|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
IP
|
$115.62
|
|
|
Service Code
|
NDC 59746024760
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.87 |
| Max. Negotiated Rate |
$104.06 |
| Rate for Payer: Aetna American Axle |
$75.15
|
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.15
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cofinity Commercial |
$80.93
|
| Rate for Payer: Cofinity Commercial |
$99.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.50
|
| Rate for Payer: Healthscope Commercial |
$104.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$80.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.28
|
| Rate for Payer: PHP Commercial |
$98.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.15
|
| Rate for Payer: Priority Health SBD |
$72.84
|
| Rate for Payer: UMR Bronson Commercial |
$50.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.72
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
IP
|
$100.11
|
|
|
Service Code
|
NDC 65862022960
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$90.10 |
| Rate for Payer: Aetna American Axle |
$65.07
|
| Rate for Payer: Aetna Commercial |
$85.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.07
|
| Rate for Payer: Cash Price |
$80.09
|
| Rate for Payer: Cofinity Commercial |
$70.08
|
| Rate for Payer: Cofinity Commercial |
$86.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.09
|
| Rate for Payer: Healthscope Commercial |
$90.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.09
|
| Rate for Payer: PHP Commercial |
$85.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.07
|
| Rate for Payer: Priority Health SBD |
$63.07
|
| Rate for Payer: UMR Bronson Commercial |
$44.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.08
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
OP
|
$3.63
|
|
|
Service Code
|
NDC 60687069311
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna American Axle |
$2.36
|
| Rate for Payer: Aetna Commercial |
$3.09
|
| Rate for Payer: Aetna Medicare |
$1.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.36
|
| Rate for Payer: BCBS Complete |
$1.45
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$3.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.36
|
| Rate for Payer: Priority Health SBD |
$2.29
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.72
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
IP
|
$115.62
|
|
|
Service Code
|
NDC 51672413204
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.87 |
| Max. Negotiated Rate |
$104.06 |
| Rate for Payer: Aetna American Axle |
$75.15
|
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.15
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cofinity Commercial |
$80.93
|
| Rate for Payer: Cofinity Commercial |
$99.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.50
|
| Rate for Payer: Healthscope Commercial |
$104.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$80.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.28
|
| Rate for Payer: PHP Commercial |
$98.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.15
|
| Rate for Payer: Priority Health SBD |
$72.84
|
| Rate for Payer: UMR Bronson Commercial |
$50.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.72
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
NDC 60687069301
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.68 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna American Axle |
$235.88
|
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$254.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$254.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health SBD |
$228.63
|
| Rate for Payer: UMR Bronson Commercial |
$159.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
IP
|
$3.63
|
|
|
Service Code
|
NDC 60687069311
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna American Axle |
$2.36
|
| Rate for Payer: Aetna Commercial |
$3.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.36
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$3.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.09
|
| Rate for Payer: PHP Commercial |
$3.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.36
|
| Rate for Payer: Priority Health SBD |
$2.29
|
| Rate for Payer: UMR Bronson Commercial |
$1.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.72
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
OP
|
$100.11
|
|
|
Service Code
|
NDC 65862022960
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.04 |
| Max. Negotiated Rate |
$90.10 |
| Rate for Payer: Aetna American Axle |
$65.07
|
| Rate for Payer: Aetna Commercial |
$85.09
|
| Rate for Payer: Aetna Medicare |
$50.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.07
|
| Rate for Payer: BCBS Complete |
$40.04
|
| Rate for Payer: Cash Price |
$80.09
|
| Rate for Payer: Cofinity Commercial |
$70.08
|
| Rate for Payer: Cofinity Commercial |
$86.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.09
|
| Rate for Payer: Healthscope Commercial |
$90.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.09
|
| Rate for Payer: PHP Commercial |
$85.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.07
