|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3,865.02
|
|
|
Service Code
|
NDC 54092047612
|
| Hospital Charge Code |
78310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,700.61 |
| Max. Negotiated Rate |
$3,478.52 |
| Rate for Payer: Aetna American Axle |
$2,512.26
|
| Rate for Payer: Aetna Commercial |
$3,285.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,512.26
|
| Rate for Payer: Cash Price |
$3,092.02
|
| Rate for Payer: Cofinity Commercial |
$2,705.51
|
| Rate for Payer: Cofinity Commercial |
$3,323.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,705.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,092.02
|
| Rate for Payer: Healthscope Commercial |
$3,478.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,705.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,898.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,285.27
|
| Rate for Payer: PHP Commercial |
$3,285.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,512.26
|
| Rate for Payer: Priority Health SBD |
$2,434.96
|
| Rate for Payer: UMR Bronson Commercial |
$1,700.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,898.76
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$1,835.94
|
|
|
Service Code
|
NDC 68382071119
|
| Hospital Charge Code |
78310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$807.81 |
| Max. Negotiated Rate |
$1,652.35 |
| Rate for Payer: Aetna American Axle |
$1,193.36
|
| Rate for Payer: Aetna Commercial |
$1,560.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,193.36
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cofinity Commercial |
$1,285.16
|
| Rate for Payer: Cofinity Commercial |
$1,578.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,285.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,468.75
|
| Rate for Payer: Healthscope Commercial |
$1,652.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,285.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,376.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,560.55
|
| Rate for Payer: PHP Commercial |
$1,560.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,193.36
|
| Rate for Payer: Priority Health SBD |
$1,156.64
|
| Rate for Payer: UMR Bronson Commercial |
$807.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,376.96
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$1,835.94
|
|
|
Service Code
|
NDC 68382071119
|
| Hospital Charge Code |
78310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$679.30 |
| Max. Negotiated Rate |
$1,652.35 |
| Rate for Payer: Aetna American Axle |
$1,193.36
|
| Rate for Payer: Aetna Commercial |
$1,560.55
|
| Rate for Payer: Aetna Medicare |
$917.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,193.36
|
| Rate for Payer: BCBS Complete |
$734.38
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cofinity Commercial |
$1,285.16
|
| Rate for Payer: Cofinity Commercial |
$1,578.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,285.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,468.75
|
| Rate for Payer: Healthscope Commercial |
$1,652.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,285.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,376.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,560.55
|
| Rate for Payer: PHP Commercial |
$1,560.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,193.36
|
| Rate for Payer: Priority Health SBD |
$1,156.64
|
| Rate for Payer: UMR Bronson Commercial |
$679.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,376.96
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)
|
Facility
|
IP
|
$1,550.45
|
|
|
Service Code
|
NDC 59762011701
|
| Hospital Charge Code |
179241
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$682.20 |
| Max. Negotiated Rate |
$1,395.40 |
| Rate for Payer: Aetna American Axle |
$1,007.79
|
| Rate for Payer: Aetna Commercial |
$1,317.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,007.79
|
| Rate for Payer: Cash Price |
$1,240.36
|
| Rate for Payer: Cofinity Commercial |
$1,085.32
|
| Rate for Payer: Cofinity Commercial |
$1,333.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,085.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,240.36
|
| Rate for Payer: Healthscope Commercial |
$1,395.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,085.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,162.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,317.88
|
| Rate for Payer: PHP Commercial |
$1,317.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,007.79
|
| Rate for Payer: Priority Health SBD |
$976.78
|
| Rate for Payer: UMR Bronson Commercial |
$682.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,162.84
