|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$30,833.46
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
202156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$27,750.11 |
| Rate for Payer: Aetna American Axle |
$20,041.75
|
| Rate for Payer: Aetna Commercial |
$26,208.44
|
| Rate for Payer: Aetna Medicare |
$73.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20,041.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$88.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$88.91
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: BCBS MAPPO |
$71.13
|
| Rate for Payer: BCBS Trust/PPO |
$230.74
|
| Rate for Payer: BCN Commercial |
$230.74
|
| Rate for Payer: BCN Medicare Advantage |
$71.13
|
| Rate for Payer: Cash Price |
$24,666.77
|
| Rate for Payer: Cash Price |
$24,666.77
|
| Rate for Payer: Cofinity Advantage |
$21,583.42
|
| Rate for Payer: Cofinity Commercial |
$26,516.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24,666.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$71.13
|
| Rate for Payer: Healthscope Commercial |
$27,750.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21,583.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23,125.10
|
| Rate for Payer: Mclaren Medicaid |
$71.13
|
| Rate for Payer: Mclaren Medicare |
$71.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$74.69
|
| Rate for Payer: Meridian Medicaid |
$74.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$81.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$78.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,208.44
|
| Rate for Payer: Nomi Health Commercial |
$213.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23,125.10
|
| Rate for Payer: PACE Medicare |
$67.57
|
| Rate for Payer: PACE SWMI |
$71.13
|
| Rate for Payer: PHP Commercial |
$26,208.44
|
| Rate for Payer: PHP Medicare Advantage |
$71.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$37.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$219.15
|
| Rate for Payer: Priority Health Medicare |
$71.13
|
| Rate for Payer: Priority Health SBD |
$19,425.08
|
| Rate for Payer: Priority Health Tiered Network |
$175.32
|
| Rate for Payer: Railroad Medicare Medicare |
$71.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$117.43
|
| Rate for Payer: UHC Core |
$117.43
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$71.13
|
| Rate for Payer: UHC Exchange |
$117.43
|
| Rate for Payer: UHC Medicaid |
$37.20
|
| Rate for Payer: UHCCP Medicaid |
$37.20
|
| Rate for Payer: UMR Bronson Commercial |
$11,408.38
|
| Rate for Payer: VA VA |
$71.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23,125.10
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$26,783.94
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$11,174.07 |
| Max. Negotiated Rate |
$26,783.94 |
| Rate for Payer: Aetna Medicare |
$12,232.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,702.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,702.73
|
| Rate for Payer: BCBS MAPPO |
$11,762.18
|
| Rate for Payer: BCBS Trust/PPO |
$26,783.94
|
| Rate for Payer: BCN Commercial |
$26,783.94
|
| Rate for Payer: BCN Medicare Advantage |
$11,762.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,762.18
|
| Rate for Payer: Mclaren Medicare |
$11,762.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,350.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,526.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$12,938.40
|
| Rate for Payer: Nomi Health Commercial |
$17,229.24
|
| Rate for Payer: PACE Medicare |
$11,174.07
|
| Rate for Payer: PACE SWMI |
$11,762.18
|
| Rate for Payer: PHP Medicare Advantage |
$11,762.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$21,532.73
|
| Rate for Payer: Priority Health Medicare |
$11,762.18
|
| Rate for Payer: Priority Health Tiered Network |
$17,226.18
|
| Rate for Payer: Railroad Medicare Medicare |
$11,762.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21,770.28
|
| Rate for Payer: UHC Core |
$18,213.58
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,762.18
|
| Rate for Payer: UHC Exchange |
$14,874.58
|
| Rate for Payer: VA VA |
$11,762.18
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$14,971.78
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$6,745.79 |
| Max. Negotiated Rate |
$14,971.78 |
| Rate for Payer: Aetna Medicare |
$7,384.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,876.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,876.04
|
| Rate for Payer: BCBS MAPPO |
$7,100.83
|
| Rate for Payer: BCBS Trust/PPO |
$14,971.78
|
| Rate for Payer: BCN Commercial |
$14,971.78
|
| Rate for Payer: BCN Medicare Advantage |
$7,100.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,100.83