|
| Rate for Payer: Priority Health SBD |
$63.07
|
| Rate for Payer: UMR Bronson Commercial |
$37.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.08
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
OP
|
$115.62
|
|
|
Service Code
|
NDC 59746024760
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.78 |
| Max. Negotiated Rate |
$104.06 |
| Rate for Payer: Aetna American Axle |
$75.15
|
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Medicare |
$57.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.15
|
| Rate for Payer: BCBS Complete |
$46.25
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cofinity Commercial |
$80.93
|
| Rate for Payer: Cofinity Commercial |
$99.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.50
|
| Rate for Payer: Healthscope Commercial |
$104.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$80.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.28
|
| Rate for Payer: PHP Commercial |
$98.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.15
|
| Rate for Payer: Priority Health SBD |
$72.84
|
| Rate for Payer: UMR Bronson Commercial |
$42.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.72
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
IP
|
$117.03
|
|
|
Service Code
|
NDC 13668004860
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.49 |
| Max. Negotiated Rate |
$105.33 |
| Rate for Payer: Aetna American Axle |
$76.07
|
| Rate for Payer: Aetna Commercial |
$99.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.07
|
| Rate for Payer: Cash Price |
$93.62
|
| Rate for Payer: Cofinity Commercial |
$100.65
|
| Rate for Payer: Cofinity Commercial |
$81.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.62
|
| Rate for Payer: Healthscope Commercial |
$105.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.48
|
| Rate for Payer: PHP Commercial |
$99.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.07
|
| Rate for Payer: Priority Health SBD |
$73.73
|
| Rate for Payer: UMR Bronson Commercial |
$51.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.77
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
OP
|
$132.81
|
|
|
Service Code
|
NDC 68382000914
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$119.53 |
| Rate for Payer: Aetna American Axle |
$86.33
|
| Rate for Payer: Aetna Commercial |
$112.89
|
| Rate for Payer: Aetna Medicare |
$66.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.33
|
| Rate for Payer: BCBS Complete |
$53.12
|
| Rate for Payer: Cash Price |
$106.25
|
| Rate for Payer: Cofinity Commercial |
$114.22
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.25
|
| Rate for Payer: Healthscope Commercial |
$119.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.89
|
| Rate for Payer: PHP Commercial |
$112.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.33
|
| Rate for Payer: Priority Health SBD |
$83.67
|
| Rate for Payer: UMR Bronson Commercial |
$49.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.61
|
|
|
LAMOTRIGINE 150 MG TABLET
|
Facility
|
OP
|
$117.03
|
|
|
Service Code
|
NDC 13668004860
|
| Hospital Charge Code |
14266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.30 |
| Max. Negotiated Rate |
$105.33 |
| Rate for Payer: Aetna American Axle |
$76.07
|
| Rate for Payer: Aetna Commercial |
$99.48
|
| Rate for Payer: Aetna Medicare |
$58.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.07
|
| Rate for Payer: BCBS Complete |
$46.81
|
| Rate for Payer: Cash Price |
$93.62
|
| Rate for Payer: Cofinity Commercial |
$100.65
|
| Rate for Payer: Cofinity Commercial |
$81.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.62
|
| Rate for Payer: Healthscope Commercial |
$105.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.48
|
| Rate for Payer: PHP Commercial |
$99.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.07
|
| Rate for Payer: Priority Health SBD |
$73.73
|
| Rate for Payer: UMR Bronson Commercial |
$43.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.77
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 00904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.37
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$141.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 00904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.12 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna Medicare |
$160.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.37
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$119.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET
|
Facility
|
OP
|
$365.75
|
|
|
Service Code
|
NDC 68462022801
|
| Hospital Charge Code |
104568
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.33 |
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Aetna American Axle |
$237.74
|
| Rate for Payer: Aetna Commercial |
$310.89
|
| Rate for Payer: Aetna Medicare |
$182.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.74
|
| Rate for Payer: BCBS Complete |
$146.30
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$256.02
|
| Rate for Payer: Cofinity Commercial |
$314.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$329.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: PHP Commercial |