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)
|
Facility
|
OP
|
$1,550.45
|
|
|
Service Code
|
NDC 59762011701
|
| Hospital Charge Code |
179241
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$573.67 |
| Max. Negotiated Rate |
$1,395.40 |
| Rate for Payer: Aetna American Axle |
$1,007.79
|
| Rate for Payer: Aetna Commercial |
$1,317.88
|
| Rate for Payer: Aetna Medicare |
$775.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,007.79
|
| Rate for Payer: BCBS Complete |
$620.18
|
| Rate for Payer: Cash Price |
$1,240.36
|
| Rate for Payer: Cofinity Commercial |
$1,085.32
|
| Rate for Payer: Cofinity Commercial |
$1,333.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,085.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,240.36
|
| Rate for Payer: Healthscope Commercial |
$1,395.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,085.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,162.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,317.88
|
| Rate for Payer: PHP Commercial |
$1,317.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,007.79
|
| Rate for Payer: Priority Health SBD |
$976.78
|
| Rate for Payer: UMR Bronson Commercial |
$573.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,162.84
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)
|
Facility
|
OP
|
$2,402.93
|
|
|
Service Code
|
NDC 00023585318
|
| Hospital Charge Code |
179241
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$889.08 |
| Max. Negotiated Rate |
$2,162.64 |
| Rate for Payer: Aetna American Axle |
$1,561.90
|
| Rate for Payer: Aetna Commercial |
$2,042.49
|
| Rate for Payer: Aetna Medicare |
$1,201.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,561.90
|
| Rate for Payer: BCBS Complete |
$961.17
|
| Rate for Payer: Cash Price |
$1,922.34
|
| Rate for Payer: Cofinity Commercial |
$1,682.05
|
| Rate for Payer: Cofinity Commercial |
$2,066.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,682.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,922.34
|
| Rate for Payer: Healthscope Commercial |
$2,162.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,682.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,802.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,042.49
|
| Rate for Payer: PHP Commercial |
$2,042.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,561.90
|
| Rate for Payer: Priority Health SBD |
$1,513.85
|
| Rate for Payer: UMR Bronson Commercial |
$889.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,802.20
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)
|
Facility
|
IP
|
$2,402.93
|
|
|
Service Code
|
NDC 00023585318
|
| Hospital Charge Code |
179241
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,057.29 |
| Max. Negotiated Rate |
$2,162.64 |
| Rate for Payer: Aetna American Axle |
$1,561.90
|
| Rate for Payer: Aetna Commercial |
$2,042.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,561.90
|
| Rate for Payer: Cash Price |
$1,922.34
|
| Rate for Payer: Cofinity Commercial |
$1,682.05
|
| Rate for Payer: Cofinity Commercial |
$2,066.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,682.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,922.34
|
| Rate for Payer: Healthscope Commercial |
$2,162.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,682.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,802.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,042.49
|
| Rate for Payer: PHP Commercial |
$2,042.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,561.90
|
| Rate for Payer: Priority Health SBD |
$1,513.85
|
| Rate for Payer: UMR Bronson Commercial |
$1,057.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,802.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA
|
Facility
|
IP
|
$39.08
|
|
|
Service Code
|
NDC 45802009846
|
| Hospital Charge Code |
10535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna American Axle |
$25.40
|
| Rate for Payer: Aetna Commercial |
$33.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.40
|
| Rate for Payer: Cash Price |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$33.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.26
|
| Rate for Payer: Healthscope Commercial |
$35.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.22
|
| Rate for Payer: PHP Commercial |
$33.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.40
|
| Rate for Payer: Priority Health SBD |
$24.62
|
| Rate for Payer: UMR Bronson Commercial |
$17.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.31
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA
|
Facility
|
OP
|
$46.85
|
|
|
Service Code
|
NDC 62559042007
|
| Hospital Charge Code |
