|
NORETHINDRONE ACETATE 5 MG TABLET
|
Facility
|
IP
|
$133.92
|
|
|
Service Code
|
NDC 50742026750
|
| Hospital Charge Code |
10747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.92 |
| Max. Negotiated Rate |
$120.53 |
| Rate for Payer: Aetna American Axle |
$87.05
|
| Rate for Payer: Aetna Commercial |
$113.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.05
|
| Rate for Payer: Cash Price |
$107.14
|
| Rate for Payer: Cofinity Advantage |
$93.74
|
| Rate for Payer: Cofinity Commercial |
$115.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.14
|
| Rate for Payer: Healthscope Commercial |
$120.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.44
|
| Rate for Payer: PHP Commercial |
$113.83
|
| Rate for Payer: Priority Health SBD |
$84.37
|
| Rate for Payer: UMR Bronson Commercial |
$58.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.44
|
|
|
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET
|
Facility
|
IP
|
$23.94
|
|
|
Service Code
|
NDC 00555901658
|
| Hospital Charge Code |
10749
|
|
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 Advantage |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| 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 |
$17.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.95
|
| Rate for Payer: PHP Commercial |
$20.35
|
| 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 |
$17.95
|
|
|
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET
|
Facility
|
OP
|
$23.94
|
|
|
Service Code
|
NDC 00555901658
|
| Hospital Charge Code |
10749
|
|
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 Advantage |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| 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 |
$17.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.95
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.56
|
| Rate for Payer: UHC Core |
$12.47
|
| Rate for Payer: UHC Exchange |
$9.41
|
| Rate for Payer: UMR Bronson Commercial |
$8.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.95
|
|
|
NORGESTIMATE-ETHINYL ESTRADIOL 0.18MG/0.215MG/0.25MG-0.035MG(28)TABLET
|
Facility
|
OP
|
$93.28
|
|
|
Service Code
|
NDC 00555901858
|
| Hospital Charge Code |
10750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.51 |
| Max. Negotiated Rate |
$83.95 |
| Rate for Payer: Aetna American Axle |
$60.63
|
| Rate for Payer: Aetna Commercial |
$79.29
|
| Rate for Payer: Aetna Medicare |
$46.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.63
|
| Rate for Payer: BCBS Complete |
$37.31
|
| Rate for Payer: Cash Price |
$74.62
|
| Rate for Payer: Cofinity Advantage |
$65.30
|
| Rate for Payer: Cofinity Commercial |
$80.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.62
|
| Rate for Payer: Healthscope Commercial |
$83.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$69.96
|
| Rate for Payer: PHP Commercial |
$79.29
|
| Rate for Payer: Priority Health SBD |
$58.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.63
|
| Rate for Payer: UHC Core |
$48.60
|
| Rate for Payer: UHC Exchange |
$36.66
|
| Rate for Payer: UMR Bronson Commercial |
$34.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69.96
|
|
|
NORGESTIMATE-ETHINYL ESTRADIOL 0.18MG/0.215MG/0.25MG-0.035MG(28)TABLET
|
Facility
|
IP
|
$93.28
|
|
|
Service Code
|
NDC 00555901858
|
| Hospital Charge Code |
10750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.04 |
| Max. Negotiated Rate |
$83.95 |
| Rate for Payer: Aetna American Axle |
$60.63
|
| Rate for Payer: Aetna Commercial |
$79.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.63
|
| Rate for Payer: Cash Price |
$74.62
|
| Rate for Payer: Cofinity Advantage |
$65.30
|
| Rate for Payer: Cofinity Commercial |
$80.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.62
|
| Rate for Payer: Healthscope Commercial |
$83.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$69.96
|
| Rate for Payer: PHP Commercial |
$79.29
|
| Rate for Payer: Priority Health SBD |
$58.77
|
| Rate for Payer: UMR Bronson Commercial |
$41.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69.96
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$3,256.74
|
|
|
Service Code
|
MSDRG 795
|
| Min. Negotiated Rate |
$1,831.47 |
| Max. Negotiated Rate |
$3,256.74 |
| Rate for Payer: Aetna Medicare |
$2,354.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,829.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,829.80
|
| Rate for Payer: BCBS MAPPO |
$2,263.84
|
| Rate for Payer: BCBS Trust/PPO |
$3,014.12
|
| Rate for Payer: BCN Commercial |
$3,014.12
|
| Rate for Payer: BCN Medicare Advantage |
$2,263.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,263.84
|
| Rate for Payer: Mclaren Medicare |
$2,263.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,377.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,603.42
|
| Rate for Payer: Molina Medicare/Medicaid |
$2,490.22
|
| Rate for Payer: Nomi Health Commercial |
$2,577.42
|
| Rate for Payer: PACE Medicare |
$2,150.65
|
| Rate for Payer: PACE SWMI |
$2,263.84
|
| Rate for Payer: PHP Medicare Advantage |
$2,263.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$2,289.34
|
| Rate for Payer: Priority Health Medicare |
$2,263.84
|
| Rate for Payer: Priority Health Tiered Network |
$1,831.47
|
| Rate for Payer: Railroad Medicare Medicare |
$2,263.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,256.74
|
| Rate for Payer: UHC Core |
$2,724.67
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$2,263.84
|
| Rate for Payer: UHC Exchange |
$2,225.17
|
| Rate for Payer: VA VA |
$2,263.84
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
OP
|
$324.30
|
|
|
Service Code
|
NDC 00093081001
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.99 |
| Max. Negotiated Rate |
$291.87 |
| Rate for Payer: Aetna American Axle |
$210.79
|
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna Medicare |
$162.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.79
|
| Rate for Payer: BCBS Complete |