|
| Rate for Payer: Mclaren Medicare |
$7,100.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,455.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,165.95
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,810.91
|
| Rate for Payer: Nomi Health Commercial |
$10,038.78
|
| Rate for Payer: PACE Medicare |
$6,745.79
|
| Rate for Payer: PACE SWMI |
$7,100.83
|
| Rate for Payer: PHP Medicare Advantage |
$7,100.83
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,546.25
|
| Rate for Payer: Priority Health Medicare |
$7,100.83
|
| Rate for Payer: Priority Health Tiered Network |
$10,037.00
|
| Rate for Payer: Railroad Medicare Medicare |
$7,100.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,684.66
|
| Rate for Payer: UHC Core |
$10,612.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,100.83
|
| Rate for Payer: UHC Exchange |
$8,666.81
|
| Rate for Payer: VA VA |
$7,100.83
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$8.78
|
|
|
Service Code
|
NDC 60687073511
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$7.90 |
| Rate for Payer: Aetna American Axle |
$5.71
|
| Rate for Payer: Aetna Commercial |
$7.46
|
| Rate for Payer: Aetna Medicare |
$4.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.71
|
| Rate for Payer: BCBS Complete |
$3.51
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cofinity Advantage |
$6.15
|
| Rate for Payer: Cofinity Commercial |
$7.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.02
|
| Rate for Payer: Healthscope Commercial |
$7.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.58
|
| Rate for Payer: PHP Commercial |
$7.46
|
| Rate for Payer: Priority Health SBD |
$5.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.71
|
| Rate for Payer: UHC Core |
$4.57
|
| Rate for Payer: UHC Exchange |
$3.45
|
| Rate for Payer: UMR Bronson Commercial |
$3.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.58
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$177.41
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.64 |
| Max. Negotiated Rate |
$159.67 |
| Rate for Payer: Aetna American Axle |
$115.32
|
| Rate for Payer: Aetna Commercial |
$150.80
|
| Rate for Payer: Aetna Medicare |
$88.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.32
|
| Rate for Payer: BCBS Complete |
$70.96
|
| Rate for Payer: Cash Price |
$141.93
|
| Rate for Payer: Cofinity Advantage |
$124.19
|
| Rate for Payer: Cofinity Commercial |
$152.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.93
|
| Rate for Payer: Healthscope Commercial |
$159.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$141.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$133.06
|
| Rate for Payer: PHP Commercial |
$150.80
|
| Rate for Payer: Priority Health SBD |
$111.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.32
|
| Rate for Payer: UHC Core |
$92.43
|
| Rate for Payer: UHC Exchange |
$69.72
|
| Rate for Payer: UMR Bronson Commercial |
$65.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.06
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$354.82
|
|
|
Service Code
|
NDC 43386016012
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.12 |
| Max. Negotiated Rate |
$319.34 |
| Rate for Payer: Aetna American Axle |
$230.63
|
| Rate for Payer: Aetna Commercial |
$301.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.63
|
| Rate for Payer: Cash Price |
$283.86
|
| Rate for Payer: Cofinity Advantage |
$248.37
|
| Rate for Payer: Cofinity Commercial |
$305.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.86
|
| Rate for Payer: Healthscope Commercial |
$319.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$266.12
|
| Rate for Payer: PHP Commercial |
$301.60
|
| Rate for Payer: Priority Health SBD |
$223.54
|
| Rate for Payer: UMR Bronson Commercial |
$156.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.12
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$699.84
|
|
|
Service Code
|
NDC 68084004001
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.94 |
| Max. Negotiated Rate |
$629.86 |
| Rate for Payer: Aetna American Axle |
$454.90
|
| Rate for Payer: Aetna Commercial |
$594.86
|
| Rate for Payer: Aetna Medicare |
$349.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$454.90
|
| Rate for Payer: BCBS Complete |
$279.94
|
| Rate for Payer: Cash Price |
$559.87
|
| Rate for Payer: Cofinity Advantage |
$489.89
|
| Rate for Payer: Cofinity Commercial |
$601.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$559.87
|
| Rate for Payer: Healthscope Commercial |
$629.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$489.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$524.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$559.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$594.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$524.88