$310.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health SBD |
$230.42
|
| Rate for Payer: UMR Bronson Commercial |
$135.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.31
|
|
|
LAMOTRIGINE 5 MG CHEWABLE DISPERSIBLE TABLET
|
Facility
|
IP
|
$365.75
|
|
|
Service Code
|
NDC 68462022801
|
| Hospital Charge Code |
104568
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.93 |
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Aetna American Axle |
$237.74
|
| Rate for Payer: Aetna Commercial |
$310.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.74
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$256.02
|
| Rate for Payer: Cofinity Commercial |
$314.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$329.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: PHP Commercial |
$310.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health SBD |
$230.42
|
| Rate for Payer: UMR Bronson Commercial |
$160.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.31
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM
|
Facility
|
IP
|
$18.39
|
|
|
Service Code
|
NDC 00904775127
|
| Hospital Charge Code |
118468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.09 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna American Axle |
$11.95
|
| Rate for Payer: Aetna Commercial |
$15.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.95
|
| Rate for Payer: Cash Price |
$14.71
|
| Rate for Payer: Cofinity Commercial |
$12.87
|
| Rate for Payer: Cofinity Commercial |
$15.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.71
|
| Rate for Payer: Healthscope Commercial |
$16.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.63
|
| Rate for Payer: PHP Commercial |
$15.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.95
|
| Rate for Payer: Priority Health SBD |
$11.59
|
| Rate for Payer: UMR Bronson Commercial |
$8.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.79
|
|
|
LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM
|
Facility
|
OP
|
$18.39
|
|
|
Service Code
|
NDC 00904775127
|
| Hospital Charge Code |
118468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna American Axle |
$11.95
|
| Rate for Payer: Aetna Commercial |
$15.63
|
| Rate for Payer: Aetna Medicare |
$9.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.95
|
| Rate for Payer: BCBS Complete |
$7.36
|
| Rate for Payer: Cash Price |
$14.71
|
| Rate for Payer: Cofinity Commercial |
$12.87
|
| Rate for Payer: Cofinity Commercial |
$15.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.71
|
| Rate for Payer: Healthscope Commercial |
$16.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.63
|
| Rate for Payer: PHP Commercial |
$15.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.95
|
| Rate for Payer: Priority Health SBD |
$11.59
|
| Rate for Payer: UMR Bronson Commercial |
$6.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.79
|
|
|
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$42,933.38
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
87861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,890.69 |
| Max. Negotiated Rate |
$38,640.04 |
| Rate for Payer: Aetna American Axle |
$27,906.70
|
| Rate for Payer: Aetna Commercial |
$36,493.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27,906.70
|
| Rate for Payer: Cash Price |
$34,346.70
|
| Rate for Payer: Cofinity Commercial |
$30,053.37
|
| Rate for Payer: Cofinity Commercial |
$36,922.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$30,053.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34,346.70
|
| Rate for Payer: Healthscope Commercial |
$38,640.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30,053.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32,200.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36,493.37
|
| Rate for Payer: PHP Commercial |
$36,493.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27,906.70
|
| Rate for Payer: Priority Health SBD |
$27,048.03
|
| Rate for Payer: UMR Bronson Commercial |
$18,890.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32,200.03
|
|
|
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$42,933.38
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
87861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$38,640.04 |
| Rate for Payer: Aetna American Axle |
$27,906.70
|
| Rate for Payer: Aetna Commercial |
$36,493.37
|
| Rate for Payer: Aetna Medicare |
$35.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27,906.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.56
|
| Rate for Payer: BCBS Complete |
$19.16
|
| Rate for Payer: BCBS MAPPO |
$34.05
|
| Rate for Payer: BCN Medicare Advantage |
$34.05
|
| Rate for Payer: Cash Price |
$34,346.70
|
| Rate for Payer: Cash Price |
$34,346.70
|
| Rate for Payer: Cofinity Commercial |
$36,922.71
|
| Rate for Payer: Cofinity Commercial |
$30,053.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$30,053.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34,346.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.05
|
| Rate for Payer: Healthscope Commercial |
