|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$6.48
|
|
|
Service Code
|
NDC 00135019408
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: Aetna American Axle |
$4.21
|
| Rate for Payer: Aetna Commercial |
$5.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.21
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cofinity Commercial |
$4.54
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.18
|
| Rate for Payer: Healthscope Commercial |
$5.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.51
|
| Rate for Payer: PHP Commercial |
$5.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.21
|
| Rate for Payer: Priority Health SBD |
$4.08
|
| Rate for Payer: UMR Bronson Commercial |
$2.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.86
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$284.70
|
|
|
Service Code
|
NDC 00135019403
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.27 |
| Max. Negotiated Rate |
$256.23 |
| Rate for Payer: Aetna American Axle |
$185.06
|
| Rate for Payer: Aetna Commercial |
$242.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.06
|
| Rate for Payer: Cash Price |
$227.76
|
| Rate for Payer: Cofinity Commercial |
$199.29
|
| Rate for Payer: Cofinity Commercial |
$244.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.76
|
| Rate for Payer: Healthscope Commercial |
$256.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.00
|
| Rate for Payer: PHP Commercial |
$242.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.06
|
| Rate for Payer: Priority Health SBD |
$179.36
|
| Rate for Payer: UMR Bronson Commercial |
$125.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.53
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$170.53
|
|
|
Service Code
|
NDC 00766142020
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.03 |
| Max. Negotiated Rate |
$153.48 |
| Rate for Payer: Aetna American Axle |
$110.84
|
| Rate for Payer: Aetna Commercial |
$144.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.84
|
| Rate for Payer: Cash Price |
$136.42
|
| Rate for Payer: Cofinity Commercial |
$119.37
|
| Rate for Payer: Cofinity Commercial |
$146.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$119.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.42
|
| Rate for Payer: Healthscope Commercial |
$153.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.95
|
| Rate for Payer: PHP Commercial |
$144.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.84
|
| Rate for Payer: Priority Health SBD |
$107.43
|
| Rate for Payer: UMR Bronson Commercial |
$75.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.90
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.86
|
|
|
Service Code
|
NDC 60505709000
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.98 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Aetna American Axle |
$75.31
|
| Rate for Payer: Aetna Commercial |
$98.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.31
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cofinity Commercial |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$99.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.69
|
| Rate for Payer: Healthscope Commercial |
$104.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.48
|
| Rate for Payer: PHP Commercial |
$98.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.31
|
| Rate for Payer: Priority Health SBD |
$72.99
|
| Rate for Payer: UMR Bronson Commercial |
$50.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.89
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$95.09
|
|
|
Service Code
|
NDC 00536589688
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.18 |
| Max. Negotiated Rate |
$85.58 |
| Rate for Payer: Aetna American Axle |
$61.81
|
| Rate for Payer: Aetna Commercial |
$80.83
|
| Rate for Payer: Aetna Medicare |
$47.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.81
|
| Rate for Payer: BCBS Complete |
$38.04
|
| Rate for Payer: Cash Price |
$76.07
|
| Rate for Payer: Cofinity Commercial |
$66.56
|
| Rate for Payer: Cofinity Commercial |
$81.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.07
|
| Rate for Payer: Healthscope Commercial |
$85.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.83
|
| Rate for Payer: PHP Commercial |
$80.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.81
|
| Rate for Payer: Priority Health SBD |
$59.91
|
| Rate for Payer: UMR Bronson Commercial |
$35.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.32
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$115.86
|
|
|
Service Code
|
NDC 60505709000
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.87 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Aetna American Axle |
$75.31
|
| Rate for Payer: Aetna Commercial |
$98.48
|
| Rate for Payer: Aetna Medicare |
$57.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.31
|
| Rate for Payer: BCBS Complete |
$46.34
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cofinity Commercial |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$99.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.69
