|
MINOXIDIL 2.5 MG TABLET
|
Facility
|
IP
|
$453.55
|
|
|
Service Code
|
NDC 49884025601
|
| Hospital Charge Code |
5115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.56 |
| Max. Negotiated Rate |
$408.20 |
| Rate for Payer: Aetna American Axle |
$294.81
|
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$294.81
|
| Rate for Payer: Cash Price |
$362.84
|
| Rate for Payer: Cofinity Commercial |
$317.48
|
| Rate for Payer: Cofinity Commercial |
$390.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$317.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$362.84
|
| Rate for Payer: Healthscope Commercial |
$408.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$317.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$340.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$385.52
|
| Rate for Payer: PHP Commercial |
$385.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$294.81
|
| Rate for Payer: Priority Health SBD |
$285.74
|
| Rate for Payer: UMR Bronson Commercial |
$199.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$340.16
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,267.07
|
|
|
Service Code
|
NDC 70710115903
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$557.51 |
| Max. Negotiated Rate |
$1,140.36 |
| Rate for Payer: Aetna American Axle |
$823.60
|
| Rate for Payer: Aetna Commercial |
$1,077.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$823.60
|
| Rate for Payer: Cash Price |
$1,013.66
|
| Rate for Payer: Cofinity Commercial |
$1,089.68
|
| Rate for Payer: Cofinity Commercial |
$886.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$886.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,013.66
|
| Rate for Payer: Healthscope Commercial |
$1,140.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$886.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$950.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,077.01
|
| Rate for Payer: PHP Commercial |
$1,077.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$823.60
|
| Rate for Payer: Priority Health SBD |
$798.25
|
| Rate for Payer: UMR Bronson Commercial |
$557.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$950.30
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,267.07
|
|
|
Service Code
|
NDC 70710115903
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$468.82 |
| Max. Negotiated Rate |
$1,140.36 |
| Rate for Payer: Aetna American Axle |
$823.60
|
| Rate for Payer: Aetna Commercial |
$1,077.01
|
| Rate for Payer: Aetna Medicare |
$633.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$823.60
|
| Rate for Payer: BCBS Complete |
$506.83
|
| Rate for Payer: Cash Price |
$1,013.66
|
| Rate for Payer: Cofinity Commercial |
$1,089.68
|
| Rate for Payer: Cofinity Commercial |
$886.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$886.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,013.66
|
| Rate for Payer: Healthscope Commercial |
$1,140.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$886.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$950.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,077.01
|
| Rate for Payer: PHP Commercial |
$1,077.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$823.60
|
| Rate for Payer: Priority Health SBD |
$798.25
|
| Rate for Payer: UMR Bronson Commercial |
$468.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$950.30
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$586.03 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna American Axle |
$1,029.51
|
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna Medicare |
$791.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: BCBS Complete |
$633.54
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,108.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,187.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
| Rate for Payer: UMR Bronson Commercial |
$586.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,187.90
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260130
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$696.90 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna American Axle |
$1,029.51
|
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,108.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,187.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
| Rate for Payer: UMR Bronson Commercial |
$696.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,187.90
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,362.20
|
|
|
Service Code
|
NDC 70710116003
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$599.37 |
| Max. Negotiated Rate |
$1,225.98 |
| Rate for Payer: Aetna American Axle |
$885.43
|
| Rate for Payer: Aetna Commercial |
$1,157.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$885.43
|
| Rate for Payer: Cash Price |
$1,089.76
|
| Rate for Payer: Cofinity Commercial |
$1,171.49
|
| Rate for Payer: Cofinity Commercial |