$129.72
|
| Rate for Payer: Cash Price |
$259.44
|
| Rate for Payer: Cofinity Advantage |
$227.01
|
| Rate for Payer: Cofinity Commercial |
$278.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.44
|
| Rate for Payer: Healthscope Commercial |
$291.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$259.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$243.22
|
| Rate for Payer: PHP Commercial |
$275.65
|
| Rate for Payer: Priority Health SBD |
$204.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.79
|
| Rate for Payer: UHC Core |
$168.96
|
| Rate for Payer: UHC Exchange |
$127.45
|
| Rate for Payer: UMR Bronson Commercial |
$119.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.22
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$227.95
|
|
|
Service Code
|
NDC 51672400101
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna American Axle |
$148.17
|
| Rate for Payer: Aetna Commercial |
$193.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.17
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Advantage |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.36
|
| Rate for Payer: Healthscope Commercial |
$205.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$170.96
|
| Rate for Payer: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health SBD |
$143.61
|
| Rate for Payer: UMR Bronson Commercial |
$100.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.96
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$324.30
|
|
|
Service Code
|
NDC 00093081001
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.69 |
| Max. Negotiated Rate |
$291.87 |
| Rate for Payer: Aetna American Axle |
$210.79
|
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.79
|
| Rate for Payer: Cash Price |
$259.44
|
| Rate for Payer: Cofinity Advantage |
$227.01
|
| Rate for Payer: Cofinity Commercial |
$278.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.44
|
| Rate for Payer: Healthscope Commercial |
$291.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$243.22
|
| Rate for Payer: PHP Commercial |
$275.65
|
| Rate for Payer: Priority Health SBD |
$204.31
|
| Rate for Payer: UMR Bronson Commercial |
$142.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.22
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
OP
|
$425.35
|
|
|
Service Code
|
NDC 51862094501
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.38 |
| Max. Negotiated Rate |
$382.81 |
| Rate for Payer: Aetna American Axle |
$276.48
|
| Rate for Payer: Aetna Commercial |
$361.55
|
| Rate for Payer: Aetna Medicare |
$212.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.48
|
| Rate for Payer: BCBS Complete |
$170.14
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Advantage |
$297.75
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$382.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$340.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.01
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health SBD |
$267.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.48
|
| Rate for Payer: UHC Core |
$221.61
|
| Rate for Payer: UHC Exchange |
$167.16
|
| Rate for Payer: UMR Bronson Commercial |
$157.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.01
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$425.35
|
|
|
Service Code
|
NDC 51862094501
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.15 |
| Max. Negotiated Rate |
$382.81 |
| Rate for Payer: Aetna American Axle |
$276.48
|
| Rate for Payer: Aetna Commercial |
$361.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.48
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Advantage |
$297.75
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$382.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.01
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health SBD |
$267.97
|
| Rate for Payer: UMR Bronson Commercial |
$187.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.01
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
OP
|
$227.95
|
|
|
Service Code
|
NDC 51672400101
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.34 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna American Axle |
$148.17
|
| Rate for Payer: Aetna Commercial |
$193.76
|
| Rate for Payer: Aetna Medicare |
$113.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.17
|
| Rate for Payer: BCBS Complete |
$91.18
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Advantage |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.36
|
| Rate for Payer: Healthscope Commercial |
$205.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$182.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$170.96
|
| Rate for Payer: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health SBD |
$143.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$148.17
|
| Rate for Payer: UHC Core |
$118.76
|
| Rate for Payer: UHC Exchange |
$89.58
|
| Rate for Payer: UMR Bronson Commercial |
$84.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.96
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$281.30
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.77 |
| Max. Negotiated Rate |
$253.17 |
| Rate for Payer: Aetna American Axle |
$182.84
|
| Rate for Payer: Aetna Commercial |
$239.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.84
|
| Rate for Payer: Cash Price |
$225.04
|
| Rate for Payer: Cofinity Advantage |
$196.91
|
| Rate for Payer: Cofinity Commercial |
$241.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.04
|
| Rate for Payer: Healthscope Commercial |
$253.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$210.97
|
| Rate for Payer: PHP Commercial |
$239.10
|
| Rate for Payer: Priority Health SBD |
$177.22
|
| Rate for Payer: UMR Bronson Commercial |
$123.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.97
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$206.80
|
|
|
Service Code
|
NDC 51672400201
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$186.12 |