10535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: Aetna American Axle |
$30.45
|
| Rate for Payer: Aetna Commercial |
$39.82
|
| Rate for Payer: Aetna Medicare |
$23.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.45
|
| Rate for Payer: BCBS Complete |
$18.74
|
| Rate for Payer: Cash Price |
$37.48
|
| Rate for Payer: Cofinity Commercial |
$32.80
|
| Rate for Payer: Cofinity Commercial |
$40.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.48
|
| Rate for Payer: Healthscope Commercial |
$42.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.82
|
| Rate for Payer: PHP Commercial |
$39.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.45
|
| Rate for Payer: Priority Health SBD |
$29.52
|
| Rate for Payer: UMR Bronson Commercial |
$17.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.14
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA
|
Facility
|
OP
|
$39.08
|
|
|
Service Code
|
NDC 45802009846
|
| Hospital Charge Code |
10535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.46 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna American Axle |
$25.40
|
| Rate for Payer: Aetna Commercial |
$33.22
|
| Rate for Payer: Aetna Medicare |
$19.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.40
|
| Rate for Payer: BCBS Complete |
$15.63
|
| Rate for Payer: Cash Price |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$33.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.26
|
| Rate for Payer: Healthscope Commercial |
$35.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.22
|
| Rate for Payer: PHP Commercial |
$33.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.40
|
| Rate for Payer: Priority Health SBD |
$24.62
|
| Rate for Payer: UMR Bronson Commercial |
$14.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.31
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA
|
Facility
|
IP
|
$46.85
|
|
|
Service Code
|
NDC 62559042007
|
| Hospital Charge Code |
10535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.61 |
| Max. Negotiated Rate |
$42.16 |
| Rate for Payer: Aetna American Axle |
$30.45
|
| Rate for Payer: Aetna Commercial |
$39.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.45
|
| Rate for Payer: Cash Price |
$37.48
|
| Rate for Payer: Cofinity Commercial |
$32.80
|
| Rate for Payer: Cofinity Commercial |
$40.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.48
|
| Rate for Payer: Healthscope Commercial |
$42.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.82
|
| Rate for Payer: PHP Commercial |
$39.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.45
|
| Rate for Payer: Priority Health SBD |
$29.52
|
| Rate for Payer: UMR Bronson Commercial |
$20.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.14
|
|
|
MESALAMINE 800 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4,595.40
|
|
|
Service Code
|
NDC 68382043528
|
| Hospital Charge Code |
96949
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,021.98 |
| Max. Negotiated Rate |
$4,135.86 |
| Rate for Payer: Aetna American Axle |
$2,987.01
|
| Rate for Payer: Aetna Commercial |
$3,906.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,987.01
|
| Rate for Payer: Cash Price |
$3,676.32
|
| Rate for Payer: Cofinity Commercial |
$3,216.78
|
| Rate for Payer: Cofinity Commercial |
$3,952.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,216.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,676.32
|
| Rate for Payer: Healthscope Commercial |
$4,135.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,216.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,446.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,906.09
|
| Rate for Payer: PHP Commercial |
$3,906.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,987.01
|
| Rate for Payer: Priority Health SBD |
$2,895.10
|
| Rate for Payer: UMR Bronson Commercial |
$2,021.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,446.55
|
|
|
MESALAMINE 800 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$4,595.40
|
|
|
Service Code
|
NDC 68382043528
|
| Hospital Charge Code |
96949
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,700.30 |
| Max. Negotiated Rate |
$4,135.86 |
| Rate for Payer: Aetna American Axle |
$2,987.01
|
| Rate for Payer: Aetna Commercial |
$3,906.09
|
| Rate for Payer: Aetna Medicare |
$2,297.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,987.01
|
| Rate for Payer: BCBS Complete |
$1,838.16
|
| Rate for Payer: Cash Price |
$3,676.32
|
| Rate for Payer: Cofinity Commercial |
$3,216.78
|
| Rate for Payer: Cofinity Commercial |
$3,952.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,216.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,676.32