$953.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$953.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,089.76
|
| Rate for Payer: Healthscope Commercial |
$1,225.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$953.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,021.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,157.87
|
| Rate for Payer: PHP Commercial |
$1,157.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$885.43
|
| Rate for Payer: Priority Health SBD |
$858.19
|
| Rate for Payer: UMR Bronson Commercial |
$599.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,021.65
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,362.20
|
|
|
Service Code
|
NDC 70710116003
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$504.01 |
| Max. Negotiated Rate |
$1,225.98 |
| Rate for Payer: Aetna American Axle |
$885.43
|
| Rate for Payer: Aetna Commercial |
$1,157.87
|
| Rate for Payer: Aetna Medicare |
$681.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$885.43
|
| Rate for Payer: BCBS Complete |
$544.88
|
| Rate for Payer: Cash Price |
$1,089.76
|
| Rate for Payer: Cofinity Commercial |
$1,171.49
|
| Rate for Payer: Cofinity Commercial |
$953.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$953.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,089.76
|
| Rate for Payer: Healthscope Commercial |
$1,225.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$953.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,021.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,157.87
|
| Rate for Payer: PHP Commercial |
$1,157.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$885.43
|
| Rate for Payer: Priority Health SBD |
$858.19
|
| Rate for Payer: UMR Bronson Commercial |
$504.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,021.65
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$586.03 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna American Axle |
$1,029.51
|
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna Medicare |
$791.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: BCBS Complete |
$633.54
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,108.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,187.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
| Rate for Payer: UMR Bronson Commercial |
$586.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,187.90
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4,086.25
|
|
|
Service Code
|
NDC 70710116009
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,797.95 |
| Max. Negotiated Rate |
$3,677.62 |
| Rate for Payer: Aetna American Axle |
$2,656.06
|
| Rate for Payer: Aetna Commercial |
$3,473.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,656.06
|
| Rate for Payer: Cash Price |
$3,269.00
|
| Rate for Payer: Cofinity Commercial |
$2,860.38
|
| Rate for Payer: Cofinity Commercial |
$3,514.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,860.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,269.00
|
| Rate for Payer: Healthscope Commercial |
$3,677.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,860.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,064.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,473.31
|
| Rate for Payer: PHP Commercial |
$3,473.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,656.06
|
| Rate for Payer: Priority Health SBD |
$2,574.34
|
| Rate for Payer: UMR Bronson Commercial |
$1,797.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,064.69
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,583.86
|
|
|
Service Code
|
NDC 00469260230
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$696.90 |
| Max. Negotiated Rate |
$1,425.47 |
| Rate for Payer: Aetna American Axle |
$1,029.51
|
| Rate for Payer: Aetna Commercial |
$1,346.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,029.51
|
| Rate for Payer: Cash Price |
$1,267.09
|
| Rate for Payer: Cofinity Commercial |
$1,108.70
|
| Rate for Payer: Cofinity Commercial |
$1,362.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,108.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,267.09
|
| Rate for Payer: Healthscope Commercial |
$1,425.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,108.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,187.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,346.28
|
| Rate for Payer: PHP Commercial |
$1,346.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,029.51
|
| Rate for Payer: Priority Health SBD |
$997.83
|
| Rate for Payer: UMR Bronson Commercial |
$696.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,187.90
|
|
|
MIRABEGRON ER 50 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$4,086.25
|
|
|
Service Code
|
NDC 70710116009
|
| Hospital Charge Code |
161791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,511.91 |
| Max. Negotiated Rate |
$3,677.62 |
| Rate for Payer: Aetna American Axle |
$2,656.06
|
| Rate for Payer: Aetna Commercial |
$3,473.31
|
