|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 00904680861
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.92 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Advantage |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UMR Bronson Commercial |
$104.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$64.16
|
|
|
Service Code
|
NDC 29300022013
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.23 |
| Max. Negotiated Rate |
$57.74 |
| Rate for Payer: Aetna American Axle |
$41.70
|
| Rate for Payer: Aetna Commercial |
$54.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.70
|
| Rate for Payer: Cash Price |
$51.33
|
| Rate for Payer: Cofinity Advantage |
$44.91
|
| Rate for Payer: Cofinity Commercial |
$55.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.33
|
| Rate for Payer: Healthscope Commercial |
$57.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.12
|
| Rate for Payer: PHP Commercial |
$54.54
|
| Rate for Payer: Priority Health SBD |
$40.42
|
| Rate for Payer: UMR Bronson Commercial |
$28.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.12
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$3.13
|
|
|
Service Code
|
NDC 50268055611
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: BCBS Complete |
$1.25
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Advantage |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.35
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.03
|
| Rate for Payer: UHC Core |
$1.63
|
| Rate for Payer: UHC Exchange |
$1.23
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.35
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$276.45
|
|
|
Service Code
|
NDC 68084087501
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.64 |
| Max. Negotiated Rate |
$248.81 |
| Rate for Payer: Aetna American Axle |
$179.69
|
| Rate for Payer: Aetna Commercial |
$234.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.69
|
| Rate for Payer: Cash Price |
$221.16
|
| Rate for Payer: Cofinity Advantage |
$193.51
|
| Rate for Payer: Cofinity Commercial |
$237.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.16
|
| Rate for Payer: Healthscope Commercial |
$248.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.34
|
| Rate for Payer: PHP Commercial |
$234.98
|
| Rate for Payer: Priority Health SBD |
$174.16
|
| Rate for Payer: UMR Bronson Commercial |
$121.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.34
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$142.03
|
|
|
Service Code
|
NDC 904680806
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.55 |
| Max. Negotiated Rate |
$127.83 |
| Rate for Payer: Aetna American Axle |
$92.32
|
| Rate for Payer: Aetna Commercial |
$120.73
|
| Rate for Payer: Aetna Medicare |
$71.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.32
|
| Rate for Payer: BCBS Complete |
$56.81
|
| Rate for Payer: Cash Price |
$113.62
|
| Rate for Payer: Cofinity Advantage |
$99.42
|
| Rate for Payer: Cofinity Commercial |
$122.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.62
|
| Rate for Payer: Healthscope Commercial |
$127.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.52
|
| Rate for Payer: PHP Commercial |
$120.73
|
| Rate for Payer: Priority Health SBD |
$89.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.32
|
| Rate for Payer: UHC Core |
$74.00
|
| Rate for Payer: UHC Exchange |
$55.82
|
| Rate for Payer: UMR Bronson Commercial |
$52.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.52
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$156.28
|
|
|
Service Code
|
NDC 50268055615
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.76 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna American Axle |
$101.58
|
| Rate for Payer: Aetna Commercial |
$132.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.58
|
| Rate for Payer: Cash Price |
$125.02
|
| Rate for Payer: Cofinity Advantage |
$109.40
|
| Rate for Payer: Cofinity Commercial |
$134.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.02
|
| Rate for Payer: Healthscope Commercial |
$140.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.21
|
| Rate for Payer: PHP Commercial |
$132.84
|
| Rate for Payer: Priority Health SBD |
$98.46
|
| Rate for Payer: UMR Bronson Commercial |
$68.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.21
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$276.45
|
|
|
Service Code
|
NDC 68084087501
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.29 |
| Max. Negotiated Rate |
$248.81 |
| Rate for Payer: Aetna American Axle |
$179.69
|
| Rate for Payer: Aetna Commercial |
$234.98
|
| Rate for Payer: Aetna Medicare |
$138.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.69
|
| Rate for Payer: BCBS Complete |
$110.58
|
| Rate for Payer: Cash Price |
$221.16
|
| Rate for Payer: Cofinity Advantage |
$193.51
|
| Rate for Payer: Cofinity Commercial |
$237.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.16
|
| Rate for Payer: Healthscope Commercial |
$248.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$221.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.34
|
| Rate for Payer: PHP Commercial |
$234.98
|
| Rate for Payer: Priority Health SBD |
$174.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$179.69
|
| Rate for Payer: UHC Core |
$144.03
|
| Rate for Payer: UHC Exchange |
$108.64
|
| Rate for Payer: UMR Bronson Commercial |