|
| Rate for Payer: Healthscope Commercial |
$4,135.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,216.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,446.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,906.09
|
| Rate for Payer: PHP Commercial |
$3,906.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,987.01
|
| Rate for Payer: Priority Health SBD |
$2,895.10
|
| Rate for Payer: UMR Bronson Commercial |
$1,700.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,446.55
|
|
|
MESALAMINE ER 0.375 GRAM CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,756.02
|
|
|
Service Code
|
NDC 65649010302
|
| Hospital Charge Code |
95687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$649.73 |
| Max. Negotiated Rate |
$1,580.42 |
| Rate for Payer: Aetna American Axle |
$1,141.41
|
| Rate for Payer: Aetna Commercial |
$1,492.62
|
| Rate for Payer: Aetna Medicare |
$878.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,141.41
|
| Rate for Payer: BCBS Complete |
$702.41
|
| Rate for Payer: Cash Price |
$1,404.82
|
| Rate for Payer: Cofinity Commercial |
$1,229.21
|
| Rate for Payer: Cofinity Commercial |
$1,510.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,229.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,404.82
|
| Rate for Payer: Healthscope Commercial |
$1,580.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,229.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,317.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,492.62
|
| Rate for Payer: PHP Commercial |
$1,492.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,141.41
|
| Rate for Payer: Priority Health SBD |
$1,106.29
|
| Rate for Payer: UMR Bronson Commercial |
$649.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,317.02
|
|
|
MESALAMINE ER 0.375 GRAM CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,756.02
|
|
|
Service Code
|
NDC 65649010302
|
| Hospital Charge Code |
95687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$772.65 |
| Max. Negotiated Rate |
$1,580.42 |
| Rate for Payer: Aetna American Axle |
$1,141.41
|
| Rate for Payer: Aetna Commercial |
$1,492.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,141.41
|
| Rate for Payer: Cash Price |
$1,404.82
|
| Rate for Payer: Cofinity Commercial |
$1,229.21
|
| Rate for Payer: Cofinity Commercial |
$1,510.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,229.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,404.82
|
| Rate for Payer: Healthscope Commercial |
$1,580.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,229.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,317.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,492.62
|
| Rate for Payer: PHP Commercial |
$1,492.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,141.41
|
| Rate for Payer: Priority Health SBD |
$1,106.29
|
| Rate for Payer: UMR Bronson Commercial |
$772.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,317.02
|
|
|
MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$2,507.72
|
|
|
Service Code
|
NDC 54092018981
|
| Hospital Charge Code |
10533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,103.40 |
| Max. Negotiated Rate |
$2,256.95 |
| Rate for Payer: Aetna American Axle |
$1,630.02
|
| Rate for Payer: Aetna Commercial |
$2,131.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,630.02
|
| Rate for Payer: Cash Price |
$2,006.18
|
| Rate for Payer: Cofinity Commercial |
$1,755.40
|
| Rate for Payer: Cofinity Commercial |
$2,156.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,755.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,006.18
|
| Rate for Payer: Healthscope Commercial |
$2,256.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,755.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,880.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,131.56
|
| Rate for Payer: PHP Commercial |
$2,131.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,630.02
|
| Rate for Payer: Priority Health SBD |
$1,579.86
|
| Rate for Payer: UMR Bronson Commercial |
$1,103.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,880.79
|
|
|
MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$2,507.72
|
|
|
Service Code
|
NDC 54092018981
|
| Hospital Charge Code |
10533
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$927.86 |
| Max. Negotiated Rate |
$2,256.95 |
| Rate for Payer: Aetna American Axle |
$1,630.02
|
| Rate for Payer: Aetna Commercial |
$2,131.56
|
| Rate for Payer: Aetna Medicare |
$1,253.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,630.02
|
| Rate for Payer: BCBS Complete |
$1,003.09
|
| Rate for Payer: Cash Price |
$2,006.18
|
| Rate for Payer: Cofinity Commercial |
