|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
OP
|
$611.00
|
|
|
Service Code
|
NDC 13107003105
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$226.07 |
| Max. Negotiated Rate |
$549.90 |
| Rate for Payer: Aetna American Axle |
$397.15
|
| Rate for Payer: Aetna Commercial |
$519.35
|
| Rate for Payer: Aetna Medicare |
$305.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$397.15
|
| Rate for Payer: BCBS Complete |
$244.40
|
| Rate for Payer: Cash Price |
$488.80
|
| Rate for Payer: Cofinity Commercial |
$427.70
|
| Rate for Payer: Cofinity Commercial |
$525.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$427.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$488.80
|
| Rate for Payer: Healthscope Commercial |
$549.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$427.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$458.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$519.35
|
| Rate for Payer: PHP Commercial |
$519.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.15
|
| Rate for Payer: Priority Health SBD |
$384.93
|
| Rate for Payer: UMR Bronson Commercial |
$226.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$458.25
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$448.85
|
|
|
Service Code
|
NDC 68084011901
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.49 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna American Axle |
$291.75
|
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.19
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.08
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$336.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.75
|
| Rate for Payer: Priority Health SBD |
$282.78
|
| Rate for Payer: UMR Bronson Commercial |
$197.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$336.64
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
OP
|
$448.85
|
|
|
Service Code
|
NDC 68084011911
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.07 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna American Axle |
$291.75
|
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna Medicare |
$224.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: BCBS Complete |
$179.54
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.19
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.08
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$336.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.75
|
| Rate for Payer: Priority Health SBD |
$282.78
|
| Rate for Payer: UMR Bronson Commercial |
$166.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$336.64
|
|
|
MIRTAZAPINE 30 MG TABLET
|
Facility
|
IP
|
$57.11
|
|
|
Service Code
|
NDC 13107000334
|
| Hospital Charge Code |
17465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.13 |
| Max. Negotiated Rate |
$51.40 |
| Rate for Payer: Aetna American Axle |
$37.12
|
| Rate for Payer: Aetna Commercial |
$48.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.12
|
| Rate for Payer: Cash Price |
$45.69
|
| Rate for Payer: Cofinity Commercial |
$39.98
|
| Rate for Payer: Cofinity Commercial |
$49.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.69
|
| Rate for Payer: Healthscope Commercial |
$51.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.54
|
| Rate for Payer: PHP Commercial |
$48.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.12
|
| Rate for Payer: Priority Health SBD |
$35.98
|
| Rate for Payer: UMR Bronson Commercial |
$25.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.83
|
|
|
MIRTAZAPINE 30 MG TABLET
|
Facility
|
OP
|
$57.11
|
|
|
Service Code
|
NDC 13107000334
|
| Hospital Charge Code |
17465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.13 |
| Max. Negotiated Rate |
$51.40 |
| Rate for Payer: Aetna American Axle |
$37.12
|
| Rate for Payer: Aetna Commercial |
$48.54
|
| Rate for Payer: Aetna Medicare |
$28.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.12
|
| Rate for Payer: BCBS Complete |
$22.84
|
| Rate for Payer: Cash Price |
$45.69
|
| Rate for Payer: Cofinity Commercial |
$39.98
|
| Rate for Payer: Cofinity Commercial |
$49.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.69
|
| Rate for Payer: Healthscope Commercial |
$51.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.54
|
| Rate for Payer: PHP Commercial |
$48.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.12
|
| Rate for Payer: Priority Health SBD |
$35.98
|
| Rate for Payer: UMR Bronson Commercial |
$21.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.83
|
|
|
MIRTAZAPINE 30 MG TABLET
|
Facility
|
OP
|
$455.90
|
|
|
Service Code
|
NDC 68084012011
|
| Hospital Charge Code |
17465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.68 |
| Max. Negotiated Rate |
$410.31 |
| Rate for Payer: Aetna American Axle |
$296.33
|
| Rate for Payer: Aetna Commercial |
$387.51
|
| Rate for Payer: Aetna Medicare |
$227.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.33
|
| Rate for Payer: BCBS Complete |
$182.36
|
| Rate for Payer: Cash Price |
$364.72
|
| Rate for Payer: Cofinity Commercial |
$319.13
|
| Rate for Payer: Cofinity Commercial |
$392.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$319.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.72
|
| Rate for Payer: Healthscope Commercial |
$410.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.51
|
| Rate for Payer: PHP Commercial |
$387.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.33
|
