|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$63.80
|
|
|
Service Code
|
NDC 09900000103
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.61 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna American Axle |
$41.47
|
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna Medicare |
$31.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.47
|
| Rate for Payer: BCBS Complete |
$25.52
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Advantage |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.85
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health SBD |
$40.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.47
|
| Rate for Payer: UHC Core |
$33.24
|
| Rate for Payer: UHC Exchange |
$25.07
|
| Rate for Payer: UMR Bronson Commercial |
$23.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.85
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$108.48
|
|
|
Service Code
|
NDC 09900000106
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.73 |
| Max. Negotiated Rate |
$97.63 |
| Rate for Payer: Aetna American Axle |
$70.51
|
| Rate for Payer: Aetna Commercial |
$92.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.51
|
| Rate for Payer: Cash Price |
$86.78
|
| Rate for Payer: Cofinity Advantage |
$75.94
|
| Rate for Payer: Cofinity Commercial |
$93.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.78
|
| Rate for Payer: Healthscope Commercial |
$97.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.36
|
| Rate for Payer: PHP Commercial |
$92.21
|
| Rate for Payer: Priority Health SBD |
$68.34
|
| Rate for Payer: UMR Bronson Commercial |
$47.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.36
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 09900000102
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.45
|
| Rate for Payer: UHC Core |
$36.43
|
| Rate for Payer: UHC Exchange |
$27.48
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$73.42
|
|
|
Service Code
|
NDC 00090000239
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Advantage |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.06
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UMR Bronson Commercial |
$32.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$73.44
|
|
|
Service Code
|
NDC 09900000104
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.31 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Advantage |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.08
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UMR Bronson Commercial |
$32.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$108.48
|
|
|
Service Code
|
NDC 09900000106
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.14 |
| Max. Negotiated Rate |
$97.63 |
| Rate for Payer: Aetna American Axle |
$70.51
|
| Rate for Payer: Aetna Commercial |
$92.21
|
| Rate for Payer: Aetna Medicare |
$54.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.51
|
| Rate for Payer: BCBS Complete |
$43.39
|
| Rate for Payer: Cash Price |
$86.78
|
| Rate for Payer: Cofinity Advantage |
$75.94
|
| Rate for Payer: Cofinity Commercial |
$93.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.78
|
| Rate for Payer: Healthscope Commercial |
$97.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.36
|
| Rate for Payer: PHP Commercial |
$92.21
|
| Rate for Payer: Priority Health SBD |
$68.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.51
|
| Rate for Payer: UHC Core |
$56.52
|
| Rate for Payer: UHC Exchange |
$42.63
|
| Rate for Payer: UMR Bronson Commercial |
$40.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.36
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$73.44
|
|
|
Service Code
|
NDC 09900000104
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna Medicare |
$36.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: BCBS Complete |
$29.38
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Advantage |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.08
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.74
|
| Rate for Payer: UHC Core |
$38.26
|
| Rate for Payer: UHC Exchange |
$28.86
|
| Rate for Payer: UMR Bronson Commercial |
$27.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$73.42
|
|
|
Service Code
|
NDC 00090000239
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna Medicare |
$36.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: BCBS Complete |
$29.37
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Advantage |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.06
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.72
|
| Rate for Payer: UHC Core |
$38.25
|
| Rate for Payer: UHC Exchange |
$28.85
|
| Rate for Payer: UMR Bronson Commercial |
$27.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$1,302.99
|
|
|
Service Code
|
NDC 57664004688
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$573.32 |
| Max. Negotiated Rate |
$1,172.69 |
| Rate for Payer: Aetna American Axle |
$846.94
|
| Rate for Payer: Aetna Commercial |
$1,107.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$846.94
|
| Rate for Payer: Cash Price |
$1,042.39
|
| Rate for Payer: Cofinity Advantage |
$912.09
|
| Rate for Payer: Cofinity Commercial |
$1,120.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,042.39
|
| Rate for Payer: Healthscope Commercial |
$1,172.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$912.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$977.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,107.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$977.24
|
| Rate for Payer: PHP Commercial |
$1,107.54
|
| Rate for Payer: Priority Health SBD |
$820.88
|
| Rate for Payer: UMR Bronson Commercial |