|
| Rate for Payer: Healthscope Commercial |
$104.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.48
|
| Rate for Payer: PHP Commercial |
$98.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.31
|
| Rate for Payer: Priority Health SBD |
$72.99
|
| Rate for Payer: UMR Bronson Commercial |
$42.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.89
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$121.91
|
|
|
Service Code
|
NDC 48985000152
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.11 |
| Max. Negotiated Rate |
$109.72 |
| Rate for Payer: Aetna American Axle |
$79.24
|
| Rate for Payer: Aetna Commercial |
$103.62
|
| Rate for Payer: Aetna Medicare |
$60.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.24
|
| Rate for Payer: BCBS Complete |
$48.76
|
| Rate for Payer: Cash Price |
$97.53
|
| Rate for Payer: Cofinity Commercial |
$104.84
|
| Rate for Payer: Cofinity Commercial |
$85.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$85.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.53
|
| Rate for Payer: Healthscope Commercial |
$109.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$103.62
|
| Rate for Payer: PHP Commercial |
$103.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.24
|
| Rate for Payer: Priority Health SBD |
$76.80
|
| Rate for Payer: UMR Bronson Commercial |
$45.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.43
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$170.53
|
|
|
Service Code
|
NDC 00766142020
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.10 |
| Max. Negotiated Rate |
$153.48 |
| Rate for Payer: Aetna American Axle |
$110.84
|
| Rate for Payer: Aetna Commercial |
$144.95
|
| Rate for Payer: Aetna Medicare |
$85.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.84
|
| Rate for Payer: BCBS Complete |
$68.21
|
| Rate for Payer: Cash Price |
$136.42
|
| Rate for Payer: Cofinity Commercial |
$119.37
|
| Rate for Payer: Cofinity Commercial |
$146.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$119.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.42
|
| Rate for Payer: Healthscope Commercial |
$153.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.95
|
| Rate for Payer: PHP Commercial |
$144.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.84
|
| Rate for Payer: Priority Health SBD |
$107.43
|
| Rate for Payer: UMR Bronson Commercial |
$63.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.90
|
|
|
NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$189.80
|
|
|
Service Code
|
NDC 00766145020
|
| Hospital Charge Code |
27863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.51 |
| Max. Negotiated Rate |
$170.82 |
| Rate for Payer: Aetna American Axle |
$123.37
|
| Rate for Payer: Aetna Commercial |
$161.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.37
|
| Rate for Payer: Cash Price |
$151.84
|
| Rate for Payer: Cofinity Commercial |
$132.86
|
| Rate for Payer: Cofinity Commercial |
$163.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.84
|
| Rate for Payer: Healthscope Commercial |
$170.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.33
|
| Rate for Payer: PHP Commercial |
$161.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.37
|
| Rate for Payer: Priority Health SBD |
$119.57
|
| Rate for Payer: UMR Bronson Commercial |
$83.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.35
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$115.86
|
|
|
Service Code
|
NDC 60505708800
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.87 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Aetna American Axle |
$75.31
|
| Rate for Payer: Aetna Commercial |
$98.48
|
| Rate for Payer: Aetna Medicare |
$57.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.31
|
| Rate for Payer: BCBS Complete |
$46.34
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cofinity Commercial |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$99.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.69
|
| Rate for Payer: Healthscope Commercial |
$104.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.48
|
| Rate for Payer: PHP Commercial |
$98.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.31
|
| Rate for Payer: Priority Health SBD |
$72.99
|
| Rate for Payer: UMR Bronson Commercial |
$42.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.89
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$8.28
|
|
|
Service Code
|
NDC 60505706100
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna American Axle |
$5.38
|
| Rate for Payer: Aetna Commercial |
$7.04
|
| Rate for Payer: Aetna Medicare |
$4.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.38
|
| Rate for Payer: BCBS Complete |
$3.31
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$5.80
|
| Rate for Payer: Cofinity Commercial |
$7.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$7.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.04