|
| Rate for Payer: PHP Commercial |
$594.86
|
| Rate for Payer: Priority Health SBD |
$440.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$454.90
|
| Rate for Payer: UHC Core |
$364.62
|
| Rate for Payer: UHC Exchange |
$275.04
|
| Rate for Payer: UMR Bronson Commercial |
$258.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$524.88
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 68084004011
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna American Axle |
$4.55
|
| Rate for Payer: Aetna Commercial |
$5.95
|
| Rate for Payer: Aetna Medicare |
$3.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.55
|
| Rate for Payer: BCBS Complete |
$2.80
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cofinity Advantage |
$4.90
|
| Rate for Payer: Cofinity Commercial |
$6.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.60
|
| Rate for Payer: Healthscope Commercial |
$6.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.25
|
| Rate for Payer: PHP Commercial |
$5.95
|
| Rate for Payer: Priority Health SBD |
$4.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.55
|
| Rate for Payer: UHC Core |
$3.65
|
| Rate for Payer: UHC Exchange |
$2.75
|
| Rate for Payer: UMR Bronson Commercial |
$2.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.25
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$699.84
|
|
|
Service Code
|
NDC 68084004001
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$307.93 |
| Max. Negotiated Rate |
$629.86 |
| Rate for Payer: Aetna American Axle |
$454.90
|
| Rate for Payer: Aetna Commercial |
$594.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$454.90
|
| Rate for Payer: Cash Price |
$559.87
|
| Rate for Payer: Cofinity Advantage |
$489.89
|
| Rate for Payer: Cofinity Commercial |
$601.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$559.87
|
| Rate for Payer: Healthscope Commercial |
$629.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$489.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$524.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$594.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$524.88
|
| Rate for Payer: PHP Commercial |
$594.86
|
| Rate for Payer: Priority Health SBD |
$440.90
|
| Rate for Payer: UMR Bronson Commercial |
$307.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$524.88
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$1,442.63
|
|
|
Service Code
|
NDC 00025145134
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$634.76 |
| Max. Negotiated Rate |
$1,298.37 |
| Rate for Payer: Aetna American Axle |
$937.71
|
| Rate for Payer: Aetna Commercial |
$1,226.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$937.71
|
| Rate for Payer: Cash Price |
$1,154.10
|
| Rate for Payer: Cofinity Advantage |
$1,009.84
|
| Rate for Payer: Cofinity Commercial |
$1,240.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.10
|
| Rate for Payer: Healthscope Commercial |
$1,298.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,009.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,081.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,226.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,081.97
|
| Rate for Payer: PHP Commercial |
$1,226.24
|
| Rate for Payer: Priority Health SBD |
$908.86
|
| Rate for Payer: UMR Bronson Commercial |
$634.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,081.97
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$877.92
|
|
|
Service Code
|
NDC 60687073501
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$386.28 |
| Max. Negotiated Rate |
$790.13 |
| Rate for Payer: Aetna American Axle |
$570.65
|
| Rate for Payer: Aetna Commercial |
$746.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$570.65
|
| Rate for Payer: Cash Price |
$702.34
|
| Rate for Payer: Cofinity Advantage |
$614.54
|
| Rate for Payer: Cofinity Commercial |
$755.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$702.34
|
| Rate for Payer: Healthscope Commercial |
$790.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$614.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$658.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$746.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$658.44
|
| Rate for Payer: PHP Commercial |
$746.23
|
| Rate for Payer: Priority Health SBD |
$553.09
|
| Rate for Payer: UMR Bronson Commercial |
$386.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$658.44
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$1,442.63
|
|
|
Service Code
|
NDC 00025145134
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$533.77 |