$573.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$977.24
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$1,201.90
|
|
|
Service Code
|
NDC 00527466137
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$528.84 |
| Max. Negotiated Rate |
$1,081.71 |
| Rate for Payer: Aetna American Axle |
$781.24
|
| Rate for Payer: Aetna Commercial |
$1,021.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.24
|
| Rate for Payer: Cash Price |
$961.52
|
| Rate for Payer: Cofinity Advantage |
$841.33
|
| Rate for Payer: Cofinity Commercial |
$1,033.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$961.52
|
| Rate for Payer: Healthscope Commercial |
$1,081.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$841.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$901.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,021.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$901.42
|
| Rate for Payer: PHP Commercial |
$1,021.62
|
| Rate for Payer: Priority Health SBD |
$757.20
|
| Rate for Payer: UMR Bronson Commercial |
$528.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$901.42
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417010110
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,745.45 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Advantage |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,371.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,975.20
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UMR Bronson Commercial |
$1,745.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$1,302.00
|
|
|
Service Code
|
NDC 43547060210
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$481.74 |
| Max. Negotiated Rate |
$1,171.80 |
| Rate for Payer: Aetna American Axle |
$846.30
|
| Rate for Payer: Aetna Commercial |
$1,106.70
|
| Rate for Payer: Aetna Medicare |
$651.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$846.30
|
| Rate for Payer: BCBS Complete |
$520.80
|
| Rate for Payer: Cash Price |
$1,041.60
|
| Rate for Payer: Cofinity Advantage |
$911.40
|
| Rate for Payer: Cofinity Commercial |
$1,119.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,041.60
|
| Rate for Payer: Healthscope Commercial |
$1,171.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$911.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$976.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,041.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,106.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$976.50
|
| Rate for Payer: PHP Commercial |
$1,106.70
|
| Rate for Payer: Priority Health SBD |
$820.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$846.30
|
| Rate for Payer: UHC Core |
$678.34
|
| Rate for Payer: UHC Exchange |
$511.69
|
| Rate for Payer: UMR Bronson Commercial |
$481.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$976.50
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$2,249.13
|
|
|
Service Code
|
NDC 60505473901
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$832.18 |
| Max. Negotiated Rate |
$2,024.22 |
| Rate for Payer: Aetna American Axle |
$1,461.93
|
| Rate for Payer: Aetna Commercial |
$1,911.76
|
| Rate for Payer: Aetna Medicare |
$1,124.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,461.93
|
| Rate for Payer: BCBS Complete |
$899.65
|
| Rate for Payer: Cash Price |
$1,799.30
|
| Rate for Payer: Cofinity Advantage |
$1,574.39
|
| Rate for Payer: Cofinity Commercial |
$1,934.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,799.30
|
| Rate for Payer: Healthscope Commercial |
$2,024.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,574.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,686.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,799.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,911.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,686.85
|
| Rate for Payer: PHP Commercial |
$1,911.76
|
| Rate for Payer: Priority Health SBD |
$1,416.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,461.93
|
| Rate for Payer: UHC Core |
$1,171.80
|
| Rate for Payer: UHC Exchange |
$883.91
|
| Rate for Payer: UMR Bronson Commercial |
$832.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,686.85
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$2,249.13
|
|
|
Service Code
|
NDC 60505473901
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$989.62 |
| Max. Negotiated Rate |
$2,024.22 |
| Rate for Payer: Aetna American Axle |
$1,461.93
|
| Rate for Payer: Aetna Commercial |
$1,911.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,461.93
|
| Rate for Payer: Cash Price |
$1,799.30
|
| Rate for Payer: Cofinity Advantage |
$1,574.39
|
| Rate for Payer: Cofinity Commercial |
$1,934.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,799.30
|
| Rate for Payer: Healthscope Commercial |
$2,024.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,574.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,686.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,911.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,686.85
|
| Rate for Payer: PHP Commercial |
$1,911.76
|
| Rate for Payer: Priority Health SBD |
$1,416.95
|
| Rate for Payer: UMR Bronson Commercial |
$989.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,686.85
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$1,201.90
|
|
|
Service Code
|
NDC 00527466137
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$444.70 |
| Max. Negotiated Rate |
$1,081.71 |
| Rate for Payer: Aetna American Axle |
$781.24
|
| Rate for Payer: Aetna Commercial |
$1,021.62
|
| Rate for Payer: Aetna Medicare |
$600.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.24
|
| Rate for Payer: BCBS Complete |
$480.76
|
