|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$9.33
|
|
|
Service Code
|
NDC 0536-1272-11
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna American Axle |
$6.06
|
| Rate for Payer: Aetna Commercial |
$7.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.06
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$6.53
|
| Rate for Payer: Cofinity Commercial |
$8.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.46
|
| Rate for Payer: Healthscope Commercial |
$8.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.93
|
| Rate for Payer: PHP Commercial |
$7.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.53
|
| Rate for Payer: Priority Health SBD |
$5.88
|
| Rate for Payer: UMR Bronson Commercial |
$4.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.00
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$13.44
|
|
|
Service Code
|
NDC 45802-434-01
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$12.10 |
| Rate for Payer: Aetna American Axle |
$8.74
|
| Rate for Payer: Aetna Commercial |
$11.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.74
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: Cofinity Commercial |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$9.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.75
|
| Rate for Payer: Healthscope Commercial |
$12.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.42
|
| Rate for Payer: PHP Commercial |
$11.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.41
|
| Rate for Payer: Priority Health SBD |
$8.47
|
| Rate for Payer: UMR Bronson Commercial |
$5.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.08
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$31.61
|
|
|
Service Code
|
NDC 68462-181-17
|
| Hospital Charge Code |
1767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.91 |
| Max. Negotiated Rate |
$28.45 |
| Rate for Payer: Aetna American Axle |
$20.55
|
| Rate for Payer: Aetna Commercial |
$26.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.55
|
| Rate for Payer: Cash Price |
$25.29
|
| Rate for Payer: Cofinity Commercial |
$22.13
|
| Rate for Payer: Cofinity Commercial |
$27.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.29
|
| Rate for Payer: Healthscope Commercial |
$28.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.87
|
| Rate for Payer: PHP Commercial |
$26.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.13
|
| Rate for Payer: Priority Health SBD |
$19.91
|
| Rate for Payer: UMR Bronson Commercial |
$13.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.71
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
IP
|
$22.89
|
|
|
Service Code
|
NDC 61269-220-41
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$20.60 |
| Rate for Payer: Aetna American Axle |
$14.88
|
| Rate for Payer: Aetna Commercial |
$19.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.88
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Cofinity Commercial |
$19.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.31
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.46
|
| Rate for Payer: PHP Commercial |
$19.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health SBD |
$14.42
|
| Rate for Payer: UMR Bronson Commercial |
$10.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.17
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM
|
Facility
|
IP
|
$15.80
|
|
|
Service Code
|
NDC 51672-2003-6
|
| Hospital Charge Code |
1769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$14.22 |
| Rate for Payer: Aetna American Axle |
$10.27
|
| Rate for Payer: Aetna Commercial |
$13.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.27
|
| Rate for Payer: Cash Price |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$11.06
|
| Rate for Payer: Cofinity Commercial |
$13.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.64
|
| Rate for Payer: Healthscope Commercial |
$14.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.43
|
| Rate for Payer: PHP Commercial |
$13.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.06
|
| Rate for Payer: Priority Health SBD |
$9.95
|
| Rate for Payer: UMR Bronson Commercial |
$6.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.85
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$19.51
|
|
|
Service Code
|
NDC 68462-298-17
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna American Axle |
$12.68
|
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cofinity Commercial |
$13.66
|
| Rate for Payer: Cofinity Commercial |
$16.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.61
|
| Rate for Payer: Healthscope Commercial |
$17.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.58
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.66
|
| Rate for Payer: Priority Health SBD |
$12.29
|
| Rate for Payer: UMR Bronson Commercial |
$8.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.63
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$19.92
|
|
|
Service Code
|
NDC 0168-0258-15
|
| Hospital Charge Code |
29424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$17.93 |
| Rate for Payer: Aetna American Axle |
$12.95
|
| Rate for Payer: Aetna Commercial |
$16.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.95
|
| Rate for Payer: Cash Price |
$15.94
|
| Rate for Payer: Cofinity Commercial |
$13.94
|
| Rate for Payer: Cofinity Commercial |
$17.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.94
|
| Rate for Payer: Healthscope Commercial |
$17.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.93
|
| Rate for Payer: PHP Commercial |