|
| Rate for Payer: PHP Commercial |
$7.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.38
|
| Rate for Payer: Priority Health SBD |
$5.22
|
| Rate for Payer: UMR Bronson Commercial |
$3.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.21
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$112.50
|
|
|
Service Code
|
NDC 00536110688
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.62 |
| Max. Negotiated Rate |
$101.25 |
| Rate for Payer: Aetna American Axle |
$73.12
|
| Rate for Payer: Aetna Commercial |
$95.62
|
| Rate for Payer: Aetna Medicare |
$56.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.12
|
| Rate for Payer: BCBS Complete |
$45.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cofinity Commercial |
$78.75
|
| Rate for Payer: Cofinity Commercial |
$96.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.00
|
| Rate for Payer: Healthscope Commercial |
$101.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.62
|
| Rate for Payer: PHP Commercial |
$95.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$73.12
|
| Rate for Payer: Priority Health SBD |
$70.88
|
| Rate for Payer: UMR Bronson Commercial |
$41.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.38
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$8.28
|
|
|
Service Code
|
NDC 60505706100
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna American Axle |
$5.38
|
| Rate for Payer: Aetna Commercial |
$7.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.38
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$5.80
|
| Rate for Payer: Cofinity Commercial |
$7.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$7.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.04
|
| Rate for Payer: PHP Commercial |
$7.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.38
|
| Rate for Payer: Priority Health SBD |
$5.22
|
| Rate for Payer: UMR Bronson Commercial |
$3.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.21
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$115.86
|
|
|
Service Code
|
NDC 60505708800
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.98 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Aetna American Axle |
$75.31
|
| Rate for Payer: Aetna Commercial |
$98.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.31
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cofinity Commercial |
$81.10
|
| Rate for Payer: Cofinity Commercial |
$99.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.69
|
| Rate for Payer: Healthscope Commercial |
$104.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.48
|
| Rate for Payer: PHP Commercial |
$98.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.31
|
| Rate for Payer: Priority Health SBD |
$72.99
|
| Rate for Payer: UMR Bronson Commercial |
$50.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.89
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
OP
|
$106.92
|
|
|
Service Code
|
NDC 00536589488
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.56 |
| Max. Negotiated Rate |
$96.23 |
| Rate for Payer: Aetna American Axle |
$69.50
|
| Rate for Payer: Aetna Commercial |
$90.88
|
| Rate for Payer: Aetna Medicare |
$53.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.50
|
| Rate for Payer: BCBS Complete |
$42.77
|
| Rate for Payer: Cash Price |
$85.54
|
| Rate for Payer: Cofinity Commercial |
$74.84
|
| Rate for Payer: Cofinity Commercial |
$91.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.54
|
| Rate for Payer: Healthscope Commercial |
$96.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.88
|
| Rate for Payer: PHP Commercial |
$90.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.50
|
| Rate for Payer: Priority Health SBD |
$67.36
|
| Rate for Payer: UMR Bronson Commercial |
$39.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.19
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$106.92
|
|
|
Service Code
|
NDC 00536589488
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$96.23 |
| Rate for Payer: Aetna American Axle |
$69.50
|
| Rate for Payer: Aetna Commercial |
$90.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.50
|
| Rate for Payer: Cash Price |
$85.54
|
| Rate for Payer: Cofinity Commercial |
$74.84
|
| Rate for Payer: Cofinity Commercial |
$91.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.54
|
| Rate for Payer: Healthscope Commercial |
$96.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.88
|
| Rate for Payer: PHP Commercial |
$90.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.50
|
| Rate for Payer: Priority Health SBD |
$67.36
|
| Rate for Payer: UMR Bronson Commercial |
$47.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.19
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH
|
Facility
|
IP
|
$112.50
|
|
|
Service Code
|
NDC 00536110688
|
| Hospital Charge Code |
27860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$101.25 |
| Rate for Payer: Aetna American Axle |
$73.12
|
| Rate for Payer: Aetna Commercial |
