|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.49 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$120.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.25 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$102.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.54 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$230.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070102
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.54 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$230.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.87 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$193.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$232.38
|
|
|
Service Code
|
NDC 17238042425
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.98 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna Medicare |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: BCBS Complete |
$92.95
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$85.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.87 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Commercial |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.57
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$193.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070102
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.49 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$120.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Commercial |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.67
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$957.40
|
|
|
Service Code
|
NDC 63323065903
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$421.26 |
| Max. Negotiated Rate |
$861.66 |
| Rate for Payer: Aetna American Axle |
$622.31
|
| Rate for Payer: Aetna Commercial |
$813.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.31
|
| Rate for Payer: Cash Price |
$765.92
|
| Rate for Payer: Cofinity Commercial |
$670.18
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$670.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$765.92
|
| Rate for Payer: Healthscope Commercial |
$861.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$813.79
|
| Rate for Payer: PHP Commercial |
$813.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$622.31
|
| Rate for Payer: Priority Health SBD |
$603.16
|
| Rate for Payer: UMR Bronson Commercial |
$421.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.05
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$962.98
|
|
|
Service Code
|
NDC 63323065909
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$356.30 |
| Max. Negotiated Rate |
$866.68 |
| Rate for Payer: Aetna American Axle |
$625.94
|
| Rate for Payer: Aetna Commercial |
$818.53
|
| Rate for Payer: Aetna Medicare |
$481.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$625.94
|
| Rate for Payer: BCBS Complete |
$385.19
|
| Rate for Payer: Cash Price |
$770.38
|
| Rate for Payer: Cofinity Commercial |
$674.09
|
| Rate for Payer: Cofinity Commercial |
$828.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$674.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$770.38
|
| Rate for Payer: Healthscope Commercial |
$866.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$674.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$722.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$818.53
|
| Rate for Payer: PHP Commercial |
$818.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$625.94
|
| Rate for Payer: Priority Health SBD |
$606.68
|
| Rate for Payer: UMR Bronson Commercial |
$356.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$722.24
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$957.40
|
|
|
Service Code
|
NDC 63323065903
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$354.24 |
| Max. Negotiated Rate |
$861.66 |
| Rate for Payer: Aetna American Axle |
$622.31
|
| Rate for Payer: Aetna Commercial |
$813.79
|
| Rate for Payer: Aetna Medicare |
$478.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.31
|
| Rate for Payer: BCBS Complete |
$382.96
|
| Rate for Payer: Cash Price |
$765.92
|
| Rate for Payer: Cofinity Commercial |
$670.18
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$670.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$765.92
|
| Rate for Payer: Healthscope Commercial |
$861.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$813.79
|
| Rate for Payer: PHP Commercial |
$813.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$622.31
|
| Rate for Payer: Priority Health SBD |
$603.16
|
| Rate for Payer: UMR Bronson Commercial |
$354.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.05
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$962.98
|
|
|
Service Code
|
NDC 63323065909
|
| Hospital Charge Code |
10267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$423.71 |
| Max. Negotiated Rate |
$866.68 |
| Rate for Payer: Aetna American Axle |
$625.94
|
| Rate for Payer: Aetna Commercial |
$818.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$625.94
|
| Rate for Payer: Cash Price |
$770.38
|
| Rate for Payer: Cofinity Commercial |
$674.09
|
| Rate for Payer: Cofinity Commercial |
$828.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$674.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$770.38
|
| Rate for Payer: Healthscope Commercial |
$866.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$674.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$722.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$818.53
|
| Rate for Payer: PHP Commercial |
$818.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$625.94
|
| Rate for Payer: Priority Health SBD |
$606.68
|
| Rate for Payer: UMR Bronson Commercial |
$423.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$722.24
|
|
|
INDOMETHACIN 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$7,707.72
|
|
|
Service Code
|
NDC 69344010101
|
| Hospital Charge Code |
3900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,391.40 |
| Max. Negotiated Rate |
$6,936.95 |
| Rate for Payer: Aetna American Axle |
$5,010.02
|
| Rate for Payer: Aetna Commercial |
$6,551.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,010.02
|
| Rate for Payer: Cash Price |
$6,166.18
|
| Rate for Payer: Cofinity Commercial |
$5,395.40
|
| Rate for Payer: Cofinity Commercial |
$6,628.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,395.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,166.18
|
| Rate for Payer: Healthscope Commercial |
$6,936.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,395.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,780.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,551.56
|
| Rate for Payer: PHP Commercial |
$6,551.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,010.02
|
| Rate for Payer: Priority Health SBD |
$4,855.86
|
| Rate for Payer: UMR Bronson Commercial |
$3,391.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,780.79
|
|
|
INDOMETHACIN 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$7,707.72
|
|
|
Service Code
|