| Rate for Payer: Cash Price |
$961.52
|
| Rate for Payer: Cofinity Advantage |
$841.33
|
| Rate for Payer: Cofinity Commercial |
$1,033.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$961.52
|
| Rate for Payer: Healthscope Commercial |
$1,081.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$841.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$901.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$961.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,021.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$901.42
|
| Rate for Payer: PHP Commercial |
$1,021.62
|
| Rate for Payer: Priority Health SBD |
$757.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$781.24
|
| Rate for Payer: UHC Core |
$626.19
|
| Rate for Payer: UHC Exchange |
$472.35
|
| Rate for Payer: UMR Bronson Commercial |
$444.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$901.42
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417010110
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,467.76 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna Medicare |
$1,983.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: BCBS Complete |
$1,586.77
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Advantage |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,173.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,371.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,975.20
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,578.50
|
| Rate for Payer: UHC Core |
$2,066.77
|
| Rate for Payer: UHC Exchange |
$1,559.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,467.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$1,302.00
|
|
|
Service Code
|
NDC 43547060210
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$572.88 |
| Max. Negotiated Rate |
$1,171.80 |
| Rate for Payer: Aetna American Axle |
$846.30
|
| Rate for Payer: Aetna Commercial |
$1,106.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$846.30
|
| Rate for Payer: Cash Price |
$1,041.60
|
| Rate for Payer: Cofinity Advantage |
$911.40
|
| Rate for Payer: Cofinity Commercial |
$1,119.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,041.60
|
| Rate for Payer: Healthscope Commercial |
$1,171.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$911.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$976.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,106.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$976.50
|
| Rate for Payer: PHP Commercial |
$1,106.70
|
| Rate for Payer: Priority Health SBD |
$820.26
|
| Rate for Payer: UMR Bronson Commercial |
$572.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$976.50
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$1,302.99
|
|
|
Service Code
|
NDC 57664004688
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$482.11 |
| Max. Negotiated Rate |
$1,172.69 |
| Rate for Payer: Aetna American Axle |
$846.94
|
| Rate for Payer: Aetna Commercial |
$1,107.54
|
| Rate for Payer: Aetna Medicare |
$651.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$846.94
|
| Rate for Payer: BCBS Complete |
$521.20
|
| Rate for Payer: Cash Price |
$1,042.39
|
| Rate for Payer: Cofinity Advantage |
$912.09
|
| Rate for Payer: Cofinity Commercial |
$1,120.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,042.39
|
| Rate for Payer: Healthscope Commercial |
$1,172.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$912.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$977.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,042.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,107.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$977.24
|
| Rate for Payer: PHP Commercial |
$1,107.54
|
| Rate for Payer: Priority Health SBD |
$820.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$846.94
|
| Rate for Payer: UHC Core |
$678.86
|
| Rate for Payer: UHC Exchange |
$512.08
|
| Rate for Payer: UMR Bronson Commercial |
$482.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$977.24
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
IP
|
$880.23
|
|
|
Service Code
|
NDC 43547060410
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$387.30 |
| Max. Negotiated Rate |
$792.21 |
| Rate for Payer: Aetna American Axle |
$572.15
|
| Rate for Payer: Aetna Commercial |
$748.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$572.15
|
| Rate for Payer: Cash Price |
$704.18
|
| Rate for Payer: Cofinity Advantage |
$616.16
|
| Rate for Payer: Cofinity Commercial |
$757.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$704.18
|
| Rate for Payer: Healthscope Commercial |
$792.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$616.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$660.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$748.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$660.17
|
| Rate for Payer: PHP Commercial |
$748.20
|
| Rate for Payer: Priority Health SBD |
$554.54
|
| Rate for Payer: UMR Bronson Commercial |
$387.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$660.17
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
OP
|
$880.23
|
|
|
Service Code
|
NDC 43547060410
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$325.69 |
| Max. Negotiated Rate |
$792.21 |
| Rate for Payer: Aetna American Axle |
$572.15
|
| Rate for Payer: Aetna Commercial |
$748.20
|
| Rate for Payer: Aetna Medicare |
$440.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$572.15
|
| Rate for Payer: BCBS Complete |
$352.09
|
| Rate for Payer: Cash Price |
$704.18
|
| Rate for Payer: Cofinity Advantage |
$616.16
|
| Rate for Payer: Cofinity Commercial |
$757.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$704.18
