|
LUBIPROSTONE 8 MCG CAPSULE
|
Facility
|
IP
|
$1,276.95
|
|
|
Service Code
|
NDC 64764008060
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$561.86 |
| Max. Negotiated Rate |
$1,149.26 |
| Rate for Payer: Aetna American Axle |
$830.02
|
| Rate for Payer: Aetna Commercial |
$1,085.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$830.02
|
| Rate for Payer: Cash Price |
$1,021.56
|
| Rate for Payer: Cofinity Commercial |
$1,098.18
|
| Rate for Payer: Cofinity Commercial |
$893.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$893.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,021.56
|
| Rate for Payer: Healthscope Commercial |
$1,149.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$893.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$957.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,085.41
|
| Rate for Payer: PHP Commercial |
$1,085.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$830.02
|
| Rate for Payer: Priority Health SBD |
$804.48
|
| Rate for Payer: UMR Bronson Commercial |
$561.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$957.71
|
|
|
LUBIPROSTONE 8 MCG CAPSULE
|
Facility
|
IP
|
$388.23
|
|
|
Service Code
|
NDC 00480347906
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.82 |
| Max. Negotiated Rate |
$349.41 |
| Rate for Payer: Aetna American Axle |
$252.35
|
| Rate for Payer: Aetna Commercial |
$330.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.35
|
| Rate for Payer: Cash Price |
$310.58
|
| Rate for Payer: Cofinity Commercial |
$271.76
|
| Rate for Payer: Cofinity Commercial |
$333.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$271.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.58
|
| Rate for Payer: Healthscope Commercial |
$349.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$271.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$291.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.00
|
| Rate for Payer: PHP Commercial |
$330.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.35
|
| Rate for Payer: Priority Health SBD |
$244.58
|
| Rate for Payer: UMR Bronson Commercial |
$170.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$291.17
|
|
|
LUBIPROSTONE 8 MCG CAPSULE
|
Facility
|
OP
|
$388.23
|
|
|
Service Code
|
NDC 00480347906
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.65 |
| Max. Negotiated Rate |
$349.41 |
| Rate for Payer: Aetna American Axle |
$252.35
|
| Rate for Payer: Aetna Commercial |
$330.00
|
| Rate for Payer: Aetna Medicare |
$194.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.35
|
| Rate for Payer: BCBS Complete |
$155.29
|
| Rate for Payer: Cash Price |
$310.58
|
| Rate for Payer: Cofinity Commercial |
$271.76
|
| Rate for Payer: Cofinity Commercial |
$333.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$271.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.58
|
| Rate for Payer: Healthscope Commercial |
$349.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$271.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$291.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.00
|
| Rate for Payer: PHP Commercial |
$330.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.35
|
| Rate for Payer: Priority Health SBD |
$244.58
|
| Rate for Payer: UMR Bronson Commercial |
$143.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$291.17
|
|
|
LUBIPROSTONE 8 MCG CAPSULE
|
Facility
|
IP
|
$281.38
|
|
|
Service Code
|
NDC 00254302802
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.81 |
| Max. Negotiated Rate |
$253.24 |
| Rate for Payer: Aetna American Axle |
$182.90
|
| Rate for Payer: Aetna Commercial |
$239.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.90
|
| Rate for Payer: Cash Price |
$225.10
|
| Rate for Payer: Cofinity Commercial |
$196.97
|
| Rate for Payer: Cofinity Commercial |
$241.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.10
|
| Rate for Payer: Healthscope Commercial |
$253.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.17
|
| Rate for Payer: PHP Commercial |
$239.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.90
|
| Rate for Payer: Priority Health SBD |
$177.27
|
| Rate for Payer: UMR Bronson Commercial |
$123.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.04
|
|
|
LUBIPROSTONE 8 MCG CAPSULE
|
Facility
|
OP
|
$1,276.95
|
|
|
Service Code
|
NDC 64764008060
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$472.47 |
| Max. Negotiated Rate |
$1,149.26 |
| Rate for Payer: Aetna American Axle |
$830.02
|
| Rate for Payer: Aetna Commercial |
$1,085.41
|
| Rate for Payer: Aetna Medicare |
$638.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$830.02
|
| Rate for Payer: BCBS Complete |
$510.78
|
| Rate for Payer: Cash Price |
$1,021.56
|
| Rate for Payer: Cofinity Commercial |
$1,098.18
|
| Rate for Payer: Cofinity Commercial |
$893.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$893.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,021.56
|
| Rate for Payer: Healthscope Commercial |
$1,149.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$893.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$957.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,085.41
|
| Rate for Payer: PHP Commercial |
$1,085.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$830.02
|
| Rate for Payer: Priority Health SBD |
$804.48
|
| Rate for Payer: UMR Bronson Commercial |
$472.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$957.71
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
IP
|
$89.28
|
|
|
Service Code
|
NDC 68180067006
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.28 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna American Axle |
$58.03
|
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UMR Bronson Commercial |
$39.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.96
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
IP
|
$79.20
|
|
|
Service Code
|
NDC 43598035130
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.85 |