| Rate for Payer: Aetna Medicare |
$2,043.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,656.06
|
| Rate for Payer: BCBS Complete |
$1,634.50
|
| Rate for Payer: Cash Price |
$3,269.00
|
| Rate for Payer: Cofinity Commercial |
$2,860.38
|
| Rate for Payer: Cofinity Commercial |
$3,514.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,860.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,269.00
|
| Rate for Payer: Healthscope Commercial |
$3,677.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,860.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,064.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,473.31
|
| Rate for Payer: PHP Commercial |
$3,473.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,656.06
|
| Rate for Payer: Priority Health SBD |
$2,574.34
|
| Rate for Payer: UMR Bronson Commercial |
$1,511.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,064.69
|
|
|
MIRIKIZUMAB-MRKZ 300 MG/15 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$24,942.38
|
|
|
Service Code
|
HCPCS J2267
|
| Hospital Charge Code |
205881
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$22,448.14 |
| Rate for Payer: Aetna American Axle |
$16,212.55
|
| Rate for Payer: Aetna Commercial |
$21,201.02
|
| Rate for Payer: Aetna Medicare |
$47.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16,212.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$56.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$56.74
|
| Rate for Payer: BCBS Complete |
$25.55
|
| Rate for Payer: BCBS MAPPO |
$45.39
|
| Rate for Payer: BCBS Trust/PPO |
$106.60
|
| Rate for Payer: BCN Commercial |
$106.60
|
| Rate for Payer: BCN Medicare Advantage |
$45.39
|
| Rate for Payer: Cash Price |
$19,953.90
|
| Rate for Payer: Cash Price |
$19,953.90
|
| Rate for Payer: Cofinity Commercial |
$21,450.45
|
| Rate for Payer: Cofinity Commercial |
$17,459.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$17,459.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19,953.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$45.39
|
| Rate for Payer: Healthscope Commercial |
$22,448.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17,459.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18,706.78
|
| Rate for Payer: Mclaren Medicaid |
$24.33
|
| Rate for Payer: Mclaren Medicare |
$45.39
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$47.66
|
| Rate for Payer: Meridian Medicaid |
$25.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$52.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21,201.02
|
| Rate for Payer: Nomi Health Commercial |
$136.17
|
| Rate for Payer: PACE Medicare |
$43.12
|
| Rate for Payer: PACE SWMI |
$45.39
|
| Rate for Payer: PHP Commercial |
$21,201.02
|
| Rate for Payer: PHP Medicare Advantage |
$45.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$24.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16,212.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$113.82
|
| Rate for Payer: Priority Health Medicare |
$45.39
|
| Rate for Payer: Priority Health Narrow Network |
$91.06
|
| Rate for Payer: Priority Health SBD |
$15,713.70
|
| Rate for Payer: Railroad Medicare Medicare |
$45.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$127.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$45.39
|
| Rate for Payer: UHC Exchange |
$86.74
|
| Rate for Payer: UHC Medicare Advantage |
$45.39
|
| Rate for Payer: UHCCP Medicaid |
$24.33
|
| Rate for Payer: UMR Bronson Commercial |
$9,228.68
|
| Rate for Payer: VA VA |
$45.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18,706.78
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$88.01
|
|
|
Service Code
|
NDC 00052010606
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.56 |
| Max. Negotiated Rate |
$79.21 |
| Rate for Payer: Aetna American Axle |
$57.21
|
| Rate for Payer: Aetna Commercial |
$74.81
|
| Rate for Payer: Aetna Medicare |
$44.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.21
|
| Rate for Payer: BCBS Complete |
$35.20
|
| Rate for Payer: Cash Price |
$70.41
|
| Rate for Payer: Cofinity Commercial |
$61.61
|
| Rate for Payer: Cofinity Commercial |
$75.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.41
|
| Rate for Payer: Healthscope Commercial |
$79.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.81
|
| Rate for Payer: PHP Commercial |
$74.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.21
|
| Rate for Payer: Priority Health SBD |
$55.45
|
| Rate for Payer: UMR Bronson Commercial |
$32.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.01
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$440.01
|
|
|
Service Code
|
NDC 00052010630
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.80 |
| Max. Negotiated Rate |
$396.01 |
| Rate for Payer: Aetna American Axle |
$286.01
|
| Rate for Payer: Aetna Commercial |
$374.01
|
| Rate for Payer: Aetna Medicare |
$220.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.01
|
| Rate for Payer: BCBS Complete |