|
| Rate for Payer: Healthscope Commercial |
$792.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$616.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$660.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$704.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$748.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$660.17
|
| Rate for Payer: PHP Commercial |
$748.20
|
| Rate for Payer: Priority Health SBD |
$554.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$572.15
|
| Rate for Payer: UHC Core |
$458.60
|
| Rate for Payer: UHC Exchange |
$345.93
|
| Rate for Payer: UMR Bronson Commercial |
$325.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$660.17
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
IP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417010310
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,745.45 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Advantage |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,371.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,975.20
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UMR Bronson Commercial |
$1,745.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
IP
|
$852.23
|
|
|
Service Code
|
NDC 65162002409
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$374.98 |
| Max. Negotiated Rate |
$767.01 |
| Rate for Payer: Aetna American Axle |
$553.95
|
| Rate for Payer: Aetna Commercial |
$724.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$553.95
|
| Rate for Payer: Cash Price |
$681.78
|
| Rate for Payer: Cofinity Advantage |
$596.56
|
| Rate for Payer: Cofinity Commercial |
$732.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$681.78
|
| Rate for Payer: Healthscope Commercial |
$767.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$596.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$639.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$724.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$639.17
|
| Rate for Payer: PHP Commercial |
$724.40
|
| Rate for Payer: Priority Health SBD |
$536.90
|
| Rate for Payer: UMR Bronson Commercial |
$374.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$639.17
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
OP
|
$1,201.90
|
|
|
Service Code
|
NDC 00527466337
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$444.70 |
| Max. Negotiated Rate |
$1,081.71 |
| Rate for Payer: Aetna American Axle |
$781.24
|
| Rate for Payer: Aetna Commercial |
$1,021.62
|
| Rate for Payer: Aetna Medicare |
$600.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.24
|
| Rate for Payer: BCBS Complete |
$480.76
|
| Rate for Payer: Cash Price |
$961.52
|
| Rate for Payer: Cofinity Advantage |
$841.33
|
| Rate for Payer: Cofinity Commercial |
$1,033.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$961.52
|
| Rate for Payer: Healthscope Commercial |
$1,081.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$841.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$901.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$961.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,021.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$901.42
|
| Rate for Payer: PHP Commercial |
$1,021.62
|
| Rate for Payer: Priority Health SBD |
$757.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$781.24
|
| Rate for Payer: UHC Core |
$626.19
|
| Rate for Payer: UHC Exchange |
$472.35
|
| Rate for Payer: UMR Bronson Commercial |
$444.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$901.42
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
OP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417010310
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,467.76 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna Medicare |
$1,983.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: BCBS Complete |
$1,586.77
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Advantage |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,173.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,371.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,975.20
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,578.50
|
| Rate for Payer: UHC Core |
$2,066.77
|
| Rate for Payer: UHC Exchange |
$1,559.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,467.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 30 MG CAPSULE
|
Facility
|
OP
|
$852.23
|
|
|
Service Code
|
NDC 65162002409
|
| Hospital Charge Code |
81474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.33 |
| Max. Negotiated Rate |
$767.01 |
| Rate for Payer: Aetna American Axle |
$553.95
|
| Rate for Payer: Aetna Commercial |
$724.40
|
| Rate for Payer: Aetna Medicare |
$426.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$553.95
|
| Rate for Payer: BCBS Complete |
$340.89
|
| Rate for Payer: Cash Price |
$681.78
|
| Rate for Payer: Cofinity Advantage |
$596.56
|
| Rate for Payer: Cofinity Commercial |
$732.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$681.78
|
| Rate for Payer: Healthscope Commercial |
$767.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$596.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$639.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$681.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$724.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$639.17
|
| Rate for Payer: PHP Commercial |
$724.40
|
| Rate for Payer: Priority Health SBD |
$536.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$553.95
|
| Rate for Payer: UHC Core |
$444.01
|
| Rate for Payer: UHC Exchange |
$334.93
|
| Rate for Payer: UMR Bronson Commercial |
$315.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$639.17
|
|