$102.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.34
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 00904680861
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$119.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Advantage |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.99
|
| Rate for Payer: UHC Core |
$124.23
|
| Rate for Payer: UHC Exchange |
$93.71
|
| Rate for Payer: UMR Bronson Commercial |
$88.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 33342011007
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.09 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.83
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna Medicare |
$35.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.83
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Advantage |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.88
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health SBD |
$44.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.83
|
| Rate for Payer: UHC Core |
$36.73
|
| Rate for Payer: UHC Exchange |
$27.71
|
| Rate for Payer: UMR Bronson Commercial |
$26.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 50268057311
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna American Axle |
$2.34
|
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Aetna Medicare |
$1.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.34
|
| Rate for Payer: BCBS Complete |
$1.44
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cofinity Advantage |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.88
|
| Rate for Payer: Healthscope Commercial |
$3.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.70
|
| Rate for Payer: PHP Commercial |
$3.06
|
| Rate for Payer: Priority Health SBD |
$2.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.34
|
| Rate for Payer: UHC Core |
$1.88
|
| Rate for Payer: UHC Exchange |
$1.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.70
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 33342011007
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.83
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.83
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Advantage |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.88
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health SBD |
$44.41
|
| Rate for Payer: UMR Bronson Commercial |
$31.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$138.89
|
|
|
Service Code
|
NDC 69452010613
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.39 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna American Axle |
$90.28
|
| Rate for Payer: Aetna Commercial |
$118.06
|
| Rate for Payer: Aetna Medicare |
$69.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.28
|
| Rate for Payer: BCBS Complete |
$55.56
|
| Rate for Payer: Cash Price |
$111.11
|
| Rate for Payer: Cofinity Advantage |
$97.22
|
| Rate for Payer: Cofinity Commercial |
$119.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.11
|
| Rate for Payer: Healthscope Commercial |
$125.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.17
|
| Rate for Payer: PHP Commercial |
$118.06
|
| Rate for Payer: Priority Health SBD |
$87.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.28
|
| Rate for Payer: UHC Core |
$72.36
|
| Rate for Payer: UHC Exchange |
$54.58
|
| Rate for Payer: UMR Bronson Commercial |
$51.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.17
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
NDC 50268057315
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna American Axle |
$117.00
|
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Medicare |
$90.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.00
|
| Rate for Payer: BCBS Complete |
$72.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cofinity Advantage |
$126.00
|
| Rate for Payer: Cofinity Commercial |
$154.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.00
|
| Rate for Payer: Healthscope Commercial |
$162.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$126.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$153.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$135.00
|
| Rate for Payer: PHP Commercial |
$153.00
|
| Rate for Payer: Priority Health SBD |
$113.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$117.00
|
| Rate for Payer: UHC Core |
$93.78
|
| Rate for Payer: UHC Exchange |
$70.74
|
| Rate for Payer: UMR Bronson Commercial |
$66.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.00
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
IP
|
$138.89
|
|
|
Service Code
|
NDC 69452010613
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.11 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna American Axle |
$90.28
|
| Rate for Payer: Aetna Commercial |
$118.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.28
|
| Rate for Payer: Cash Price |
$111.11
|
| Rate for Payer: Cofinity Advantage |
$97.22
|
| Rate for Payer: Cofinity Commercial |
$119.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.11
|
| Rate for Payer: Healthscope Commercial |
$125.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.17
|
| Rate for Payer: PHP Commercial |
$118.06
|
| Rate for Payer: Priority Health SBD |
$87.50
|
| Rate for Payer: UMR Bronson Commercial |
$61.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.17
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$470.20