$176.00
|
| Rate for Payer: Cash Price |
$352.01
|
| Rate for Payer: Cofinity Commercial |
$308.01
|
| Rate for Payer: Cofinity Commercial |
$378.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.01
|
| Rate for Payer: Healthscope Commercial |
$396.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.01
|
| Rate for Payer: PHP Commercial |
$374.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.01
|
| Rate for Payer: Priority Health SBD |
$277.21
|
| Rate for Payer: UMR Bronson Commercial |
$162.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.01
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$103.74
|
|
|
Service Code
|
NDC 65862002106
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.65 |
| Max. Negotiated Rate |
$93.37 |
| Rate for Payer: Aetna American Axle |
$67.43
|
| Rate for Payer: Aetna Commercial |
$88.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.43
|
| Rate for Payer: Cash Price |
$82.99
|
| Rate for Payer: Cofinity Commercial |
$72.62
|
| Rate for Payer: Cofinity Commercial |
$89.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.99
|
| Rate for Payer: Healthscope Commercial |
$93.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.18
|
| Rate for Payer: PHP Commercial |
$88.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.43
|
| Rate for Payer: Priority Health SBD |
$65.36
|
| Rate for Payer: UMR Bronson Commercial |
$45.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.80
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$88.01
|
|
|
Service Code
|
NDC 00052010606
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$79.21 |
| Rate for Payer: Aetna American Axle |
$57.21
|
| Rate for Payer: Aetna Commercial |
$74.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.21
|
| Rate for Payer: Cash Price |
$70.41
|
| Rate for Payer: Cofinity Commercial |
$61.61
|
| Rate for Payer: Cofinity Commercial |
$75.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.41
|
| Rate for Payer: Healthscope Commercial |
$79.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.81
|
| Rate for Payer: PHP Commercial |
$74.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.21
|
| Rate for Payer: Priority Health SBD |
$55.45
|
| Rate for Payer: UMR Bronson Commercial |
$38.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.01
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$103.74
|
|
|
Service Code
|
NDC 65862002106
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.38 |
| Max. Negotiated Rate |
$93.37 |
| Rate for Payer: Aetna American Axle |
$67.43
|
| Rate for Payer: Aetna Commercial |
$88.18
|
| Rate for Payer: Aetna Medicare |
$51.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.43
|
| Rate for Payer: BCBS Complete |
$41.50
|
| Rate for Payer: Cash Price |
$82.99
|
| Rate for Payer: Cofinity Commercial |
$72.62
|
| Rate for Payer: Cofinity Commercial |
$89.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.99
|
| Rate for Payer: Healthscope Commercial |
$93.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.18
|
| Rate for Payer: PHP Commercial |
$88.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.43
|
| Rate for Payer: Priority Health SBD |
$65.36
|
| Rate for Payer: UMR Bronson Commercial |
$38.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.80
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$440.01
|
|
|
Service Code
|
NDC 00052010630
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.60 |
| Max. Negotiated Rate |
$396.01 |
| Rate for Payer: Aetna American Axle |
$286.01
|
| Rate for Payer: Aetna Commercial |
$374.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.01
|
| Rate for Payer: Cash Price |
$352.01
|
| Rate for Payer: Cofinity Commercial |
$308.01
|
| Rate for Payer: Cofinity Commercial |
$378.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.01
|
| Rate for Payer: Healthscope Commercial |
$396.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.01
|
| Rate for Payer: PHP Commercial |
$374.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.01
|
| Rate for Payer: Priority Health SBD |
$277.21
|
| Rate for Payer: UMR Bronson Commercial |
$193.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.01
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$284.35
|
|
|
Service Code
|
NDC 00904651961
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.11 |
| Max. Negotiated Rate |
$255.92 |
| Rate for Payer: Aetna American Axle |
$184.83
|
| Rate for Payer: Aetna Commercial |
$241.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.83
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Commercial |
$199.04
|
| Rate for Payer: Cofinity Commercial |
$244.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.48
|
| Rate for Payer: Healthscope Commercial |
$255.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.70
|
| Rate for Payer: PHP Commercial |
$241.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.83
|
| Rate for Payer: Priority Health SBD |
