: Priority Health SBD |
$12,708.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,111.68
|
| Rate for Payer: UHC Core |
$10,509.51
|
| Rate for Payer: UHC Exchange |
$7,927.52
|
| Rate for Payer: UMR Bronson Commercial |
$7,463.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,128.86
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$14,624.25
|
|
|
Service Code
|
NDC 69344010233
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,410.97 |
| Max. Negotiated Rate |
$13,161.83 |
| Rate for Payer: Aetna American Axle |
$9,505.76
|
| Rate for Payer: Aetna Commercial |
$12,430.61
|
| Rate for Payer: Aetna Medicare |
$7,312.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,505.76
|
| Rate for Payer: BCBS Complete |
$5,849.70
|
| Rate for Payer: Cash Price |
$11,699.40
|
| Rate for Payer: Cofinity Advantage |
$10,236.98
|
| Rate for Payer: Cofinity Commercial |
$12,576.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,699.40
|
| Rate for Payer: Healthscope Commercial |
$13,161.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,236.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,968.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,699.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,430.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10,968.19
|
| Rate for Payer: PHP Commercial |
$12,430.61
|
| Rate for Payer: Priority Health SBD |
$9,213.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,505.76
|
| Rate for Payer: UHC Core |
$7,619.23
|
| Rate for Payer: UHC Exchange |
$5,747.33
|
| Rate for Payer: UMR Bronson Commercial |
$5,410.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,968.19
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$595.76
|
|
|
Service Code
|
NDC 70710185206
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$220.43 |
| Max. Negotiated Rate |
$536.18 |
| Rate for Payer: Aetna American Axle |
$387.24
|
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna Medicare |
$297.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.24
|
| Rate for Payer: BCBS Complete |
$238.30
|
| Rate for Payer: Cash Price |
$476.61
|
| Rate for Payer: Cofinity Advantage |
$417.03
|
| Rate for Payer: Cofinity Commercial |
$512.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.61
|
| Rate for Payer: Healthscope Commercial |
$536.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$417.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$476.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$446.82
|
| Rate for Payer: PHP Commercial |
$506.40
|
| Rate for Payer: Priority Health SBD |
$375.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$387.24
|
| Rate for Payer: UHC Core |
$310.39
|
| Rate for Payer: UHC Exchange |
$234.13
|
| Rate for Payer: UMR Bronson Commercial |
$220.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.82
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$14,624.25
|
|
|
Service Code
|
NDC 69344010233
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,434.67 |
| Max. Negotiated Rate |
$13,161.83 |
| Rate for Payer: Aetna American Axle |
$9,505.76
|
| Rate for Payer: Aetna Commercial |
$12,430.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,505.76
|
| Rate for Payer: Cash Price |
$11,699.40
|
| Rate for Payer: Cofinity Advantage |
$10,236.98
|
| Rate for Payer: Cofinity Commercial |
$12,576.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,699.40
|
| Rate for Payer: Healthscope Commercial |
$13,161.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,236.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,968.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,430.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10,968.19
|
| Rate for Payer: PHP Commercial |
$12,430.61
|
| Rate for Payer: Priority Health SBD |
$9,213.28
|
| Rate for Payer: UMR Bronson Commercial |
$6,434.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,968.19
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$595.76
|
|
|
Service Code
|
NDC 70710185206
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$262.13 |
| Max. Negotiated Rate |
$536.18 |
| Rate for Payer: Aetna American Axle |
$387.24
|
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.24
|
| Rate for Payer: Cash Price |
$476.61
|
| Rate for Payer: Cofinity Advantage |
$417.03
|
| Rate for Payer: Cofinity Commercial |
$512.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.61
|
| Rate for Payer: Healthscope Commercial |
$536.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$417.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$446.82
|
| Rate for Payer: PHP Commercial |
$506.40
|
| Rate for Payer: Priority Health SBD |
$375.33
|
| Rate for Payer: UMR Bronson Commercial |
$262.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.82