| Rate for Payer: Priority Health SBD |
$287.22
|
| Rate for Payer: UMR Bronson Commercial |
$168.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.93
|
|
|
MIRTAZAPINE 30 MG TABLET
|
Facility
|
OP
|
$455.90
|
|
|
Service Code
|
NDC 68084012001
|
| Hospital Charge Code |
17465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.68 |
| Max. Negotiated Rate |
$410.31 |
| Rate for Payer: Aetna American Axle |
$296.33
|
| Rate for Payer: Aetna Commercial |
$387.51
|
| Rate for Payer: Aetna Medicare |
$227.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.33
|
| Rate for Payer: BCBS Complete |
$182.36
|
| Rate for Payer: Cash Price |
$364.72
|
| Rate for Payer: Cofinity Commercial |
$319.13
|
| Rate for Payer: Cofinity Commercial |
$392.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$319.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.72
|
| Rate for Payer: Healthscope Commercial |
$410.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.51
|
| Rate for Payer: PHP Commercial |
$387.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.33
|
| Rate for Payer: Priority Health SBD |
$287.22
|
| Rate for Payer: UMR Bronson Commercial |
$168.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.93
|
|
|
MIRTAZAPINE 30 MG TABLET
|
Facility
|
IP
|
$455.90
|
|
|
Service Code
|
NDC 68084012001
|
| Hospital Charge Code |
17465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.60 |
| Max. Negotiated Rate |
$410.31 |
| Rate for Payer: Aetna American Axle |
$296.33
|
| Rate for Payer: Aetna Commercial |
$387.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.33
|
| Rate for Payer: Cash Price |
$364.72
|
| Rate for Payer: Cofinity Commercial |
$319.13
|
| Rate for Payer: Cofinity Commercial |
$392.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$319.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.72
|
| Rate for Payer: Healthscope Commercial |
$410.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.51
|
| Rate for Payer: PHP Commercial |
$387.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.33
|
| Rate for Payer: Priority Health SBD |
$287.22
|
| Rate for Payer: UMR Bronson Commercial |
$200.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.93
|
|
|
MIRTAZAPINE 30 MG TABLET
|
Facility
|
IP
|
$455.90
|
|
|
Service Code
|
NDC 68084012011
|
| Hospital Charge Code |
17465
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.60 |
| Max. Negotiated Rate |
$410.31 |
| Rate for Payer: Aetna American Axle |
$296.33
|
| Rate for Payer: Aetna Commercial |
$387.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.33
|
| Rate for Payer: Cash Price |
$364.72
|
| Rate for Payer: Cofinity Commercial |
$319.13
|
| Rate for Payer: Cofinity Commercial |
$392.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$319.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.72
|
| Rate for Payer: Healthscope Commercial |
$410.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$341.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.51
|
| Rate for Payer: PHP Commercial |
$387.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.33
|
| Rate for Payer: Priority Health SBD |
$287.22
|
| Rate for Payer: UMR Bronson Commercial |
$200.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$341.93
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
OP
|
$253.86
|
|
|
Service Code
|
NDC 60687058421
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.93 |
| Max. Negotiated Rate |
$228.47 |
| Rate for Payer: Aetna American Axle |
$165.01
|
| Rate for Payer: Aetna Commercial |
$215.78
|
| Rate for Payer: Aetna Medicare |
$126.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.01
|
| Rate for Payer: BCBS Complete |
$101.54
|
| Rate for Payer: Cash Price |
$203.09
|
| Rate for Payer: Cofinity Commercial |
$177.70
|
| Rate for Payer: Cofinity Commercial |
$218.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.09
|
| Rate for Payer: Healthscope Commercial |
$228.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.78
|
| Rate for Payer: PHP Commercial |
$215.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.01
|
| Rate for Payer: Priority Health SBD |
$159.93
|
| Rate for Payer: UMR Bronson Commercial |
$93.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.40
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
IP
|
$86.12
|
|
|
Service Code
|
NDC 13107000130
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$77.51 |
| Rate for Payer: Aetna American Axle |
$55.98
|
| Rate for Payer: Aetna Commercial |
$73.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.98
|
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Cofinity Commercial |
$60.28
|
| Rate for Payer: Cofinity Commercial |
$74.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.90
|
| Rate for Payer: Healthscope Commercial |
$77.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.20
|
| Rate for Payer: PHP Commercial |
$73.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.98
|
| Rate for Payer: Priority Health SBD |
$54.26
|
| Rate for Payer: UMR Bronson Commercial |
$37.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.59
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
OP
|
$86.12
|
|
|
Service Code
|
NDC 13107000130
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.86 |
| Max. Negotiated Rate |
$77.51 |
| Rate for Payer: Aetna American Axle |
$55.98
|
| Rate for Payer: Aetna Commercial |
$73.20
|
| Rate for Payer: Aetna Medicare |
