|
MOLASSES
|
Facility
|
IP
|
$23.94
|
|
|
Service Code
|
NDC 00990000075
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna American Axle |
$15.56
|
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.56
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.15
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.35
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.56
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.96
|
|
|
MOLASSES
|
Facility
|
OP
|
$23.94
|
|
|
Service Code
|
NDC 00990000075
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna American Axle |
$15.56
|
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: Aetna Medicare |
$11.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.56
|
| Rate for Payer: BCBS Complete |
$9.58
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.15
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.35
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.56
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: UMR Bronson Commercial |
$8.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.96
|
|
|
MOMETASONE 110 MCG/ACTUATION(30 DOSES) BREATH ACTIVATED POWDER INHALER
|
Facility
|
OP
|
$432.53
|
|
|
Service Code
|
NDC 00085146102
|
| Hospital Charge Code |
91877
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.04 |
| Max. Negotiated Rate |
$389.28 |
| Rate for Payer: Cofinity Commercial |
$371.98
|
| Rate for Payer: Aetna American Axle |
$281.14
|
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna Medicare |
$216.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$281.14
|
| Rate for Payer: BCBS Complete |
$173.01
|
| Rate for Payer: Cash Price |
$346.02
|
| Rate for Payer: Cofinity Commercial |
$302.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$302.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$346.02
|
| Rate for Payer: Healthscope Commercial |
$389.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$302.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$324.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$367.65
|
| Rate for Payer: PHP Commercial |
$367.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.14
|
| Rate for Payer: Priority Health SBD |
$272.49
|
| Rate for Payer: UMR Bronson Commercial |
$160.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$324.40
|
|
|
MOMETASONE 110 MCG/ACTUATION(30 DOSES) BREATH ACTIVATED POWDER INHALER
|
Facility
|
IP
|
$432.53
|
|
|
Service Code
|
NDC 00085146102
|
| Hospital Charge Code |
91877
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.31 |
| Max. Negotiated Rate |
$389.28 |
| Rate for Payer: Aetna American Axle |
$281.14
|
| Rate for Payer: Aetna Commercial |
$367.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$281.14
|
| Rate for Payer: Cash Price |
$346.02
|
| Rate for Payer: Cofinity Commercial |
$302.77
|
| Rate for Payer: Cofinity Commercial |
$371.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$302.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$346.02
|
| Rate for Payer: Healthscope Commercial |
$389.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$302.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$324.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$367.65
|
| Rate for Payer: PHP Commercial |
$367.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.14
|
| Rate for Payer: Priority Health SBD |
$272.49
|
| Rate for Payer: UMR Bronson Commercial |
$190.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$324.40
|
|
|
MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
OP
|
$526.35
|
|
|
Service Code
|
NDC 00085461001
|
| Hospital Charge Code |
105699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.75 |
| Max. Negotiated Rate |
$473.72 |
| Rate for Payer: Aetna American Axle |
$342.13
|
| Rate for Payer: Aetna Commercial |
$447.40
|
| Rate for Payer: Aetna Medicare |
$263.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$342.13
|
| Rate for Payer: BCBS Complete |
$210.54
|
| Rate for Payer: Cash Price |
$421.08
|
| Rate for Payer: Cofinity Commercial |
$368.44
|
| Rate for Payer: Cofinity Commercial |
$452.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$368.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$421.08
|
| Rate for Payer: Healthscope Commercial |
$473.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$368.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$394.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$447.40
|
| Rate for Payer: PHP Commercial |
$447.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$342.13
|
| Rate for Payer: Priority Health SBD |
$331.60
|
| Rate for Payer: UMR Bronson Commercial |
$194.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$394.76
|
|
|
MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
IP
|
$526.35
|
|
|
Service Code
|
NDC 00085461001
|
| Hospital Charge Code |
105699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.59 |
| Max. Negotiated Rate |
$473.72 |
| Rate for Payer: Aetna American Axle |
$342.13
|
| Rate for Payer: Aetna Commercial |
$447.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$342.13
|
| Rate for Payer: Cash Price |
$421.08
|
| Rate for Payer: Cofinity Commercial |
$368.44
|
| Rate for Payer: Cofinity Commercial |
$452.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$368.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$421.08
|
| Rate for Payer: Healthscope Commercial |
$473.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$368.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$394.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$447.40
|
| Rate for Payer: PHP Commercial |
$447.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$342.13
|
| Rate for Payer: Priority Health SBD |
$331.60
|
| Rate for Payer: UMR Bronson Commercial |