| Max. Negotiated Rate |
$1,298.37 |
| Rate for Payer: Aetna American Axle |
$937.71
|
| Rate for Payer: Aetna Commercial |
$1,226.24
|
| Rate for Payer: Aetna Medicare |
$721.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$937.71
|
| Rate for Payer: BCBS Complete |
$577.05
|
| Rate for Payer: Cash Price |
$1,154.10
|
| Rate for Payer: Cofinity Advantage |
$1,009.84
|
| Rate for Payer: Cofinity Commercial |
$1,240.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.10
|
| Rate for Payer: Healthscope Commercial |
$1,298.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,009.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,081.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,154.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,226.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,081.97
|
| Rate for Payer: PHP Commercial |
$1,226.24
|
| Rate for Payer: Priority Health SBD |
$908.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$937.71
|
| Rate for Payer: UHC Core |
$751.61
|
| Rate for Payer: UHC Exchange |
$566.95
|
| Rate for Payer: UMR Bronson Commercial |
$533.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,081.97
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$177.12
|
|
|
Service Code
|
NDC 43386016006
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.93 |
| Max. Negotiated Rate |
$159.41 |
| Rate for Payer: Aetna American Axle |
$115.13
|
| Rate for Payer: Aetna Commercial |
$150.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.13
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cofinity Advantage |
$123.98
|
| Rate for Payer: Cofinity Commercial |
$152.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.70
|
| Rate for Payer: Healthscope Commercial |
$159.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$132.84
|
| Rate for Payer: PHP Commercial |
$150.55
|
| Rate for Payer: Priority Health SBD |
$111.59
|
| Rate for Payer: UMR Bronson Commercial |
$77.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.84
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$354.82
|
|
|
Service Code
|
NDC 43386016012
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.28 |
| Max. Negotiated Rate |
$319.34 |
| Rate for Payer: Aetna American Axle |
$230.63
|
| Rate for Payer: Aetna Commercial |
$301.60
|
| Rate for Payer: Aetna Medicare |
$177.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.63
|
| Rate for Payer: BCBS Complete |
$141.93
|
| Rate for Payer: Cash Price |
$283.86
|
| Rate for Payer: Cofinity Advantage |
$248.37
|
| Rate for Payer: Cofinity Commercial |
$305.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.86
|
| Rate for Payer: Healthscope Commercial |
$319.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$283.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$266.12
|
| Rate for Payer: PHP Commercial |
$301.60
|
| Rate for Payer: Priority Health SBD |
$223.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$230.63
|
| Rate for Payer: UHC Core |
$184.86
|
| Rate for Payer: UHC Exchange |
$139.44
|
| Rate for Payer: UMR Bronson Commercial |
$131.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.12
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$177.41
|
|
|
Service Code
|
NDC 59762500701
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.06 |
| Max. Negotiated Rate |
$159.67 |
| Rate for Payer: Aetna American Axle |
$115.32
|
| Rate for Payer: Aetna Commercial |
$150.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.32
|
| Rate for Payer: Cash Price |
$141.93
|
| Rate for Payer: Cofinity Advantage |
$124.19
|
| Rate for Payer: Cofinity Commercial |
$152.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.93
|
| Rate for Payer: Healthscope Commercial |
$159.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$133.06
|
| Rate for Payer: PHP Commercial |
$150.80
|
| Rate for Payer: Priority Health SBD |
$111.77
|
| Rate for Payer: UMR Bronson Commercial |
$78.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.06
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 68084004011
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna American Axle |
$4.55
|
| Rate for Payer: Aetna Commercial |
$5.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.55
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cofinity Advantage |
$4.90
|
| Rate for Payer: Cofinity Commercial |
$6.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.60
|
| Rate for Payer: Healthscope Commercial |
$6.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.25
|
| Rate for Payer: PHP Commercial |
$5.95
|
| Rate for Payer: Priority Health SBD |
$4.41
|
| Rate for Payer: UMR Bronson Commercial |