$16.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health SBD |
$12.55
|
| Rate for Payer: UMR Bronson Commercial |
$8.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.94
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$856.75
|
|
|
Service Code
|
NDC 0093-5419-84
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$376.97 |
| Max. Negotiated Rate |
$771.08 |
| Rate for Payer: Aetna American Axle |
$556.89
|
| Rate for Payer: Aetna Commercial |
$728.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$556.89
|
| Rate for Payer: Cash Price |
$685.40
|
| Rate for Payer: Cofinity Commercial |
$599.72
|
| Rate for Payer: Cofinity Commercial |
$736.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$685.40
|
| Rate for Payer: Healthscope Commercial |
$771.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$599.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$642.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$728.24
|
| Rate for Payer: PHP Commercial |
$728.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$599.72
|
| Rate for Payer: Priority Health SBD |
$539.75
|
| Rate for Payer: UMR Bronson Commercial |
$376.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$642.56
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$764.28
|
|
|
Service Code
|
NDC 51079-288-04
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$336.28 |
| Max. Negotiated Rate |
$687.85 |
| Rate for Payer: Aetna American Axle |
$496.78
|
| Rate for Payer: Aetna Commercial |
$649.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$496.78
|
| Rate for Payer: Cash Price |
$611.42
|
| Rate for Payer: Cofinity Commercial |
$535.00
|
| Rate for Payer: Cofinity Commercial |
$657.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$611.42
|
| Rate for Payer: Healthscope Commercial |
$687.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$535.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$573.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$649.64
|
| Rate for Payer: PHP Commercial |
$649.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$535.00
|
| Rate for Payer: Priority Health SBD |
$481.50
|
| Rate for Payer: UMR Bronson Commercial |
$336.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$573.21
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$17.85
|
|
|
Service Code
|
NDC 0093-5419-19
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$16.06 |
| Rate for Payer: Aetna American Axle |
$11.60
|
| Rate for Payer: Aetna Commercial |
$15.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.60
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cofinity Commercial |
$12.50
|
| Rate for Payer: Cofinity Commercial |
$15.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.28
|
| Rate for Payer: Healthscope Commercial |
$16.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.17
|
| Rate for Payer: PHP Commercial |
$15.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health SBD |
$11.25
|
| Rate for Payer: UMR Bronson Commercial |
$7.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.39
|
|
|
CLOZAPINE 100 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$19.11
|
|
|
Service Code
|
NDC 51079-288-01
|
| Hospital Charge Code |
38480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Aetna American Axle |
$12.42
|
| Rate for Payer: Aetna Commercial |
$16.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.42
|
| Rate for Payer: Cash Price |
$15.29
|
| Rate for Payer: Cofinity Commercial |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$16.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.29
|
| Rate for Payer: Healthscope Commercial |
$17.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.24
|
| Rate for Payer: PHP Commercial |
$16.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.38
|
| Rate for Payer: Priority Health SBD |
$12.04
|
| Rate for Payer: UMR Bronson Commercial |
$8.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.33
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$48.36
|
|
|
Service Code
|
NDC 0078-0127-61
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$43.52 |
| Rate for Payer: Aetna American Axle |
$31.43
|
| Rate for Payer: Aetna Commercial |
$41.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.43
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cofinity Commercial |
$33.85
|
| Rate for Payer: Cofinity Commercial |
$41.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.69
|
| Rate for Payer: Healthscope Commercial |
$43.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.11
|
| Rate for Payer: PHP Commercial |
$41.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.85
|
| Rate for Payer: Priority Health SBD |
$30.47
|
| Rate for Payer: UMR Bronson Commercial |
$21.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.27
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.69
|
|
|
Service Code
|
NDC 51079-922-01
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$3.32 |
| Rate for Payer: Aetna American Axle |
$2.40
|
| Rate for Payer: Aetna Commercial |
$3.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.40
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cofinity Commercial |
$2.58
|
| Rate for Payer: Cofinity Commercial |
$3.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.95
|
| Rate for Payer: Healthscope Commercial |
$3.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.14
|
| Rate for Payer: PHP Commercial |
$3.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.58
|
| Rate for Payer: Priority Health SBD |
