|
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,970.05
|
|
|
Service Code
|
HCPCS J3424
|
| Hospital Charge Code |
155400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,306.82 |
| Max. Negotiated Rate |
$2,673.05 |
| Rate for Payer: Aetna American Axle |
$1,930.53
|
| Rate for Payer: Aetna Commercial |
$2,524.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,930.53
|
| Rate for Payer: Cash Price |
$2,376.04
|
| Rate for Payer: Cofinity Commercial |
$2,079.03
|
| Rate for Payer: Cofinity Commercial |
$2,554.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,079.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,376.04
|
| Rate for Payer: Healthscope Commercial |
$2,673.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,079.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,227.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,524.54
|
| Rate for Payer: PHP Commercial |
$2,524.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,930.53
|
| Rate for Payer: Priority Health SBD |
$1,871.13
|
| Rate for Payer: UMR Bronson Commercial |
$1,306.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,227.54
|
|
|
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,970.05
|
|
|
Service Code
|
HCPCS J3424
|
| Hospital Charge Code |
155400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$2,673.05 |
| Rate for Payer: Aetna American Axle |
$1,930.53
|
| Rate for Payer: Aetna Commercial |
$2,524.54
|
| Rate for Payer: Aetna Medicare |
$5.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,930.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.49
|
| Rate for Payer: BCBS Complete |
$2.92
|
| Rate for Payer: BCBS MAPPO |
$5.19
|
| Rate for Payer: BCN Medicare Advantage |
$5.19
|
| Rate for Payer: Cash Price |
$2,376.04
|
| Rate for Payer: Cash Price |
$2,376.04
|
| Rate for Payer: Cofinity Commercial |
$2,554.24
|
| Rate for Payer: Cofinity Commercial |
$2,079.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,079.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,376.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.19
|
| Rate for Payer: Healthscope Commercial |
$2,673.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,079.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,227.54
|
| Rate for Payer: Mclaren Medicaid |
$2.78
|
| Rate for Payer: Mclaren Medicare |
$5.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.45
|
| Rate for Payer: Meridian Medicaid |
$2.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,524.54
|
| Rate for Payer: PACE Medicare |
$4.93
|
| Rate for Payer: PACE SWMI |
$5.19
|
| Rate for Payer: PHP Commercial |
$2,524.54
|
| Rate for Payer: PHP Medicare Advantage |
$5.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,930.53
|
| Rate for Payer: Priority Health Medicare |
$5.19
|
| Rate for Payer: Priority Health SBD |
$1,871.13
|
| Rate for Payer: Railroad Medicare Medicare |
$5.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.19
|
| Rate for Payer: UHC Exchange |
$9.92
|
| Rate for Payer: UHC Medicare Advantage |
$5.19
|
| Rate for Payer: UHCCP Medicaid |
$2.78
|
| Rate for Payer: UMR Bronson Commercial |
$1,098.92
|
| Rate for Payer: VA VA |
$5.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,227.54
|
|
|
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 Commercial |
$171.36
|
| Rate for Payer: Cofinity Commercial |
$210.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.36
|
| 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: PHP Commercial |
$208.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.12
|
| Rate for Payer: Priority Health SBD |
$154.22
|
| 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
|
$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 Commercial |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.70
|
| 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: PHP Commercial |
$260.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.37
|
| 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
|
OP
|
$576.96
|
|
|
Service Code
|
NDC 68084026911
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.48 |
| Max. Negotiated Rate |
$519.26 |
| Rate for Payer: Aetna American Axle |
$375.02
|
| Rate for Payer: Aetna Commercial |
$490.42
|
| Rate for Payer: Aetna Medicare |
$288.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$375.02
|
| Rate for Payer: BCBS Complete |
$230.78
|
| Rate for Payer: Cash Price |
$461.57
|
| Rate for Payer: Cofinity Commercial |
$403.87
|
| Rate for Payer: Cofinity Commercial |
$496.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$403.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$461.57
|
| Rate for Payer: Healthscope Commercial |
$519.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$403.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$432.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$490.42
|
| Rate for Payer: PHP Commercial |
$490.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$375.02
|
| Rate for Payer: Priority Health SBD |
$363.48
|
| Rate for Payer: UMR Bronson Commercial |
$213.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$432.72
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$275.50
|
|
|
Service Code
|
NDC 43598072101
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.94 |
| Max. Negotiated Rate |
$247.95 |
| Rate for Payer: Aetna American Axle |
$179.07
|
| Rate for Payer: Aetna Commercial |
$234.18
|
| Rate for Payer: Aetna Medicare |
$137.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.07
|
| Rate for Payer: BCBS Complete |
$110.20
|
| Rate for Payer: Cash Price |
$220.40
|
| Rate for Payer: Cofinity Commercial |
$192.85
|
| Rate for Payer: Cofinity Commercial |
$236.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$192.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.40
|
| Rate for Payer: Healthscope Commercial |