$231.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$394.76
|
|
|
MONALISA TOUCH, SERIES, UP TO 3 VISITS
|
Professional
|
Both
|
$1,836.00
|
|
|
Service Code
|
HCPCS 00561
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$734.40 |
| Max. Negotiated Rate |
$1,193.40 |
| Rate for Payer: Aetna Medicare |
$918.00
|
| Rate for Payer: BCBS Complete |
$734.40
|
| Rate for Payer: Cash Price |
$1,468.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,193.40
|
| Rate for Payer: UMR Bronson Commercial |
$844.56
|
|
|
MONALISA TOUCH, SINGLE TREATMENT FOLLOWING A SERIES
|
Professional
|
Both
|
$612.00
|
|
|
Service Code
|
HCPCS 00562
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna Medicare |
$306.00
|
| Rate for Payer: BCBS Complete |
$244.80
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.80
|
| Rate for Payer: UMR Bronson Commercial |
$281.52
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 29300022013
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna Medicare |
$35.25
|
| Rate for Payer: Aetna American Axle |
$45.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
| Rate for Payer: UMR Bronson Commercial |
$26.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$240.35
|
|
|
Service Code
|
NDC 00904680861
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.75 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.23
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$105.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$122.08
|
|
|
Service Code
|
NDC 00904680806
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.17 |
| Max. Negotiated Rate |
$109.87 |
| Rate for Payer: Aetna American Axle |
$79.35
|
| Rate for Payer: Aetna Commercial |
$103.77
|
| Rate for Payer: Aetna Medicare |
$61.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.35
|
| Rate for Payer: BCBS Complete |
$48.83
|
| Rate for Payer: Cash Price |
$97.66
|
| Rate for Payer: Cofinity Commercial |
$104.99
|
| Rate for Payer: Cofinity Commercial |
$85.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$85.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.66
|
| Rate for Payer: Healthscope Commercial |
$109.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$103.77
|
| Rate for Payer: PHP Commercial |
$103.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.35
|
| Rate for Payer: Priority Health SBD |
$76.91
|
| Rate for Payer: UMR Bronson Commercial |
$45.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.56
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
NDC 68084087511
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna American Axle |
$1.92
|
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.92
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.36
|
| Rate for Payer: Healthscope Commercial |
$2.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.51
|
| Rate for Payer: PHP Commercial |
$2.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.92
|
| Rate for Payer: Priority Health SBD |
$1.86
|
| Rate for Payer: UMR Bronson Commercial |
$1.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.21
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 29300022013
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.82
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
| Rate for Payer: UMR Bronson Commercial |
$31.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
NDC 68084087511
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna American Axle |
$1.92
|
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Aetna Medicare |
$1.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.92
|
| Rate for Payer: BCBS Complete |
$1.18
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.36
|
| Rate for Payer: Healthscope Commercial |
$2.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.51
|
| Rate for Payer: PHP Commercial |
$2.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.92
|
| Rate for Payer: Priority Health SBD |
$1.86
|
| Rate for Payer: UMR Bronson Commercial |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.21
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$240.35
|
|
|
Service Code
|
NDC 00904680861
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.93 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Medicare |
$120.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: BCBS Complete |
$96.14
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.23
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$88.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
OP
|
$294.50
|
|
|
Service Code
|
NDC 68084087501
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.96 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna American Axle |
$191.42
|
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna Medicare |
$147.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.42
|
| Rate for Payer: BCBS Complete |
$117.80
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$206.15
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.42
|
| Rate for Payer: Priority Health SBD |
$185.54
|
| Rate for Payer: UMR Bronson Commercial |
$108.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
MONTELUKAST 10 MG TABLET
|
Facility
|
IP
|
$294.50
|
|
|
Service Code
|
NDC 68084087501
|
| Hospital Charge Code |
22509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna American Axle |
$191.42
|
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.42
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$206.15
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.42
|
| Rate for Payer: Priority Health SBD |
$185.54
|
| Rate for Payer: UMR Bronson Commercial |
$129.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
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 Commercial |
$119.45
|
| Rate for Payer: Cofinity Commercial |
$97.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.22