NDC 69344010101
|
| Hospital Charge Code |
3900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,851.86 |
| Max. Negotiated Rate |
$6,936.95 |
| Rate for Payer: Aetna American Axle |
$5,010.02
|
| Rate for Payer: Aetna Commercial |
$6,551.56
|
| Rate for Payer: Aetna Medicare |
$3,853.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,010.02
|
| Rate for Payer: BCBS Complete |
$3,083.09
|
| Rate for Payer: Cash Price |
$6,166.18
|
| Rate for Payer: Cofinity Commercial |
$5,395.40
|
| Rate for Payer: Cofinity Commercial |
$6,628.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,395.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,166.18
|
| Rate for Payer: Healthscope Commercial |
$6,936.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,395.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,780.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,551.56
|
| Rate for Payer: PHP Commercial |
$6,551.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,010.02
|
| Rate for Payer: Priority Health SBD |
$4,855.86
|
| Rate for Payer: UMR Bronson Commercial |
$2,851.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,780.79
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$2.41
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
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 Commercial |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.69
|
| 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: PHP Commercial |
$2.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.57
|
| Rate for Payer: Priority Health SBD |
$1.52
|
| Rate for Payer: UMR Bronson Commercial |
$0.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
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 Commercial |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.69
|
| 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: PHP Commercial |
$2.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.57
|
| 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 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 Commercial |
$294.45
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.45
|
| 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: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.42
|
| Rate for Payer: Priority Health SBD |
$265.01
|
| Rate for Payer: UMR Bronson Commercial |
$155.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$120.18
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
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 Commercial |
$103.35
|
| Rate for Payer: Cofinity Commercial |
$84.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$84.13
|
| 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: PHP Commercial |
$102.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.12
|
| Rate for Payer: Priority Health SBD |
$75.71
|
| Rate for Payer: UMR Bronson Commercial |
$44.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.14
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$120.18
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
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 Commercial |
$103.35
|
| Rate for Payer: Cofinity Commercial |
$84.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$84.13
|
| 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: PHP Commercial |
$102.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.12
|
| 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 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.09 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna American Axle |
$273.42
|
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.42
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Commercial |
$294.45
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.45
|
| 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: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.42
|
| Rate for Payer: Priority Health SBD |
$265.01
|
| Rate for Payer: UMR Bronson Commercial |
$185.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$1,186.75
|
|
|
Service Code
|
NDC 68462030205
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$522.17 |
| Max. Negotiated Rate |
$1,068.08 |
| Rate for Payer: Aetna American Axle |
$771.39
|
| Rate for Payer: Aetna Commercial |
$1,008.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$771.39
|
| Rate for Payer: Cash Price |
$949.40
|
| Rate for Payer: Cofinity Commercial |
$1,020.61
|
| Rate for Payer: Cofinity Commercial |
$830.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$830.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$949.40
|
| Rate for Payer: Healthscope Commercial |
$1,068.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$830.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$890.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,008.74
|
| Rate for Payer: PHP Commercial |
$1,008.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$771.39
|
| Rate for Payer: Priority Health SBD |
$747.65
|
| Rate for Payer: UMR Bronson Commercial |
$522.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$890.06
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
OP
|
$1,186.75
|
|
|
Service Code
|
NDC 68462030205
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$439.10 |
| Max. Negotiated Rate |
$1,068.08 |
| Rate for Payer: Aetna American Axle |
$771.39
|
| Rate for Payer: Aetna Commercial |
$1,008.74
|
| Rate for Payer: Aetna Medicare |
$593.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$771.39
|
| Rate for Payer: BCBS Complete |
$474.70
|
| Rate for Payer: Cash Price |
$949.40
|
| Rate for Payer: Cofinity Commercial |
$1,020.61
|
| Rate for Payer: Cofinity Commercial |
$830.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$830.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$949.40
|
| Rate for Payer: Healthscope Commercial |
$1,068.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$830.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$890.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,008.74
|
| Rate for Payer: PHP Commercial |
$1,008.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$771.39
|
| Rate for Payer: Priority Health SBD |
$747.65
|
| Rate for Payer: UMR Bronson Commercial |
$439.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$890.06
|
|
|
INDOMETHACIN 50 MG CAPSULE
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 50268043111
|
| Hospital Charge Code |
3898
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna American Axle |
$1.48
|
| Rate for Payer: Aetna Commercial |
$1.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.48
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$1.60
|
| Rate for Payer: Cofinity Commercial |
$1.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.82
|
| Rate for Payer: Healthscope Commercial |
$2.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.94
|
| Rate for Payer: PHP Commercial |
$1.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.48
|
| Rate for Payer: Priority Health SBD |
$1.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.71
|
|