| Max. Negotiated Rate |
$71.28 |
| Rate for Payer: Aetna American Axle |
$51.48
|
| Rate for Payer: Aetna Commercial |
$67.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.48
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cofinity Commercial |
$55.44
|
| Rate for Payer: Cofinity Commercial |
$68.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.36
|
| Rate for Payer: Healthscope Commercial |
$71.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.32
|
| Rate for Payer: PHP Commercial |
$67.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.48
|
| Rate for Payer: Priority Health SBD |
$49.90
|
| Rate for Payer: UMR Bronson Commercial |
$34.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.40
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
OP
|
$89.28
|
|
|
Service Code
|
NDC 68180067006
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna American Axle |
$58.03
|
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna Medicare |
$44.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: BCBS Complete |
$35.71
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UMR Bronson Commercial |
$33.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.96
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
OP
|
$117.74
|
|
|
Service Code
|
NDC 67877063830
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.56 |
| Max. Negotiated Rate |
$105.97 |
| Rate for Payer: Aetna American Axle |
$76.53
|
| Rate for Payer: Aetna Commercial |
$100.08
|
| Rate for Payer: Aetna Medicare |
$58.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.53
|
| Rate for Payer: BCBS Complete |
$47.10
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cofinity Commercial |
$101.26
|
| Rate for Payer: Cofinity Commercial |
$82.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$82.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.19
|
| Rate for Payer: Healthscope Commercial |
$105.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.08
|
| Rate for Payer: PHP Commercial |
$100.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.53
|
| Rate for Payer: Priority Health SBD |
$74.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.30
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
OP
|
$79.20
|
|
|
Service Code
|
NDC 43598035130
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.30 |
| Max. Negotiated Rate |
$71.28 |
| Rate for Payer: Aetna American Axle |
$51.48
|
| Rate for Payer: Aetna Commercial |
$67.32
|
| Rate for Payer: Aetna Medicare |
$39.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.48
|
| Rate for Payer: BCBS Complete |
$31.68
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cofinity Commercial |
$55.44
|
| Rate for Payer: Cofinity Commercial |
$68.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.36
|
| Rate for Payer: Healthscope Commercial |
$71.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.32
|
| Rate for Payer: PHP Commercial |
$67.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.48
|
| Rate for Payer: Priority Health SBD |
$49.90
|
| Rate for Payer: UMR Bronson Commercial |
$29.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.40
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
OP
|
$4,735.26
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,752.05 |
| Max. Negotiated Rate |
$4,261.73 |
| Rate for Payer: Aetna American Axle |
$3,077.92
|
| Rate for Payer: Aetna Commercial |
$4,024.97
|
| Rate for Payer: Aetna Medicare |
$2,367.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,077.92
|
| Rate for Payer: BCBS Complete |
$1,894.10
|
| Rate for Payer: Cash Price |
$3,788.21
|
| Rate for Payer: Cofinity Commercial |
$3,314.68
|
| Rate for Payer: Cofinity Commercial |
$4,072.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,314.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,788.21
|
| Rate for Payer: Healthscope Commercial |
$4,261.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,314.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,551.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,024.97
|
| Rate for Payer: PHP Commercial |
$4,024.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,077.92
|
| Rate for Payer: Priority Health SBD |
$2,983.21
|
| Rate for Payer: UMR Bronson Commercial |
$1,752.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,551.44
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
IP
|
$4,735.26
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,083.51 |
| Max. Negotiated Rate |
$4,261.73 |
| Rate for Payer: Aetna American Axle |
$3,077.92
|
| Rate for Payer: Aetna Commercial |
$4,024.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,077.92
|
| Rate for Payer: Cash Price |
$3,788.21
|
| Rate for Payer: Cofinity Commercial |
$3,314.68
|
| Rate for Payer: Cofinity Commercial |
$4,072.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,314.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,788.21
|
| Rate for Payer: Healthscope Commercial |
$4,261.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,314.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,551.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,024.97
|
| Rate for Payer: PHP Commercial |
$4,024.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,077.92
|
| Rate for Payer: Priority Health SBD |
$2,983.21
|
| Rate for Payer: UMR Bronson Commercial |
$2,083.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,551.44
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
OP
|
$204.34
|
|
|
Service Code
|
NDC 13668046430
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.61 |
| Max. Negotiated Rate |
$183.91 |
| Rate for Payer: Aetna American Axle |
$132.82
|
| Rate for Payer: Aetna Commercial |
$173.69
|
| Rate for Payer: Aetna Medicare |
$102.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.82
|
| Rate for Payer: BCBS Complete |
$81.74
|
| Rate for Payer: Cash Price |
$163.47
|
| Rate for Payer: Cofinity Commercial |
$143.04
|
| Rate for Payer: Cofinity Commercial |