$43.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.98
|
| Rate for Payer: BCBS Complete |
$34.45
|
| Rate for Payer: Cash Price |
$68.90
|
| Rate for Payer: Cofinity Commercial |
$60.28
|
| Rate for Payer: Cofinity Commercial |
$74.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.90
|
| Rate for Payer: Healthscope Commercial |
$77.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.20
|
| Rate for Payer: PHP Commercial |
$73.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.98
|
| Rate for Payer: Priority Health SBD |
$54.26
|
| Rate for Payer: UMR Bronson Commercial |
$31.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.59
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
IP
|
$253.86
|
|
|
Service Code
|
NDC 60687058421
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.70 |
| Max. Negotiated Rate |
$228.47 |
| Rate for Payer: Aetna American Axle |
$165.01
|
| Rate for Payer: Aetna Commercial |
$215.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.01
|
| Rate for Payer: Cash Price |
$203.09
|
| Rate for Payer: Cofinity Commercial |
$177.70
|
| Rate for Payer: Cofinity Commercial |
$218.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.09
|
| Rate for Payer: Healthscope Commercial |
$228.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.78
|
| Rate for Payer: PHP Commercial |
$215.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.01
|
| Rate for Payer: Priority Health SBD |
$159.93
|
| Rate for Payer: UMR Bronson Commercial |
$111.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.40
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
OP
|
$8.47
|
|
|
Service Code
|
NDC 60687058411
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna American Axle |
$5.51
|
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Medicare |
$4.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.51
|
| Rate for Payer: BCBS Complete |
$3.39
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Cofinity Commercial |
$5.93
|
| Rate for Payer: Cofinity Commercial |
$7.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.78
|
| Rate for Payer: Healthscope Commercial |
$7.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.20
|
| Rate for Payer: PHP Commercial |
$7.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.51
|
| Rate for Payer: Priority Health SBD |
$5.34
|
| Rate for Payer: UMR Bronson Commercial |
$3.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.35
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
IP
|
$8.47
|
|
|
Service Code
|
NDC 60687058411
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna American Axle |
$5.51
|
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.51
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Cofinity Commercial |
$5.93
|
| Rate for Payer: Cofinity Commercial |
$7.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.78
|
| Rate for Payer: Healthscope Commercial |
$7.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.20
|
| Rate for Payer: PHP Commercial |
$7.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.51
|
| Rate for Payer: Priority Health SBD |
$5.34
|
| Rate for Payer: UMR Bronson Commercial |
$3.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.35
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,782.71
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
202156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.25 |
| Max. Negotiated Rate |
$26,804.44 |
| Rate for Payer: Aetna American Axle |
$19,358.76
|
| Rate for Payer: Aetna Commercial |
$25,315.30
|
| Rate for Payer: Aetna Medicare |
$72.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,358.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$86.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$86.86
|
| Rate for Payer: BCBS Complete |
$39.11
|
| Rate for Payer: BCBS MAPPO |
$69.49
|
| Rate for Payer: BCN Medicare Advantage |
$69.49
|
| Rate for Payer: Cash Price |
$23,826.17
|
| Rate for Payer: Cash Price |
$23,826.17
|
| Rate for Payer: Cofinity Commercial |
$25,613.13
|
| Rate for Payer: Cofinity Commercial |
$20,847.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,847.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,826.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$69.49
|
| Rate for Payer: Healthscope Commercial |
$26,804.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,847.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22,337.03
|
| Rate for Payer: Mclaren Medicaid |
$37.25
|
| Rate for Payer: Mclaren Medicare |
$69.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$72.96
|
| Rate for Payer: Meridian Medicaid |
$39.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,315.30
|
| Rate for Payer: PACE Medicare |
$66.02
|
| Rate for Payer: PACE SWMI |
$69.49
|
| Rate for Payer: PHP Commercial |
$25,315.30
|
| Rate for Payer: PHP Medicare Advantage |
$69.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$37.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,358.76
|
| Rate for Payer: Priority Health Medicare |
$69.49
|
| Rate for Payer: Priority Health SBD |
$18,763.11
|
| Rate for Payer: Railroad Medicare Medicare |
$69.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$195.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$69.49
|
| Rate for Payer: UHC Exchange |
$132.80
|
| Rate for Payer: UHC Medicare Advantage |
$69.49
|
| Rate for Payer: UHCCP Medicaid |
$37.25
|
| Rate for Payer: UMR Bronson Commercial |