|
|
|
Service Code
|
NDC 55111076303
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.89 |
| Max. Negotiated Rate |
$423.18 |
| Rate for Payer: Aetna American Axle |
$305.63
|
| Rate for Payer: Aetna Commercial |
$399.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.63
|
| Rate for Payer: Cash Price |
$376.16
|
| Rate for Payer: Cofinity Advantage |
$329.14
|
| Rate for Payer: Cofinity Commercial |
$404.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.16
|
| Rate for Payer: Healthscope Commercial |
$423.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$352.65
|
| Rate for Payer: PHP Commercial |
$399.67
|
| Rate for Payer: Priority Health SBD |
$296.23
|
| Rate for Payer: UMR Bronson Commercial |
$206.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.65
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
OP
|
$15.68
|
|
|
Service Code
|
NDC 55111076307
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$14.11 |
| Rate for Payer: Aetna American Axle |
$10.19
|
| Rate for Payer: Aetna Commercial |
$13.33
|
| Rate for Payer: Aetna Medicare |
$7.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.19
|
| Rate for Payer: BCBS Complete |
$6.27
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: Cofinity Advantage |
$10.98
|
| Rate for Payer: Cofinity Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.54
|
| Rate for Payer: Healthscope Commercial |
$14.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.76
|
| Rate for Payer: PHP Commercial |
$13.33
|
| Rate for Payer: Priority Health SBD |
$9.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.19
|
| Rate for Payer: UHC Core |
$8.17
|
| Rate for Payer: UHC Exchange |
$6.16
|
| Rate for Payer: UMR Bronson Commercial |
$5.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.76
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$183.60
|
|
|
Service Code
|
NDC 27241001531
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.78 |
| Max. Negotiated Rate |
$165.24 |
| Rate for Payer: Aetna American Axle |
$119.34
|
| Rate for Payer: Aetna Commercial |
$156.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.34
|
| Rate for Payer: Cash Price |
$146.88
|
| Rate for Payer: Cofinity Advantage |
$128.52
|
| Rate for Payer: Cofinity Commercial |
$157.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.88
|
| Rate for Payer: Healthscope Commercial |
$165.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$156.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$137.70
|
| Rate for Payer: PHP Commercial |
$156.06
|
| Rate for Payer: Priority Health SBD |
$115.67
|
| Rate for Payer: UMR Bronson Commercial |
$80.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.70
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
OP
|
$470.20
|
|
|
Service Code
|
NDC 55111076303
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.97 |
| Max. Negotiated Rate |
$423.18 |
| Rate for Payer: Aetna American Axle |
$305.63
|
| Rate for Payer: Aetna Commercial |
$399.67
|
| Rate for Payer: Aetna Medicare |
$235.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.63
|
| Rate for Payer: BCBS Complete |
$188.08
|
| Rate for Payer: Cash Price |
$376.16
|
| Rate for Payer: Cofinity Advantage |
$329.14
|
| Rate for Payer: Cofinity Commercial |
$404.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.16
|
| Rate for Payer: Healthscope Commercial |
$423.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$376.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$352.65
|
| Rate for Payer: PHP Commercial |
$399.67
|
| Rate for Payer: Priority Health SBD |
$296.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$305.63
|
| Rate for Payer: UHC Core |
$244.97
|
| Rate for Payer: UHC Exchange |
$184.79
|
| Rate for Payer: UMR Bronson Commercial |
$173.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.65
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
OP
|
$183.60
|
|
|
Service Code
|
NDC 27241001531
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.93 |
| Max. Negotiated Rate |
$165.24 |
| Rate for Payer: Aetna American Axle |
$119.34
|
| Rate for Payer: Aetna Commercial |
$156.06
|
| Rate for Payer: Aetna Medicare |
$91.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.34
|
| Rate for Payer: BCBS Complete |
$73.44
|
| Rate for Payer: Cash Price |
$146.88
|
| Rate for Payer: Cofinity Advantage |
$128.52
|
| Rate for Payer: Cofinity Commercial |
$157.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.88
|
| Rate for Payer: Healthscope Commercial |
$165.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$146.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$156.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$137.70
|
| Rate for Payer: PHP Commercial |
$156.06
|
| Rate for Payer: Priority Health SBD |
$115.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.34
|
| Rate for Payer: UHC Core |
$95.66
|
| Rate for Payer: UHC Exchange |
$72.15
|
| Rate for Payer: UMR Bronson Commercial |
$67.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.70
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$15.68
|
|
|
Service Code
|
NDC 55111076307
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$14.11 |
| Rate for Payer: Aetna American Axle |
$10.19
|
| Rate for Payer: Aetna Commercial |
$13.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.19
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: Cofinity Advantage |