$2.32
|
| Rate for Payer: UMR Bronson Commercial |
$1.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.77
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$368.16
|
|
|
Service Code
|
NDC 51079-922-20
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.99 |
| Max. Negotiated Rate |
$331.34 |
| Rate for Payer: Aetna American Axle |
$239.30
|
| Rate for Payer: Aetna Commercial |
$312.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$239.30
|
| Rate for Payer: Cash Price |
$294.53
|
| Rate for Payer: Cofinity Commercial |
$257.71
|
| Rate for Payer: Cofinity Commercial |
$316.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$294.53
|
| Rate for Payer: Healthscope Commercial |
$331.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$257.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$276.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$312.94
|
| Rate for Payer: PHP Commercial |
$312.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.71
|
| Rate for Payer: Priority Health SBD |
$231.94
|
| Rate for Payer: UMR Bronson Commercial |
$161.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$276.12
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$315.84
|
|
|
Service Code
|
NDC 60687-415-01
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.97 |
| Max. Negotiated Rate |
$284.26 |
| Rate for Payer: Aetna American Axle |
$205.30
|
| Rate for Payer: Aetna Commercial |
$268.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$205.30
|
| Rate for Payer: Cash Price |
$252.67
|
| Rate for Payer: Cofinity Commercial |
$271.62
|
| Rate for Payer: Cofinity Commercial |
$221.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$252.67
|
| Rate for Payer: Healthscope Commercial |
$284.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$221.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$236.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$268.46
|
| Rate for Payer: PHP Commercial |
$268.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.09
|
| Rate for Payer: Priority Health SBD |
$198.98
|
| Rate for Payer: UMR Bronson Commercial |
$138.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$236.88
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$794.76
|
|
|
Service Code
|
NDC 0093-7772-01
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$349.69 |
| Max. Negotiated Rate |
$715.28 |
| Rate for Payer: Aetna American Axle |
$516.59
|
| Rate for Payer: Aetna Commercial |
$675.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$516.59
|
| Rate for Payer: Cash Price |
$635.81
|
| Rate for Payer: Cofinity Commercial |
$556.33
|
| Rate for Payer: Cofinity Commercial |
$683.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.81
|
| Rate for Payer: Healthscope Commercial |
$715.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$556.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$596.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$675.55
|
| Rate for Payer: PHP Commercial |
$675.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$556.33
|
| Rate for Payer: Priority Health SBD |
$500.70
|
| Rate for Payer: UMR Bronson Commercial |
$349.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$596.07
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 60687-415-11
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna American Axle |
$2.05
|
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.05
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Commercial |
$2.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.53
|
| Rate for Payer: Healthscope Commercial |
$2.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.69
|
| Rate for Payer: PHP Commercial |
$2.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health SBD |
$1.99
|
| Rate for Payer: UMR Bronson Commercial |
$1.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.37
|
|
|
CLOZAPINE 100 MG TABLET
|
Facility
|
IP
|
$4,339.73
|
|
|
Service Code
|
NDC 0078-0127-06
|
| Hospital Charge Code |
9647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,909.48 |
| Max. Negotiated Rate |
$3,905.76 |
| Rate for Payer: Aetna American Axle |
$2,820.82
|
| Rate for Payer: Aetna Commercial |
$3,688.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,820.82
|
| Rate for Payer: Cash Price |
$3,471.78
|
| Rate for Payer: Cofinity Commercial |
$3,037.81
|
| Rate for Payer: Cofinity Commercial |
$3,732.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,471.78
|
| Rate for Payer: Healthscope Commercial |
$3,905.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,037.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,254.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,688.77
|
| Rate for Payer: PHP Commercial |
$3,688.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,037.81
|
| Rate for Payer: Priority Health SBD |
$2,734.03
|
| Rate for Payer: UMR Bronson Commercial |
$1,909.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,254.80
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$289.75
|
|
|
Service Code
|
NDC 51079-921-20
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.49 |
| Max. Negotiated Rate |
$260.78 |
| Rate for Payer: Aetna American Axle |
$188.34
|
| Rate for Payer: Aetna Commercial |
$246.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.34
|
| Rate for Payer: Cash Price |
$231.80
|
| Rate for Payer: Cofinity Commercial |
$202.82
|
| Rate for Payer: Cofinity Commercial |
$249.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.80
|
| Rate for Payer: Healthscope Commercial |