$3.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.25
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$241.68
|
|
|
Service Code
|
NDC 70954044310
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.34 |
| Max. Negotiated Rate |
$217.51 |
| Rate for Payer: Aetna American Axle |
$157.09
|
| Rate for Payer: Aetna Commercial |
$205.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.09
|
| Rate for Payer: Cash Price |
$193.34
|
| Rate for Payer: Cofinity Advantage |
$169.18
|
| Rate for Payer: Cofinity Commercial |
$207.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.34
|
| Rate for Payer: Healthscope Commercial |
$217.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.26
|
| Rate for Payer: PHP Commercial |
$205.43
|
| Rate for Payer: Priority Health SBD |
$152.26
|
| Rate for Payer: UMR Bronson Commercial |
$106.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.26
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$177.12
|
|
|
Service Code
|
NDC 43386016006
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.53 |
| Max. Negotiated Rate |
$159.41 |
| Rate for Payer: Aetna American Axle |
$115.13
|
| Rate for Payer: Aetna Commercial |
$150.55
|
| Rate for Payer: Aetna Medicare |
$88.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.13
|
| Rate for Payer: BCBS Complete |
$70.85
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cofinity Advantage |
$123.98
|
| Rate for Payer: Cofinity Commercial |
$152.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.70
|
| Rate for Payer: Healthscope Commercial |
$159.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$141.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$132.84
|
| Rate for Payer: PHP Commercial |
$150.55
|
| Rate for Payer: Priority Health SBD |
$111.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.13
|
| Rate for Payer: UHC Core |
$92.28
|
| Rate for Payer: UHC Exchange |
$69.61
|
| Rate for Payer: UMR Bronson Commercial |
$65.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.84
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$877.92
|
|
|
Service Code
|
NDC 60687073501
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$324.83 |
| Max. Negotiated Rate |
$790.13 |
| Rate for Payer: Aetna American Axle |
$570.65
|
| Rate for Payer: Aetna Commercial |
$746.23
|
| Rate for Payer: Aetna Medicare |
$438.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$570.65
|
| Rate for Payer: BCBS Complete |
$351.17
|
| Rate for Payer: Cash Price |
$702.34
|
| Rate for Payer: Cofinity Advantage |
$614.54
|
| Rate for Payer: Cofinity Commercial |
$755.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$702.34
|
| Rate for Payer: Healthscope Commercial |
$790.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$614.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$658.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$702.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$746.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$658.44
|
| Rate for Payer: PHP Commercial |
$746.23
|
| Rate for Payer: Priority Health SBD |
$553.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$570.65
|
| Rate for Payer: UHC Core |
$457.40
|
| Rate for Payer: UHC Exchange |
$345.02
|
| Rate for Payer: UMR Bronson Commercial |
$324.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$658.44
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$8.78
|
|
|
Service Code
|
NDC 60687073511
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$7.90 |
| Rate for Payer: Aetna American Axle |
$5.71
|
| Rate for Payer: Aetna Commercial |
$7.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.71
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cofinity Advantage |
$6.15
|
| Rate for Payer: Cofinity Commercial |
$7.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.02
|
| Rate for Payer: Healthscope Commercial |
$7.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.58
|
| Rate for Payer: PHP Commercial |
$7.46
|
| Rate for Payer: Priority Health SBD |
$5.53
|
| Rate for Payer: UMR Bronson Commercial |
$3.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.58
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$355.40
|
|
|
Service Code
|
NDC 59762500702
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.50 |
| Max. Negotiated Rate |
$319.86 |
| Rate for Payer: Aetna American Axle |
$231.01
|
| Rate for Payer: Aetna Commercial |
$302.09
|
| Rate for Payer: Aetna Medicare |
$177.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.01
|
| Rate for Payer: BCBS Complete |
$142.16
|
| Rate for Payer: Cash Price |
$284.32
|
| Rate for Payer: Cofinity Advantage |
$248.78
|
| Rate for Payer: Cofinity Commercial |
$305.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.32