$247.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$192.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$206.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.18
|
| Rate for Payer: PHP Commercial |
$234.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.07
|
| Rate for Payer: Priority Health SBD |
$173.56
|
| Rate for Payer: UMR Bronson Commercial |
$101.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.62
|
|
|
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 Commercial |
$1,019.76
|
| Rate for Payer: Cofinity Commercial |
$1,252.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,019.76
|
| 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: PHP Commercial |
$1,238.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$946.92
|
| 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
|
$195.12
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.19 |
| Max. Negotiated Rate |
$175.61 |
| Rate for Payer: Aetna American Axle |
$126.83
|
| Rate for Payer: Aetna Commercial |
$165.85
|
| Rate for Payer: Aetna Medicare |
$97.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.83
|
| Rate for Payer: BCBS Complete |
$78.05
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: Cofinity Commercial |
$136.58
|
| Rate for Payer: Cofinity Commercial |
$167.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.10
|
| Rate for Payer: Healthscope Commercial |
$175.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.85
|
| Rate for Payer: PHP Commercial |
$165.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.83
|
| Rate for Payer: Priority Health SBD |
$122.93
|
| Rate for Payer: UMR Bronson Commercial |
$72.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.34
|
|
|
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 Commercial |
$265.78
|
| Rate for Payer: Cofinity Commercial |
$326.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$265.78
|
| 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: PHP Commercial |
$322.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.79
|
| Rate for Payer: Priority Health SBD |
$239.20
|
| 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
|
$275.50
|
|
|
Service Code
|
NDC 43598072101
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.22 |
| Max. Negotiated Rate |
$247.95 |
| Rate for Payer: Aetna American Axle |
$179.07
|
| Rate for Payer: Aetna Commercial |
$234.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.07
|
| Rate for Payer: Cash Price |
$220.40
|
| Rate for Payer: Cofinity Commercial |
$192.85
|
| Rate for Payer: Cofinity Commercial |
$236.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$192.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.40
|
| Rate for Payer: Healthscope Commercial |
$247.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$192.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$206.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.18
|
| Rate for Payer: PHP Commercial |
$234.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.07
|
| Rate for Payer: Priority Health SBD |
$173.56
|
| Rate for Payer: UMR Bronson Commercial |
$121.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.62
|
|
|
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 Commercial |
$1,019.76
|
| Rate for Payer: Cofinity Commercial |
$1,252.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,019.76
|
| 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: PHP Commercial |
$1,238.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$946.92
|
| Rate for Payer: Priority Health SBD |
$917.78
|
| 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
|
$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 Commercial |
$171.36
|
| Rate for Payer: Cofinity Commercial |
$210.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.36
|
| 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: PHP Commercial |
$208.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.12
|
| 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
|
$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 Commercial |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.70
|
| 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: PHP Commercial |
$260.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.37
|
| Rate for Payer: Priority Health SBD |
$193.23
|
| Rate for Payer: UMR Bronson Commercial |
$113.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.04
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$195.12
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$175.61 |
| Rate for Payer: Aetna American Axle |
$126.83
|
| Rate for Payer: Aetna Commercial |
$165.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.83
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: Cofinity Commercial |
$136.58
|
| Rate for Payer: Cofinity Commercial |
$167.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.10
|
| Rate for Payer: Healthscope Commercial |
$175.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.85
|
| Rate for Payer: PHP Commercial |
$165.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.83
|
| Rate for Payer: Priority Health SBD |
$122.93
|
| Rate for Payer: UMR Bronson Commercial |
$85.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.34
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$576.96
|
|
|
Service Code
|
NDC 68084026911
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.86 |
| Max. Negotiated Rate |
$519.26 |
| Rate for Payer: Aetna American Axle |
$375.02
|
| Rate for Payer: Aetna Commercial |
$490.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$375.02
|
| Rate for Payer: Cash Price |
$461.57
|
| Rate for Payer: Cofinity Commercial |
$403.87
|
| Rate for Payer: Cofinity Commercial |
$496.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$403.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$461.57
|
| Rate for Payer: Healthscope Commercial |
$519.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$403.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$432.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$490.42