$1,755.40
|
| Rate for Payer: Cofinity Commercial |
$2,156.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,755.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,006.18
|
| Rate for Payer: Healthscope Commercial |
$2,256.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,755.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,880.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,131.56
|
| Rate for Payer: PHP Commercial |
$2,131.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,630.02
|
| Rate for Payer: Priority Health SBD |
$1,579.86
|
| Rate for Payer: UMR Bronson Commercial |
$927.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,880.79
|
|
|
MESNA 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$34.49
|
|
|
Service Code
|
HCPCS J9209
|
| Hospital Charge Code |
10537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Aetna American Axle |
$22.42
|
| Rate for Payer: Aetna American Axle |
$22.04
|
| Rate for Payer: Aetna American Axle |
$21.61
|
| Rate for Payer: Aetna Commercial |
$29.32
|
| Rate for Payer: Aetna Commercial |
$28.26
|
| Rate for Payer: Aetna Commercial |
$28.82
|
| Rate for Payer: Aetna Medicare |
$16.96
|
| Rate for Payer: Aetna Medicare |
$16.62
|
| Rate for Payer: Aetna Medicare |
$17.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.04
|
| Rate for Payer: BCBS Complete |
$13.56
|
| Rate for Payer: BCBS Complete |
$13.80
|
| Rate for Payer: BCBS Complete |
$13.30
|
| Rate for Payer: BCBS Trust/PPO |
$5.08
|
| Rate for Payer: BCBS Trust/PPO |
$5.08
|
| Rate for Payer: BCBS Trust/PPO |
$5.08
|
| Rate for Payer: BCN Commercial |
$5.08
|
| Rate for Payer: BCN Commercial |
$5.08
|
| Rate for Payer: BCN Commercial |
$5.08
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cash Price |
$27.59
|
| Rate for Payer: Cash Price |
$26.60
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cash Price |
$26.60
|
| Rate for Payer: Cash Price |
$27.59
|
| Rate for Payer: Cofinity Commercial |
$29.16
|
| Rate for Payer: Cofinity Commercial |
$23.28
|
| Rate for Payer: Cofinity Commercial |
$28.60
|
| Rate for Payer: Cofinity Commercial |
$23.74
|
| Rate for Payer: Cofinity Commercial |
$24.14
|
| Rate for Payer: Cofinity Commercial |
$29.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.59
|
| Rate for Payer: Healthscope Commercial |
$31.04
|
| Rate for Payer: Healthscope Commercial |
$30.52
|
| Rate for Payer: Healthscope Commercial |
$29.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.32
|
| Rate for Payer: PHP Commercial |
$29.32
|
| Rate for Payer: PHP Commercial |
$28.26
|
| Rate for Payer: PHP Commercial |
$28.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.42
|
| Rate for Payer: Priority Health SBD |
$21.36
|
| Rate for Payer: Priority Health SBD |
$21.73
|
| Rate for Payer: Priority Health SBD |
$20.95
|
| Rate for Payer: UMR Bronson Commercial |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$12.30
|
| Rate for Payer: UMR Bronson Commercial |
$12.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.87
|
|
|
MESNA 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$33.25
|
|
|
Service Code
|
HCPCS J9209
|
| Hospital Charge Code |
10537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$29.92 |
| Rate for Payer: Aetna American Axle |
$21.61
|
| Rate for Payer: Aetna American Axle |
$22.04
|
| Rate for Payer: Aetna American Axle |
$22.42
|
| Rate for Payer: Aetna Commercial |
$28.82
|
| Rate for Payer: Aetna Commercial |
$28.26
|
| Rate for Payer: Aetna Commercial |
$29.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.04
|
| Rate for Payer: Cash Price |
$27.59
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cash Price |
$26.60
|
| Rate for Payer: Cofinity Commercial |
$28.60
|
| Rate for Payer: Cofinity Commercial |
$29.16
|
| Rate for Payer: Cofinity Commercial |
$23.74
|
| Rate for Payer: Cofinity Commercial |
$29.66
|
| Rate for Payer: Cofinity Commercial |
$24.14
|
| Rate for Payer: Cofinity Commercial |
$23.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.13
|
| Rate for Payer: Healthscope Commercial |
$30.52
|
| Rate for Payer: Healthscope Commercial |
$29.92
|
| Rate for Payer: Healthscope Commercial |
$31.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.82
|
| Rate for Payer: PHP Commercial |
$29.32
|
| Rate for Payer: PHP Commercial |
$28.82
|
| Rate for Payer: PHP Commercial |
$28.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.61
|
| Rate for Payer: Priority Health SBD |
$21.73
|
| Rate for Payer: Priority Health SBD |
$21.36
|
| Rate for Payer: Priority Health SBD |
$20.95
|
| Rate for Payer: UMR Bronson Commercial |
$14.63
|
| Rate for Payer: UMR Bronson Commercial |