| Rate for Payer: Aetna American Axle |
$134.42
|
| Rate for Payer: Aetna Commercial |
$175.78
|
| Rate for Payer: Aetna Medicare |
$103.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.42
|
| Rate for Payer: BCBS Complete |
$82.72
|
| Rate for Payer: Cash Price |
$165.44
|
| Rate for Payer: Cofinity Advantage |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$177.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.44
|
| Rate for Payer: Healthscope Commercial |
$186.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$165.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$155.10
|
| Rate for Payer: PHP Commercial |
$175.78
|
| Rate for Payer: Priority Health SBD |
$130.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$134.42
|
| Rate for Payer: UHC Core |
$107.74
|
| Rate for Payer: UHC Exchange |
$81.27
|
| Rate for Payer: UMR Bronson Commercial |
$76.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.10
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$281.30
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.08 |
| Max. Negotiated Rate |
$253.17 |
| Rate for Payer: Aetna American Axle |
$182.84
|
| Rate for Payer: Aetna Commercial |
$239.10
|
| Rate for Payer: Aetna Medicare |
$140.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.84
|
| Rate for Payer: BCBS Complete |
$112.52
|
| Rate for Payer: Cash Price |
$225.04
|
| Rate for Payer: Cofinity Advantage |
$196.91
|
| Rate for Payer: Cofinity Commercial |
$241.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.04
|
| Rate for Payer: Healthscope Commercial |
$253.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$225.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$210.97
|
| Rate for Payer: PHP Commercial |
$239.10
|
| Rate for Payer: Priority Health SBD |
$177.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$182.84
|
| Rate for Payer: UHC Core |
$146.56
|
| Rate for Payer: UHC Exchange |
$110.55
|
| Rate for Payer: UMR Bronson Commercial |
$104.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.97
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$385.40
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.60 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna American Axle |
$250.51
|
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna Medicare |
$192.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: BCBS Complete |
$154.16
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Advantage |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health SBD |
$242.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.51
|
| Rate for Payer: UHC Core |
$200.79
|
| Rate for Payer: UHC Exchange |
$151.46
|
| Rate for Payer: UMR Bronson Commercial |
$142.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$206.80
|
|
|
Service Code
|
NDC 51672400201
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.99 |
| Max. Negotiated Rate |
$186.12 |
| Rate for Payer: Aetna American Axle |
$134.42
|
| Rate for Payer: Aetna Commercial |
$175.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.42
|
| Rate for Payer: Cash Price |
$165.44
|
| Rate for Payer: Cofinity Advantage |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$177.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.44
|
| Rate for Payer: Healthscope Commercial |
$186.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$155.10
|
| Rate for Payer: PHP Commercial |
$175.78
|
| Rate for Payer: Priority Health SBD |
$130.28
|
| Rate for Payer: UMR Bronson Commercial |
$90.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.10
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.58 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna American Axle |
$250.51
|
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Advantage |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health SBD |
$242.80
|
| Rate for Payer: UMR Bronson Commercial |
$169.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
NOVASOURCE RENAL BOLUS FEED
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
150853
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NOVASOURCE RENAL BOLUS FEED
|
Facility
|
OP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
150853
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna Medicare |
$3.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: BCBS Complete |
$2.73
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.44
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$2.68
|
| Rate for Payer: UMR Bronson Commercial |
$2.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NOVASOURCE RENAL CONTINUOUS FEED
|
Facility
|
OP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
168945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna Medicare |
$3.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: BCBS Complete |
$2.73
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.44
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$2.68
|
| Rate for Payer: UMR Bronson Commercial |
$2.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NOVASOURCE RENAL CONTINUOUS FEED
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
168945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NOVASOURCE RENAL CYCLIC FEED
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
200087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NOVASOURCE RENAL CYCLIC FEED
|
Facility
|
OP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
200087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna Medicare |
$3.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: BCBS Complete |
$2.73
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.44
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$2.68
|
| Rate for Payer: UMR Bronson Commercial |
$2.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NOVASOURCE RENAL INTERMITTENT FEED
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
200086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