$179.14
|
| Rate for Payer: UMR Bronson Commercial |
$125.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.26
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
OP
|
$78.66
|
|
|
Service Code
|
NDC 60505024701
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.10 |
| Max. Negotiated Rate |
$70.79 |
| Rate for Payer: Aetna American Axle |
$51.13
|
| Rate for Payer: Aetna Commercial |
$66.86
|
| Rate for Payer: Aetna Medicare |
$39.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.13
|
| Rate for Payer: BCBS Complete |
$31.46
|
| Rate for Payer: Cash Price |
$62.93
|
| Rate for Payer: Cofinity Commercial |
$55.06
|
| Rate for Payer: Cofinity Commercial |
$67.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.93
|
| Rate for Payer: Healthscope Commercial |
$70.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.86
|
| Rate for Payer: PHP Commercial |
$66.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.13
|
| Rate for Payer: Priority Health SBD |
$49.56
|
| Rate for Payer: UMR Bronson Commercial |
$29.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.00
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$78.66
|
|
|
Service Code
|
NDC 60505024701
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$70.79 |
| Rate for Payer: Aetna American Axle |
$51.13
|
| Rate for Payer: Aetna Commercial |
$66.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.13
|
| Rate for Payer: Cash Price |
$62.93
|
| Rate for Payer: Cofinity Commercial |
$55.06
|
| Rate for Payer: Cofinity Commercial |
$67.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.93
|
| Rate for Payer: Healthscope Commercial |
$70.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.86
|
| Rate for Payer: PHP Commercial |
$66.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.13
|
| Rate for Payer: Priority Health SBD |
$49.56
|
| Rate for Payer: UMR Bronson Commercial |
$34.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.00
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$448.85
|
|
|
Service Code
|
NDC 68084011911
|
| 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 |
$314.20
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.20
|
| 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 |
$314.20
|
| 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
|
$312.55
|
|
|
Service Code
|
NDC 63739009810
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.64 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna American Axle |
$203.16
|
| Rate for Payer: Aetna Commercial |
$265.67
|
| Rate for Payer: Aetna Medicare |
$156.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.16
|
| Rate for Payer: BCBS Complete |
$125.02
|
| Rate for Payer: Cash Price |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Cofinity Commercial |
$268.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.04
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.67
|
| Rate for Payer: PHP Commercial |
$265.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.16
|
| Rate for Payer: Priority Health SBD |
$196.91
|
| Rate for Payer: UMR Bronson Commercial |
$115.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.41
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$312.55
|
|
|
Service Code
|
NDC 63739009810
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.52 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna American Axle |
$203.16
|
| Rate for Payer: Aetna Commercial |
$265.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.16
|
| Rate for Payer: Cash Price |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Cofinity Commercial |
$268.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.04
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.67
|
| Rate for Payer: PHP Commercial |
$265.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.16
|
| Rate for Payer: Priority Health SBD |
$196.91
|
| Rate for Payer: UMR Bronson Commercial |
$137.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.41
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
OP
|
$284.35
|
|
|
Service Code
|
NDC 00904651961
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.21 |
| Max. Negotiated Rate |
$255.92 |
| Rate for Payer: Aetna American Axle |
$184.83
|
| Rate for Payer: Aetna Commercial |
$241.70
|
| Rate for Payer: Aetna Medicare |
$142.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.83
|
| Rate for Payer: BCBS Complete |
$113.74
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Commercial |
$199.04
|
| Rate for Payer: Cofinity Commercial |
$244.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.48
|
| Rate for Payer: Healthscope Commercial |
$255.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.70
|
| Rate for Payer: PHP Commercial |
$241.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.83
|
| Rate for Payer: Priority Health SBD |
$179.14
|
| Rate for Payer: UMR Bronson Commercial |
$105.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.26
|
|