|
| 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: PHP Commercial |
$118.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.28
|
| Rate for Payer: Priority Health SBD |
$87.50
|
| 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
|
$169.20
|
|
|
Service Code
|
NDC 50268057315
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.60 |
| Max. Negotiated Rate |
$152.28 |
| Rate for Payer: Cofinity Medicare Advantage |
$118.44
|
| Rate for Payer: Aetna American Axle |
$109.98
|
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna Medicare |
$84.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.98
|
| Rate for Payer: BCBS Complete |
$67.68
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$145.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$152.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: PHP Commercial |
$143.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.98
|
| Rate for Payer: Priority Health SBD |
$106.60
|
| Rate for Payer: UMR Bronson Commercial |
$62.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.90
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$86.72
|
|
|
Service Code
|
NDC 33342011007
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna American Axle |
$56.37
|
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: Aetna Medicare |
$43.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.37
|
| Rate for Payer: BCBS Complete |
$34.69
|
| Rate for Payer: Cash Price |
$69.38
|
| Rate for Payer: Cofinity Commercial |
$60.70
|
| Rate for Payer: Cofinity Commercial |
$74.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.38
|
| Rate for Payer: Healthscope Commercial |
$78.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.71
|
| Rate for Payer: PHP Commercial |
$73.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.37
|
| Rate for Payer: Priority Health SBD |
$54.63
|
| Rate for Payer: UMR Bronson Commercial |
$32.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.04
|
|
|
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 Commercial |
$119.45
|
| Rate for Payer: Cofinity Commercial |
$97.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.22
|
| 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: PHP Commercial |
$118.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.28
|
| 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 CHEWABLE TABLET
|
Facility
|
IP
|
$86.72
|
|
|
Service Code
|
NDC 33342011007
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna American Axle |
$56.37
|
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.37
|
| Rate for Payer: Cash Price |
$69.38
|
| Rate for Payer: Cofinity Commercial |
$60.70
|
| Rate for Payer: Cofinity Commercial |
$74.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.38
|
| Rate for Payer: Healthscope Commercial |
$78.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.71
|
| Rate for Payer: PHP Commercial |
$73.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.37
|
| Rate for Payer: Priority Health SBD |
$54.63
|
| Rate for Payer: UMR Bronson Commercial |
$38.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.04
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
NDC 50268057311
|
| Hospital Charge Code |
27234
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna American Axle |
$2.20
|
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.20
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.71
|
| Rate for Payer: Healthscope Commercial |
$3.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.88
|
| Rate for Payer: PHP Commercial |
$2.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.20
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.54
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
IP
|
$784.66
|
|
|
Service Code
|
NDC 00006384130
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$345.25 |
| Max. Negotiated Rate |
$706.19 |
| Rate for Payer: Aetna American Axle |
$510.03
|
| Rate for Payer: Aetna Commercial |
$666.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$510.03
|
| Rate for Payer: Cash Price |
$627.73
|
| Rate for Payer: Cofinity Commercial |
$549.26
|
| Rate for Payer: Cofinity Commercial |
$674.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$549.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$627.73
|
| Rate for Payer: Healthscope Commercial |
$706.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$549.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$588.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$666.96
|
| Rate for Payer: PHP Commercial |
$666.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$510.03
|
| Rate for Payer: Priority Health SBD |
$494.34
|
| Rate for Payer: UMR Bronson Commercial |
$345.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$588.50
|
|
|
MONTELUKAST 4 MG ORAL GRANULES IN PACKET
|
Facility
|
OP
|
$155.81
|
|
|
Service Code
|
NDC 27241001531
|
| Hospital Charge Code |
36023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.65 |
| Max. Negotiated Rate |
$140.23 |
| Rate for Payer: Aetna American Axle |
$101.28
|
| Rate for Payer: Aetna Commercial |
$132.44
|
| Rate for Payer: Aetna Medicare |
$77.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.28
|
| Rate for Payer: BCBS Complete |
$62.32
|
| Rate for Payer: Cash Price |
$124.65
|
| Rate for Payer: Cofinity Commercial |
$109.07
|
| Rate for Payer: Cofinity Commercial |
$134.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.65
|
| Rate for Payer: Healthscope Commercial |
$140.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.44
|
| Rate for Payer: PHP Commercial |
$132.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.28
|
| Rate for Payer: Priority Health SBD |
$98.16
|
| Rate for Payer: UMR Bronson Commercial |
$57.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.86
|
|