$260.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$246.29
|
| Rate for Payer: PHP Commercial |
$246.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.82
|
| Rate for Payer: Priority Health SBD |
$182.54
|
| Rate for Payer: UMR Bronson Commercial |
$127.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.31
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$239.40
|
|
|
Service Code
|
NDC 0904-7089-61
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.34 |
| Max. Negotiated Rate |
$215.46 |
| Rate for Payer: Aetna American Axle |
$155.61
|
| Rate for Payer: Aetna Commercial |
$203.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.61
|
| Rate for Payer: Cash Price |
$191.52
|
| Rate for Payer: Cofinity Commercial |
$167.58
|
| Rate for Payer: Cofinity Commercial |
$205.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.52
|
| Rate for Payer: Healthscope Commercial |
$215.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$203.49
|
| Rate for Payer: PHP Commercial |
$203.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.58
|
| Rate for Payer: Priority Health SBD |
$150.82
|
| Rate for Payer: UMR Bronson Commercial |
$105.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.55
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
NDC 51079-921-01
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Aetna American Axle |
$1.88
|
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.88
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$2.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.32
|
| Rate for Payer: Healthscope Commercial |
$2.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.46
|
| Rate for Payer: PHP Commercial |
$2.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.83
|
| Rate for Payer: UMR Bronson Commercial |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.18
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$397.44
|
|
|
Service Code
|
NDC 0093-4359-01
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.87 |
| Max. Negotiated Rate |
$357.70 |
| Rate for Payer: Aetna American Axle |
$258.34
|
| Rate for Payer: Aetna Commercial |
$337.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.34
|
| Rate for Payer: Cash Price |
$317.95
|
| Rate for Payer: Cofinity Commercial |
$278.21
|
| Rate for Payer: Cofinity Commercial |
$341.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.95
|
| Rate for Payer: Healthscope Commercial |
$357.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$278.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$337.82
|
| Rate for Payer: PHP Commercial |
$337.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.21
|
| Rate for Payer: Priority Health SBD |
$250.39
|
| Rate for Payer: UMR Bronson Commercial |
$174.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.08
|
|
|
CLOZAPINE 25 MG TABLET
|
Facility
|
IP
|
$18.67
|
|
|
Service Code
|
NDC 0078-0126-61
|
| Hospital Charge Code |
9648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.21 |
| Max. Negotiated Rate |
$16.80 |
| Rate for Payer: Aetna American Axle |
$12.14
|
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.14
|
| Rate for Payer: Cash Price |
$14.94
|
| Rate for Payer: Cofinity Commercial |
$13.07
|
| Rate for Payer: Cofinity Commercial |
$16.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.94
|
| Rate for Payer: Healthscope Commercial |
$16.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.87
|
| Rate for Payer: PHP Commercial |
$15.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.07
|
| Rate for Payer: Priority Health SBD |
$11.76
|
| Rate for Payer: UMR Bronson Commercial |
$8.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.00
|
|
|
COAGULATION DISORDERS
|
Facility
|
IP
|
$32,082.19
|
|
|
Service Code
|
MS-DRG 813
|
| Min. Negotiated Rate |
$11,907.08 |
| Max. Negotiated Rate |
$32,082.19 |
| Rate for Payer: Aetna Medicare |
$13,035.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,667.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,667.21
|
| Rate for Payer: BCBS MAPPO |
$12,533.77
|
| Rate for Payer: BCBS Trust/PPO |
$32,082.19
|
| Rate for Payer: BCN Medicare Advantage |
$12,533.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,533.77
|
| Rate for Payer: Mclaren Medicare |
$12,533.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,160.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,413.84
|
| Rate for Payer: PACE Medicare |
$11,907.08
|
| Rate for Payer: PACE SWMI |
$12,533.77
|
| Rate for Payer: PHP Medicare Advantage |
$12,533.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,385.88
|
| Rate for Payer: Priority Health Medicare |
$12,533.77
|
| Rate for Payer: Priority Health Narrow Network |
$17,908.70
|
| Rate for Payer: Railroad Medicare Medicare |
$12,533.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23,796.24
|
| Rate for Payer: UHC Core |
$19,512.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,533.77
|
| Rate for Payer: UHC Exchange |
$15,512.64
|
| Rate for Payer: UHC Medicare Advantage |
$12,909.78
|
| Rate for Payer: VA VA |
$12,533.77
|
|
|
COAGULATION FACTOR IX (RECOMB) (BENEFIX) 1,000 UNIT INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
HCPCS J7195
|
| Hospital Charge Code |
168017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna American Axle |
$2.21
|
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.21
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.89
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.38
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