|
| Rate for Payer: Healthscope Commercial |
$319.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$284.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$266.55
|
| Rate for Payer: PHP Commercial |
$302.09
|
| Rate for Payer: Priority Health SBD |
$223.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.01
|
| Rate for Payer: UHC Core |
$185.16
|
| Rate for Payer: UHC Exchange |
$139.67
|
| Rate for Payer: UMR Bronson Commercial |
$131.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.55
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
OP
|
$241.68
|
|
|
Service Code
|
NDC 70954044310
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.42 |
| Max. Negotiated Rate |
$217.51 |
| Rate for Payer: Aetna American Axle |
$157.09
|
| Rate for Payer: Aetna Commercial |
$205.43
|
| Rate for Payer: Aetna Medicare |
$120.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.09
|
| Rate for Payer: BCBS Complete |
$96.67
|
| Rate for Payer: Cash Price |
$193.34
|
| Rate for Payer: Cofinity Advantage |
$169.18
|
| Rate for Payer: Cofinity Commercial |
$207.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.34
|
| Rate for Payer: Healthscope Commercial |
$217.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$193.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.26
|
| Rate for Payer: PHP Commercial |
$205.43
|
| Rate for Payer: Priority Health SBD |
$152.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.09
|
| Rate for Payer: UHC Core |
$125.92
|
| Rate for Payer: UHC Exchange |
$94.98
|
| Rate for Payer: UMR Bronson Commercial |
$89.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.26
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$355.40
|
|
|
Service Code
|
NDC 59762500702
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.38 |
| Max. Negotiated Rate |
$319.86 |
| Rate for Payer: Aetna American Axle |
$231.01
|
| Rate for Payer: Aetna Commercial |
$302.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.01
|
| Rate for Payer: Cash Price |
$284.32
|
| Rate for Payer: Cofinity Advantage |
$248.78
|
| Rate for Payer: Cofinity Commercial |
$305.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.32
|
| Rate for Payer: Healthscope Commercial |
$319.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$266.55
|
| Rate for Payer: PHP Commercial |
$302.09
|
| Rate for Payer: Priority Health SBD |
$223.90
|
| Rate for Payer: UMR Bronson Commercial |
$156.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.55
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$7.95
|
|
|
Service Code
|
NDC 68084004111
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Aetna American Axle |
$5.17
|
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Aetna Medicare |
$3.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.17
|
| Rate for Payer: BCBS Complete |
$3.18
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cofinity Advantage |
$5.57
|
| Rate for Payer: Cofinity Commercial |
$6.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.36
|
| Rate for Payer: Healthscope Commercial |
$7.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.96
|
| Rate for Payer: PHP Commercial |
$6.76
|
| Rate for Payer: Priority Health SBD |
$5.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.17
|
| Rate for Payer: UHC Core |
$4.14
|
| Rate for Payer: UHC Exchange |
$3.12
|
| Rate for Payer: UMR Bronson Commercial |
$2.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.96
|
|
|
MISOPROSTOL 200 MCG TABLET
|
Facility
|
OP
|
$258.63
|
|
|
Service Code
|
NDC 59762500801
|
| Hospital Charge Code |
10629
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.69 |
| Max. Negotiated Rate |
$232.77 |
| Rate for Payer: Aetna American Axle |
$168.11
|
| Rate for Payer: Aetna Commercial |
$219.84
|
| Rate for Payer: Aetna Medicare |
$129.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.11
|
| Rate for Payer: BCBS Complete |
$103.45
|
| Rate for Payer: Cash Price |
$206.90
|
| Rate for Payer: Cofinity Advantage |
$181.04
|
| Rate for Payer: Cofinity Commercial |
$222.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.90
|
| Rate for Payer: Healthscope Commercial |
$232.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$181.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$206.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.97
|
| Rate for Payer: PHP Commercial |
$219.84
|
| Rate for Payer: Priority Health SBD |
$162.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$168.11
|
| Rate for Payer: UHC Core |
$134.75
|
| Rate for Payer: UHC Exchange |
$101.64
|
| Rate for Payer: UMR Bronson Commercial |
$95.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.97
|
|