$10.98
|
| Rate for Payer: Cofinity Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.54
|
| Rate for Payer: Healthscope Commercial |
$14.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.76
|
| Rate for Payer: PHP Commercial |
$13.33
|
| Rate for Payer: Priority Health SBD |
$9.88
|
| Rate for Payer: UMR Bronson Commercial |
$6.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.76
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
OP
|
$76.85
|
|
|
Service Code
|
NDC 33342011107
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.43 |
| Max. Negotiated Rate |
$69.17 |
| Rate for Payer: Aetna American Axle |
$49.95
|
| Rate for Payer: Aetna Commercial |
$65.32
|
| Rate for Payer: Aetna Medicare |
$38.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.95
|
| Rate for Payer: BCBS Complete |
$30.74
|
| Rate for Payer: Cash Price |
$61.48
|
| Rate for Payer: Cofinity Advantage |
$53.80
|
| Rate for Payer: Cofinity Commercial |
$66.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.48
|
| Rate for Payer: Healthscope Commercial |
$69.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.64
|
| Rate for Payer: PHP Commercial |
$65.32
|
| Rate for Payer: Priority Health SBD |
$48.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.95
|
| Rate for Payer: UHC Core |
$40.04
|
| Rate for Payer: UHC Exchange |
$30.20
|
| Rate for Payer: UMR Bronson Commercial |
$28.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.64
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
OP
|
$87.42
|
|
|
Service Code
|
NDC 13668008030
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.35 |
| Max. Negotiated Rate |
$78.68 |
| Rate for Payer: Aetna American Axle |
$56.82
|
| Rate for Payer: Aetna Commercial |
$74.31
|
| Rate for Payer: Aetna Medicare |
$43.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.82
|
| Rate for Payer: BCBS Complete |
$34.97
|
| Rate for Payer: Cash Price |
$69.94
|
| Rate for Payer: Cofinity Advantage |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$75.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.94
|
| Rate for Payer: Healthscope Commercial |
$78.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$69.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.56
|
| Rate for Payer: PHP Commercial |
$74.31
|
| Rate for Payer: Priority Health SBD |
$55.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.82
|
| Rate for Payer: UHC Core |
$45.55
|
| Rate for Payer: UHC Exchange |
$34.36
|
| Rate for Payer: UMR Bronson Commercial |
$32.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.56
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$76.85
|
|
|
Service Code
|
NDC 33342011107
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$69.17 |
| Rate for Payer: Aetna American Axle |
$49.95
|
| Rate for Payer: Aetna Commercial |
$65.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.95
|
| Rate for Payer: Cash Price |
$61.48
|
| Rate for Payer: Cofinity Advantage |
$53.80
|
| Rate for Payer: Cofinity Commercial |
$66.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.48
|
| Rate for Payer: Healthscope Commercial |
$69.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.64
|
| Rate for Payer: PHP Commercial |
$65.32
|
| Rate for Payer: Priority Health SBD |
$48.42
|
| Rate for Payer: UMR Bronson Commercial |
$33.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.64
|
|
|
MONTELUKAST 5 MG CHEWABLE TABLET
|
Facility
|
IP
|
$87.42
|
|
|
Service Code
|
NDC 13668008030
|
| Hospital Charge Code |
22510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.46 |
| Max. Negotiated Rate |
$78.68 |
| Rate for Payer: Aetna American Axle |
$56.82
|
| Rate for Payer: Aetna Commercial |
$74.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.82
|
| Rate for Payer: Cash Price |
$69.94
|
| Rate for Payer: Cofinity Advantage |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$75.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.94
|
| Rate for Payer: Healthscope Commercial |
$78.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.56
|
| Rate for Payer: PHP Commercial |
$74.31
|
| Rate for Payer: Priority Health SBD |
$55.07
|
| Rate for Payer: UMR Bronson Commercial |
$38.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.56
|
|
|
MORPHINE 0.1 MG/ML INJECTION (NICU)
|
Facility
|
OP
|
$22.07
|
|
|
Service Code
|
HCPCS J2274
|
| Hospital Charge Code |
500539
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$43.73 |
| Rate for Payer: Aetna American Axle |
$14.35
|
| Rate for Payer: Aetna Commercial |
$18.76
|
| Rate for Payer: Aetna Medicare |
$11.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.35
|
| Rate for Payer: BCBS Complete |
$8.83
|
| Rate for Payer: BCBS Trust/PPO |
$43.73
|
| Rate for Payer: BCN Commercial |
$43.73
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cofinity Advantage |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$18.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.66
|
| Rate for Payer: Healthscope Commercial |
$19.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.55
|
| Rate for Payer: PHP Commercial |
$18.76
|
| Rate for Payer: Priority Health SBD |
$13.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.28
|
| Rate for Payer: UHC Core |
$22.28
|
| Rate for Payer: UHC Exchange |
$22.28
|
| Rate for Payer: UMR Bronson Commercial |
$8.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.55
|
|