|
| Rate for Payer: PHP Commercial |
$490.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$375.02
|
| Rate for Payer: Priority Health SBD |
$363.48
|
| Rate for Payer: UMR Bronson Commercial |
$253.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$432.72
|
|
|
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 Commercial |
$265.78
|
| Rate for Payer: Cofinity Commercial |
$326.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$265.78
|
| 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: PHP Commercial |
$322.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.79
|
| 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
|
|
|
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 Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.06
|
| 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: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.55
|
| Rate for Payer: Priority Health SBD |
$157.55
|
| Rate for Payer: UMR Bronson Commercial |
$92.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.56
|
|
|
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 Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.06
|
| 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: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.55
|
| 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
|
$250.08
|
|
|
Service Code
|
NDC 49884072401
|
| 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 Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.06
|
| 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: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.55
|
| Rate for Payer: Priority Health SBD |
$157.55
|
| Rate for Payer: UMR Bronson Commercial |
$92.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.56
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$348.96
|
|
|
Service Code
|
NDC 00904693961
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.54 |
| Max. Negotiated Rate |
$314.06 |
| Rate for Payer: Aetna American Axle |
$226.82
|
| Rate for Payer: Aetna Commercial |
$296.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.82
|
| Rate for Payer: Cash Price |
$279.17
|
| Rate for Payer: Cofinity Commercial |
$244.27
|
| Rate for Payer: Cofinity Commercial |
$300.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$244.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$279.17
|
| Rate for Payer: Healthscope Commercial |
$314.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$244.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$296.62
|
| Rate for Payer: PHP Commercial |
$296.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.82
|
| Rate for Payer: Priority Health SBD |
$219.84
|
| Rate for Payer: UMR Bronson Commercial |
$153.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.72
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$250.08
|
|
|
Service Code
|
NDC 49884072401
|
| 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 Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.06
|
| 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: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.55
|
| 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
|
$348.96
|
|
|
Service Code
|
NDC 00904693961
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.12 |
| Max. Negotiated Rate |
$314.06 |
| Rate for Payer: Aetna American Axle |
$226.82
|
| Rate for Payer: Aetna Commercial |
$296.62
|
| Rate for Payer: Aetna Medicare |
$174.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.82
|
| Rate for Payer: BCBS Complete |
$139.58
|
| Rate for Payer: Cash Price |
$279.17
|
| Rate for Payer: Cofinity Commercial |
$244.27
|
| Rate for Payer: Cofinity Commercial |
$300.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$244.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$279.17
|
| Rate for Payer: Healthscope Commercial |
$314.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$244.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$296.62
|
| Rate for Payer: PHP Commercial |
$296.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.82
|
| Rate for Payer: Priority Health SBD |
$219.84
|
| Rate for Payer: UMR Bronson Commercial |
$129.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.72
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
OP
|
$1,272.00
|
|
|
Service Code
|
NDC 51552085104
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$470.64 |
| 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 Medicare |
$636.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$826.80
|
| Rate for Payer: BCBS Complete |
$508.80
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cofinity Commercial |
$1,093.92
|
| Rate for Payer: Cofinity Commercial |
$890.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$890.40
|
| 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: PHP Commercial |
$1,081.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$826.80
|
| Rate for Payer: Priority Health SBD |
$801.36
|
| Rate for Payer: UMR Bronson Commercial |
$470.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$954.00
|
|
|
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 Commercial |
$1,093.92
|
| Rate for Payer: Cofinity Commercial |
$890.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$890.40
|
| 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: PHP Commercial |
$1,081.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$826.80
|
| 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
|
|
|
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 Commercial |
$231.00
|
| Rate for Payer: Cofinity Commercial |
$283.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.00
|
| 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: PHP Commercial |
$280.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.50
|
| 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
|
|