$38,640.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30,053.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32,200.03
|
| Rate for Payer: Mclaren Medicaid |
$18.25
|
| Rate for Payer: Mclaren Medicare |
$34.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$35.75
|
| Rate for Payer: Meridian Medicaid |
$19.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36,493.37
|
| Rate for Payer: PACE Medicare |
$32.35
|
| Rate for Payer: PACE SWMI |
$34.05
|
| Rate for Payer: PHP Commercial |
$36,493.37
|
| Rate for Payer: PHP Medicare Advantage |
$34.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$18.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27,906.70
|
| Rate for Payer: Priority Health Medicare |
$34.05
|
| Rate for Payer: Priority Health SBD |
$27,048.03
|
| Rate for Payer: Railroad Medicare Medicare |
$34.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.05
|
| Rate for Payer: UHC Exchange |
$65.07
|
| Rate for Payer: UHC Medicare Advantage |
$34.05
|
| Rate for Payer: UHCCP Medicaid |
$18.25
|
| Rate for Payer: UMR Bronson Commercial |
$15,885.35
|
| Rate for Payer: VA VA |
$34.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32,200.03
|
|
|
LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$27,335.12
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
88570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$24,601.61 |
| Rate for Payer: Aetna American Axle |
$17,767.83
|
| Rate for Payer: Aetna Commercial |
$23,234.85
|
| Rate for Payer: Aetna Medicare |
$35.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17,767.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.56
|
| Rate for Payer: BCBS Complete |
$19.16
|
| Rate for Payer: BCBS MAPPO |
$34.05
|
| Rate for Payer: BCN Medicare Advantage |
$34.05
|
| Rate for Payer: Cash Price |
$21,868.10
|
| Rate for Payer: Cash Price |
$21,868.10
|
| Rate for Payer: Cofinity Commercial |
$23,508.20
|
| Rate for Payer: Cofinity Commercial |
$19,134.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$19,134.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21,868.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.05
|
| Rate for Payer: Healthscope Commercial |
$24,601.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19,134.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20,501.34
|
| Rate for Payer: Mclaren Medicaid |
$18.25
|
| Rate for Payer: Mclaren Medicare |
$34.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$35.75
|
| Rate for Payer: Meridian Medicaid |
$19.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23,234.85
|
| Rate for Payer: PACE Medicare |
$32.35
|
| Rate for Payer: PACE SWMI |
$34.05
|
| Rate for Payer: PHP Commercial |
$23,234.85
|
| Rate for Payer: PHP Medicare Advantage |
$34.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$18.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17,767.83
|
| Rate for Payer: Priority Health Medicare |
$34.05
|
| Rate for Payer: Priority Health SBD |
$17,221.13
|
| Rate for Payer: Railroad Medicare Medicare |
$34.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.05
|
| Rate for Payer: UHC Exchange |
$65.07
|
| Rate for Payer: UHC Medicare Advantage |
$34.05
|
| Rate for Payer: UHCCP Medicaid |
$18.25
|
| Rate for Payer: UMR Bronson Commercial |
$10,113.99
|
| Rate for Payer: VA VA |
$34.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20,501.34
|
|
|
LANREOTIDE 60 MG/0.2 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$27,335.12
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
88570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,027.45 |
| Max. Negotiated Rate |
$24,601.61 |
| Rate for Payer: Aetna American Axle |
$17,767.83
|
| Rate for Payer: Aetna Commercial |
$23,234.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17,767.83
|
| Rate for Payer: Cash Price |
$21,868.10
|
| Rate for Payer: Cofinity Commercial |
$19,134.58
|
| Rate for Payer: Cofinity Commercial |
$23,508.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$19,134.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21,868.10
|
| Rate for Payer: Healthscope Commercial |
$24,601.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19,134.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20,501.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23,234.85
|
| Rate for Payer: PHP Commercial |
$23,234.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17,767.83
|
| Rate for Payer: Priority Health SBD |
$17,221.13
|
| Rate for Payer: UMR Bronson Commercial |
$12,027.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20,501.34
|
|
|
LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$21,080.81
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
87860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,275.56 |
| Max. Negotiated Rate |
$18,972.73 |
| Rate for Payer: Aetna American Axle |
$13,702.53
|
| Rate for Payer: Aetna Commercial |
$17,918.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,702.53
|
| Rate for Payer: Cash Price |
$16,864.65
|
| Rate for Payer: Cofinity Commercial |
$14,756.57
|
| Rate for Payer: Cofinity Commercial |
$18,129.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$14,756.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,864.65