$15.18
|
| Rate for Payer: UMR Bronson Commercial |
$14.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.43
|
|
|
MESNA 50 MG/0.5 ML ORAL SOLN
|
Facility
|
OP
|
$166.65
|
|
|
Service Code
|
HCPCS J9209
|
| Hospital Charge Code |
150702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$149.98 |
| Rate for Payer: Aetna American Axle |
$108.32
|
| Rate for Payer: Aetna Commercial |
$141.65
|
| Rate for Payer: Aetna Medicare |
$83.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.32
|
| Rate for Payer: BCBS Complete |
$66.66
|
| Rate for Payer: BCBS Trust/PPO |
$5.08
|
| Rate for Payer: BCN Commercial |
$5.08
|
| Rate for Payer: Cash Price |
$133.32
|
| Rate for Payer: Cash Price |
$133.32
|
| Rate for Payer: Cofinity Commercial |
$116.66
|
| Rate for Payer: Cofinity Commercial |
$143.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.32
|
| Rate for Payer: Healthscope Commercial |
$149.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.65
|
| Rate for Payer: PHP Commercial |
$141.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.32
|
| Rate for Payer: Priority Health SBD |
$104.99
|
| Rate for Payer: UMR Bronson Commercial |
$61.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.99
|
|
|
MESNA 50 MG/0.5 ML ORAL SOLN
|
Facility
|
IP
|
$166.65
|
|
|
Service Code
|
HCPCS J9209
|
| Hospital Charge Code |
150702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.33 |
| Max. Negotiated Rate |
$149.98 |
| Rate for Payer: Aetna American Axle |
$108.32
|
| Rate for Payer: Aetna Commercial |
$141.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.32
|
| Rate for Payer: Cash Price |
$133.32
|
| Rate for Payer: Cofinity Commercial |
$116.66
|
| Rate for Payer: Cofinity Commercial |
$143.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.32
|
| Rate for Payer: Healthscope Commercial |
$149.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.65
|
| Rate for Payer: PHP Commercial |
$141.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.32
|
| Rate for Payer: Priority Health SBD |
$104.99
|
| Rate for Payer: UMR Bronson Commercial |
$73.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.99
|
|
|
METFORMIN 500 MG TABLET
|
Facility
|
IP
|
$246.75
|
|
|
Service Code
|
NDC 60687015501
|
| Hospital Charge Code |
10544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.57 |
| Max. Negotiated Rate |
$222.08 |
| Rate for Payer: Aetna American Axle |
$160.39
|
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.39
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$172.72
|
| Rate for Payer: Cofinity Commercial |
$212.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.74
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.39
|
| Rate for Payer: Priority Health SBD |
$155.45
|
| Rate for Payer: UMR Bronson Commercial |
$108.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
METFORMIN 500 MG TABLET
|
Facility
|
OP
|
$2.47
|
|
|
Service Code
|
NDC 60687015511
|
| Hospital Charge Code |
10544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$0.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.85
|
|
|
METFORMIN 500 MG TABLET
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 23155010201
|
| Hospital Charge Code |
10544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.26 |
| Max. Negotiated Rate |
$78.26 |
| Rate for Payer: Aetna American Axle |
$56.52
|
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.52
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$60.86
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Healthscope Commercial |
$78.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.91
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.52
|
| Rate for Payer: Priority Health SBD |
$54.78
|
| Rate for Payer: UMR Bronson Commercial |
$38.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
METFORMIN 500 MG TABLET
|
Facility
|
OP
|
$54.05
|
|
|
Service Code
|
NDC 65862000801
|
| Hospital Charge Code |
10544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$48.64 |
| Rate for Payer: Aetna American Axle |
$35.13
|
| Rate for Payer: Aetna Commercial |
$45.94
|
| Rate for Payer: Aetna Medicare |
$27.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.13
|
| Rate for Payer: BCBS Complete |
$21.62
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$37.84
|
| Rate for Payer: Cofinity Commercial |
$46.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$48.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: PHP Commercial |
$45.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: Priority Health SBD |
$34.05
|
| Rate for Payer: UMR Bronson Commercial |
$20.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.54
|
|