$175.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.47
|
| Rate for Payer: Healthscope Commercial |
$183.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.69
|
| Rate for Payer: PHP Commercial |
$173.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.82
|
| Rate for Payer: Priority Health SBD |
$128.73
|
| Rate for Payer: UMR Bronson Commercial |
$75.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.26
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
IP
|
$117.74
|
|
|
Service Code
|
NDC 67877063830
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.81 |
| Max. Negotiated Rate |
$105.97 |
| Rate for Payer: Aetna American Axle |
$76.53
|
| Rate for Payer: Aetna Commercial |
$100.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.53
|
| Rate for Payer: Cash Price |
$94.19
|
| Rate for Payer: Cofinity Commercial |
$101.26
|
| Rate for Payer: Cofinity Commercial |
$82.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$82.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.19
|
| Rate for Payer: Healthscope Commercial |
$105.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.08
|
| Rate for Payer: PHP Commercial |
$100.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.53
|
| Rate for Payer: Priority Health SBD |
$74.18
|
| Rate for Payer: UMR Bronson Commercial |
$51.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.30
|
|
|
LURASIDONE 20 MG TABLET
|
Facility
|
IP
|
$204.34
|
|
|
Service Code
|
NDC 13668046430
|
| Hospital Charge Code |
158952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.91 |
| Max. Negotiated Rate |
$183.91 |
| Rate for Payer: Aetna American Axle |
$132.82
|
| Rate for Payer: Aetna Commercial |
$173.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.82
|
| Rate for Payer: Cash Price |
$163.47
|
| Rate for Payer: Cofinity Commercial |
$143.04
|
| Rate for Payer: Cofinity Commercial |
$175.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.47
|
| Rate for Payer: Healthscope Commercial |
$183.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.69
|
| Rate for Payer: PHP Commercial |
$173.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.82
|
| Rate for Payer: Priority Health SBD |
$128.73
|
| Rate for Payer: UMR Bronson Commercial |
$89.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.26
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
IP
|
$4,735.26
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,083.51 |
| Max. Negotiated Rate |
$4,261.73 |
| Rate for Payer: Aetna American Axle |
$3,077.92
|
| Rate for Payer: Aetna Commercial |
$4,024.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,077.92
|
| Rate for Payer: Cash Price |
$3,788.21
|
| Rate for Payer: Cofinity Commercial |
$3,314.68
|
| Rate for Payer: Cofinity Commercial |
$4,072.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,314.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,788.21
|
| Rate for Payer: Healthscope Commercial |
$4,261.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,314.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,551.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,024.97
|
| Rate for Payer: PHP Commercial |
$4,024.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,077.92
|
| Rate for Payer: Priority Health SBD |
$2,983.21
|
| Rate for Payer: UMR Bronson Commercial |
$2,083.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,551.44
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
OP
|
$89.28
|
|
|
Service Code
|
NDC 72205020830
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna American Axle |
$58.03
|
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna Medicare |
$44.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: BCBS Complete |
$35.71
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UMR Bronson Commercial |
$33.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.96
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
IP
|
$72.68
|
|
|
Service Code
|
NDC 67877063930
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$65.41 |
| Rate for Payer: Aetna American Axle |
$47.24
|
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.24
|
| Rate for Payer: Cash Price |
$58.14
|
| Rate for Payer: Cofinity Commercial |
$50.88
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.14
|
| Rate for Payer: Healthscope Commercial |
$65.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.78
|
| Rate for Payer: PHP Commercial |
$61.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.24
|
| Rate for Payer: Priority Health SBD |
$45.79
|
| Rate for Payer: UMR Bronson Commercial |
$31.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.51
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
IP
|
$89.28
|
|
|
Service Code
|
NDC 72205020830
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.28 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna American Axle |
$58.03
|
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UMR Bronson Commercial |
$39.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.96
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
OP
|
$72.68
|
|
|
Service Code
|
NDC 67877063930
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.89 |
| Max. Negotiated Rate |
$65.41 |
| Rate for Payer: Aetna American Axle |
$47.24
|
| Rate for Payer: Aetna Commercial |
$61.78
|
| Rate for Payer: Aetna Medicare |
$36.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.24
|
| Rate for Payer: BCBS Complete |
$29.07
|
| Rate for Payer: Cash Price |
$58.14
|
| Rate for Payer: Cofinity Commercial |
$50.88
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.14
|
| Rate for Payer: Healthscope Commercial |
$65.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.78
|
| Rate for Payer: PHP Commercial |
$61.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.24
|
| Rate for Payer: Priority Health SBD |
$45.79
|
| Rate for Payer: UMR Bronson Commercial |
$26.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.51