|
| Rate for Payer: Healthscope Commercial |
$18,972.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,756.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,810.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,918.69
|
| Rate for Payer: PHP Commercial |
$17,918.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,702.53
|
| Rate for Payer: Priority Health SBD |
$13,280.91
|
| Rate for Payer: UMR Bronson Commercial |
$9,275.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,810.61
|
|
|
LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$21,080.81
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
87860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$18,972.73 |
| Rate for Payer: Aetna American Axle |
$13,702.53
|
| Rate for Payer: Aetna Commercial |
$17,918.69
|
| Rate for Payer: Aetna Medicare |
$35.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,702.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.56
|
| Rate for Payer: BCBS Complete |
$19.16
|
| Rate for Payer: BCBS MAPPO |
$34.05
|
| Rate for Payer: BCN Medicare Advantage |
$34.05
|
| Rate for Payer: Cash Price |
$16,864.65
|
| Rate for Payer: Cash Price |
$16,864.65
|
| Rate for Payer: Cofinity Commercial |
$14,756.57
|
| Rate for Payer: Cofinity Commercial |
$18,129.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$14,756.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,864.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.05
|
| Rate for Payer: Healthscope Commercial |
$18,972.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,756.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,810.61
|
| Rate for Payer: Mclaren Medicaid |
$18.25
|
| Rate for Payer: Mclaren Medicare |
$34.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$35.75
|
| Rate for Payer: Meridian Medicaid |
$19.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,918.69
|
| Rate for Payer: PACE Medicare |
$32.35
|
| Rate for Payer: PACE SWMI |
$34.05
|
| Rate for Payer: PHP Commercial |
$17,918.69
|
| Rate for Payer: PHP Medicare Advantage |
$34.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$18.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,702.53
|
| Rate for Payer: Priority Health Medicare |
$34.05
|
| Rate for Payer: Priority Health SBD |
$13,280.91
|
| Rate for Payer: Railroad Medicare Medicare |
$34.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.05
|
| Rate for Payer: UHC Exchange |
$65.07
|
| Rate for Payer: UHC Medicare Advantage |
$34.05
|
| Rate for Payer: UHCCP Medicaid |
$18.25
|
| Rate for Payer: UMR Bronson Commercial |
$7,799.90
|
| Rate for Payer: VA VA |
$34.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,810.61
|
|
|
LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$4,761.16
|
|
|
Service Code
|
NDC 64764004613
|
| Hospital Charge Code |
27692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,761.63 |
| Max. Negotiated Rate |
$4,285.04 |
| Rate for Payer: Aetna American Axle |
$3,094.75
|
| Rate for Payer: Aetna Commercial |
$4,046.99
|
| Rate for Payer: Aetna Medicare |
$2,380.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,094.75
|
| Rate for Payer: BCBS Complete |
$1,904.46
|
| Rate for Payer: Cash Price |
$3,808.93
|
| Rate for Payer: Cofinity Commercial |
$3,332.81
|
| Rate for Payer: Cofinity Commercial |
$4,094.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,332.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,808.93
|
| Rate for Payer: Healthscope Commercial |
$4,285.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,332.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,570.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,046.99
|
| Rate for Payer: PHP Commercial |
$4,046.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,094.75
|
| Rate for Payer: Priority Health SBD |
$2,999.53
|
| Rate for Payer: UMR Bronson Commercial |
$1,761.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,570.87
|
|
|
LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$4,761.16
|
|
|
Service Code
|
NDC 64764004613
|
| Hospital Charge Code |
27692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,094.91 |
| Max. Negotiated Rate |
$4,285.04 |
| Rate for Payer: Aetna American Axle |
$3,094.75
|
| Rate for Payer: Aetna Commercial |
$4,046.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,094.75
|
| Rate for Payer: Cash Price |
$3,808.93
|
| Rate for Payer: Cofinity Commercial |
$3,332.81
|
| Rate for Payer: Cofinity Commercial |
$4,094.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,332.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,808.93
|
| Rate for Payer: Healthscope Commercial |
$4,285.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,332.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,570.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,046.99
|
| Rate for Payer: PHP Commercial |
$4,046.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,094.75
|
| Rate for Payer: Priority Health SBD |
$2,999.53
|
| Rate for Payer: UMR Bronson Commercial |
$2,094.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,570.87
|
|