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$17,872.56
|
|
|
Service Code
|
NDC 70710185207
|
| Hospital Charge Code |
3901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,612.85 |
| Max. Negotiated Rate |
$16,085.30 |
| Rate for Payer: Aetna American Axle |
$11,617.16
|
| Rate for Payer: Aetna Commercial |
$15,191.68
|
| Rate for Payer: Aetna Medicare |
$8,936.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,617.16
|
| Rate for Payer: BCBS Complete |
$7,149.02
|
| Rate for Payer: Cash Price |
$14,298.05
|
| Rate for Payer: Cofinity Advantage |
$12,510.79
|
| Rate for Payer: Cofinity Commercial |
$15,370.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,298.05
|
| Rate for Payer: Healthscope Commercial |
$16,085.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,510.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,404.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,298.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,191.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,404.42
|
| Rate for Payer: PHP Commercial |
$15,191.68
|
| Rate for Payer: Priority Health SBD |
$11,259.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,617.16
|
| Rate for Payer: UHC Core |
$9,311.60
|
| Rate for Payer: UHC Exchange |
$7,023.92
|
| Rate for Payer: UMR Bronson Commercial |
$6,612.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,404.42
|
|
|
INDUCED ABORTION, BY DILATION AND CURETTAGE
|
Facility
|
OP
|
$10,430.93
|
|
|
Service Code
|
CPT 59840
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,630.99 |
| Max. Negotiated Rate |
$10,430.93 |
| Rate for Payer: Aetna Medicare |
$3,354.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,031.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,031.86
|
| Rate for Payer: BCBS Complete |
$1,771.44
|
| Rate for Payer: BCBS MAPPO |
$3,225.49
|
| Rate for Payer: BCBS Trust/PPO |
$1,630.99
|
| Rate for Payer: BCN Commercial |
$1,630.99
|
| Rate for Payer: BCN Medicare Advantage |
$3,225.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,225.49
|
| Rate for Payer: Mclaren Medicaid |
$3,225.49
|
| Rate for Payer: Mclaren Medicare |
$3,225.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,386.76
|
| Rate for Payer: Meridian Medicaid |
$3,386.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,709.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,548.04
|
| Rate for Payer: Nomi Health Commercial |
$9,676.47
|
| Rate for Payer: PACE Medicare |
$3,064.22
|
| Rate for Payer: PACE SWMI |
$3,225.49
|
| Rate for Payer: PHP Medicare Advantage |
$3,225.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,686.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,430.93
|
| Rate for Payer: Priority Health Medicare |
$3,225.49
|
| Rate for Payer: Priority Health Tiered Network |
$8,344.74
|
| Rate for Payer: Railroad Medicare Medicare |
$3,225.49
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,225.49
|
| Rate for Payer: UHC Medicaid |
$1,686.93
|
| Rate for Payer: UHCCP Medicaid |
$1,686.93
|
| Rate for Payer: VA VA |
$3,225.49
|
|
|
INDUCED ABORTION, BY DILATION AND EVACUATION
|
Facility
|
OP
|
$10,430.93
|
|
|
Service Code
|
CPT 59841
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,686.93 |
| Max. Negotiated Rate |
$10,430.93 |
| Rate for Payer: Aetna Medicare |
$3,354.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,031.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,031.86
|
| Rate for Payer: BCBS Complete |
$1,771.44
|
| Rate for Payer: BCBS MAPPO |
$3,225.49
|
| Rate for Payer: BCBS Trust/PPO |
$4,918.70
|
| Rate for Payer: BCN Commercial |
$4,918.70
|
| Rate for Payer: BCN Medicare Advantage |
$3,225.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,225.49
|
| Rate for Payer: Mclaren Medicaid |
$3,225.49
|
| Rate for Payer: Mclaren Medicare |
$3,225.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,386.76
|
| Rate for Payer: Meridian Medicaid |
$3,386.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,709.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,548.04
|
| Rate for Payer: Nomi Health Commercial |
$9,676.47
|
| Rate for Payer: PACE Medicare |
$3,064.22
|
| Rate for Payer: PACE SWMI |
$3,225.49
|
| Rate for Payer: PHP Medicare Advantage |
$3,225.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,686.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,430.93
|
| Rate for Payer: Priority Health Medicare |
$3,225.49
|
| Rate for Payer: Priority Health Tiered Network |
$8,344.74
|
| Rate for Payer: Railroad Medicare Medicare |
$3,225.49
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,225.49
|
| Rate for Payer: UHC Medicaid |
$1,686.93
|
| Rate for Payer: UHCCP Medicaid |
$1,686.93
|
| Rate for Payer: VA VA |
$3,225.49
|
|