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
OP
|
$89.28
|
|
|
Service Code
|
NDC 68180067106
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna American Axle |
$58.03
|
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna Medicare |
$44.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: BCBS Complete |
$35.71
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UMR Bronson Commercial |
$33.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.96
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
IP
|
$89.28
|
|
|
Service Code
|
NDC 68180067106
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.28 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna American Axle |
$58.03
|
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.03
|
| Rate for Payer: Priority Health SBD |
$56.25
|
| Rate for Payer: UMR Bronson Commercial |
$39.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.96
|
|
|
LURASIDONE 40 MG TABLET
|
Facility
|
OP
|
$4,735.26
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
107668
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,752.05 |
| Max. Negotiated Rate |
$4,261.73 |
| Rate for Payer: Aetna American Axle |
$3,077.92
|
| Rate for Payer: Aetna Commercial |
$4,024.97
|
| Rate for Payer: Aetna Medicare |
$2,367.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,077.92
|
| Rate for Payer: BCBS Complete |
$1,894.10
|
| Rate for Payer: Cash Price |
$3,788.21
|
| Rate for Payer: Cofinity Commercial |
$3,314.68
|
| Rate for Payer: Cofinity Commercial |
$4,072.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,314.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,788.21
|
| Rate for Payer: Healthscope Commercial |
$4,261.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,314.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,551.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,024.97
|
| Rate for Payer: PHP Commercial |
$4,024.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,077.92
|
| Rate for Payer: Priority Health SBD |
$2,983.21
|
| Rate for Payer: UMR Bronson Commercial |
$1,752.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,551.44
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$20,878.00
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
194141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.83 |
| Max. Negotiated Rate |
$18,790.20 |
| Rate for Payer: Aetna American Axle |
$13,570.70
|
| Rate for Payer: Aetna Commercial |
$17,746.30
|
| Rate for Payer: Aetna Medicare |
$213.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,570.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$256.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$256.12
|
| Rate for Payer: BCBS Complete |
$115.32
|
| Rate for Payer: BCBS MAPPO |
$204.90
|
| Rate for Payer: BCBS Trust/PPO |
$552.46
|
| Rate for Payer: BCN Commercial |
$552.46
|
| Rate for Payer: BCN Medicare Advantage |
$204.90
|
| Rate for Payer: Cash Price |
$16,702.40
|
| Rate for Payer: Cash Price |
$16,702.40
|
| Rate for Payer: Cofinity Commercial |
$17,955.08
|
| Rate for Payer: Cofinity Commercial |
$14,614.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$14,614.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,702.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$204.90
|
| Rate for Payer: Healthscope Commercial |
$18,790.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,614.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,658.50
|
| Rate for Payer: Mclaren Medicaid |
$109.83
|
| Rate for Payer: Mclaren Medicare |
$204.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$215.14
|
| Rate for Payer: Meridian Medicaid |
$115.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$235.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,746.30
|
| Rate for Payer: Nomi Health Commercial |
$614.70
|
| Rate for Payer: PACE Medicare |
$194.66
|
| Rate for Payer: PACE SWMI |
$204.90
|
| Rate for Payer: PHP Commercial |
$17,746.30
|
| Rate for Payer: PHP Medicare Advantage |
$204.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$109.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,570.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$585.96
|
| Rate for Payer: Priority Health Medicare |
$204.90
|
| Rate for Payer: Priority Health Narrow Network |
$468.77
|
| Rate for Payer: Priority Health SBD |
$13,153.14
|
| Rate for Payer: Railroad Medicare Medicare |
$204.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$576.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$204.90
|
| Rate for Payer: UHC Exchange |
$391.58
|
| Rate for Payer: UHC Medicare Advantage |
$204.90
|
| Rate for Payer: UHCCP Medicaid |
$109.83
|
| Rate for Payer: UMR Bronson Commercial |
$7,724.86
|
| Rate for Payer: VA VA |
$204.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,658.50
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20,878.00
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
194141
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,186.32 |
| Max. Negotiated Rate |
$18,790.20 |
| Rate for Payer: Aetna American Axle |
$13,570.70
|
| Rate for Payer: Aetna Commercial |
$17,746.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,570.70
|
| Rate for Payer: Cash Price |
$16,702.40
|
| Rate for Payer: Cofinity Commercial |
$14,614.60
|
| Rate for Payer: Cofinity Commercial |
$17,955.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$14,614.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,702.40
|
| Rate for Payer: Healthscope Commercial |
$18,790.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,614.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,658.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,746.30
|
| Rate for Payer: PHP Commercial |
$17,746.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,570.70
|
| Rate for Payer: Priority Health SBD |
$13,153.14
|
| Rate for Payer: UMR Bronson Commercial |
$9,186.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,658.50
|
|