$11,019.60
|
| Rate for Payer: VA VA |
$69.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22,337.03
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$937.44
|
|
|
Service Code
|
NDC 60687073501
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$412.47 |
| Max. Negotiated Rate |
$843.70 |
| Rate for Payer: Aetna American Axle |
$609.34
|
| Rate for Payer: Aetna Commercial |
$796.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$609.34
|
| Rate for Payer: Cash Price |
$749.95
|
| Rate for Payer: Cofinity Commercial |
$656.21
|
| Rate for Payer: Cofinity Commercial |
$806.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$656.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$749.95
|
| Rate for Payer: Healthscope Commercial |
$843.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$656.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$703.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$796.82
|
| Rate for Payer: PHP Commercial |
$796.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$609.34
|
| Rate for Payer: Priority Health SBD |
$590.59
|
| Rate for Payer: UMR Bronson Commercial |
$412.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$703.08
|
|
|
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 Commercial |
$124.19
|
| Rate for Payer: Cofinity Commercial |
$152.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$124.19
|
| 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: PHP Commercial |
$150.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.32
|
| Rate for Payer: Priority Health SBD |
$111.77
|
| 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 Commercial |
$248.37
|
| Rate for Payer: Cofinity Commercial |
$305.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.37
|
| 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: PHP Commercial |
$301.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.63
|
| 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
|
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 Commercial |
$124.19
|
| Rate for Payer: Cofinity Commercial |
$152.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$124.19
|
| 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: PHP Commercial |
$150.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.32
|
| 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
|
$200.07
|
|
|
Service Code
|
NDC 70954044310
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.03 |
| Max. Negotiated Rate |
$180.06 |
| Rate for Payer: Aetna American Axle |
$130.05
|
| Rate for Payer: Aetna Commercial |
$170.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.05
|
| Rate for Payer: Cash Price |
$160.06
|
| Rate for Payer: Cofinity Commercial |
$140.05
|
| Rate for Payer: Cofinity Commercial |
$172.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.06
|
| Rate for Payer: Healthscope Commercial |
$180.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.06
|
| Rate for Payer: PHP Commercial |
$170.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.05
|
| Rate for Payer: Priority Health SBD |
$126.04
|
| Rate for Payer: UMR Bronson Commercial |
$88.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.05
|
|
|
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 Commercial |
$123.98
|
| Rate for Payer: Cofinity Commercial |
$152.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.98
|
| 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: PHP Commercial |
$150.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.13
|
| Rate for Payer: Priority Health SBD |
$111.59
|
| 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
|
$9.38
|
|
|
Service Code
|
NDC 60687073511
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Aetna American Axle |
$6.10
|
| Rate for Payer: Aetna Commercial |
$7.97
|
| Rate for Payer: Aetna Medicare |
$4.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.10
|
| Rate for Payer: BCBS Complete |
$3.75
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cofinity Commercial |
$6.57
|
| Rate for Payer: Cofinity Commercial |
$8.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.50
|
| Rate for Payer: Healthscope Commercial |
$8.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.97
|
| Rate for Payer: PHP Commercial |
$7.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.10
|
| Rate for Payer: Priority Health SBD |
$5.91
|
| Rate for Payer: UMR Bronson Commercial |
$3.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.04
|
|
|
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 Commercial |
$248.37
|
| Rate for Payer: Cofinity Commercial |
$305.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.37
|
| 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: PHP Commercial |
$301.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.63
|
| Rate for Payer: Priority Health SBD |
$223.54
|
| Rate for Payer: UMR Bronson Commercial |
$131.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.12
|
|
|
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 Commercial |
$248.78
|
| Rate for Payer: Cofinity Commercial |
$305.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.78
|
| 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: PHP Commercial |
$302.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.01
|
| Rate for Payer: Priority Health SBD |
$223.90
|
| Rate for Payer: UMR Bronson Commercial |
$131.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.55
|
|