$95.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.12
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cofinity Commercial |
$78.75
|
| Rate for Payer: Cofinity Commercial |
$96.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.00
|
| Rate for Payer: Healthscope Commercial |
$101.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.62
|
| Rate for Payer: PHP Commercial |
$95.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$73.12
|
| Rate for Payer: Priority Health SBD |
$70.88
|
| Rate for Payer: UMR Bronson Commercial |
$49.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.38
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE
|
Facility
|
IP
|
$247.61
|
|
|
Service Code
|
NDC 45802034405
|
| Hospital Charge Code |
34769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.95 |
| Max. Negotiated Rate |
$222.85 |
| Rate for Payer: Aetna American Axle |
$160.95
|
| Rate for Payer: Aetna Commercial |
$210.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.95
|
| Rate for Payer: Cash Price |
$198.09
|
| Rate for Payer: Cofinity Commercial |
$173.33
|
| Rate for Payer: Cofinity Commercial |
$212.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.09
|
| Rate for Payer: Healthscope Commercial |
$222.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.47
|
| Rate for Payer: PHP Commercial |
$210.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.95
|
| Rate for Payer: Priority Health SBD |
$155.99
|
| Rate for Payer: UMR Bronson Commercial |
$108.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.71
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE
|
Facility
|
OP
|
$247.61
|
|
|
Service Code
|
NDC 45802034405
|
| Hospital Charge Code |
34769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.62 |
| Max. Negotiated Rate |
$222.85 |
| Rate for Payer: Aetna American Axle |
$160.95
|
| Rate for Payer: Aetna Commercial |
$210.47
|
| Rate for Payer: Aetna Medicare |
$123.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.95
|
| Rate for Payer: BCBS Complete |
$99.04
|
| Rate for Payer: Cash Price |
$198.09
|
| Rate for Payer: Cofinity Commercial |
$173.33
|
| Rate for Payer: Cofinity Commercial |
$212.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.09
|
| Rate for Payer: Healthscope Commercial |
$222.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.47
|
| Rate for Payer: PHP Commercial |
$210.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.95
|
| Rate for Payer: Priority Health SBD |
$155.99
|
| Rate for Payer: UMR Bronson Commercial |
$91.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.71
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$289.34
|
|
|
Service Code
|
NDC 45802008902
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.31 |
| Max. Negotiated Rate |
$260.41 |
| Rate for Payer: Aetna American Axle |
$188.07
|
| Rate for Payer: Aetna Commercial |
$245.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.07
|
| Rate for Payer: Cash Price |
$231.47
|
| Rate for Payer: Cofinity Commercial |
$202.54
|
| Rate for Payer: Cofinity Commercial |
$248.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.47
|
| Rate for Payer: Healthscope Commercial |
$260.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.94
|
| Rate for Payer: PHP Commercial |
$245.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.07
|
| Rate for Payer: Priority Health SBD |
$182.28
|
| Rate for Payer: UMR Bronson Commercial |
$127.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.00
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
IP
|
$96.45
|
|
|
Service Code
|
NDC 45802008901
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$86.81 |
| Rate for Payer: Aetna American Axle |
$62.69
|
| Rate for Payer: Aetna Commercial |
$81.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.69
|
| Rate for Payer: Cash Price |
$77.16
|
| Rate for Payer: Cofinity Commercial |
$67.52
|
| Rate for Payer: Cofinity Commercial |
$82.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.16
|
| Rate for Payer: Healthscope Commercial |
$86.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.98
|
| Rate for Payer: PHP Commercial |
$81.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.69
|
| Rate for Payer: Priority Health SBD |
$60.76
|
| Rate for Payer: UMR Bronson Commercial |
$42.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.34
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
OP
|
$96.45
|
|
|
Service Code
|
NDC 45802008901
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.69 |
| Max. Negotiated Rate |
$86.81 |
| Rate for Payer: Aetna American Axle |
$62.69
|
| Rate for Payer: Aetna Commercial |
$81.98
|
| Rate for Payer: Aetna Medicare |
$48.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.69
|
| Rate for Payer: BCBS Complete |
$38.58
|
| Rate for Payer: Cash Price |
$77.16
|
| Rate for Payer: Cofinity Commercial |
$67.52
|
| Rate for Payer: Cofinity Commercial |
$82.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.16
|
| Rate for Payer: Healthscope Commercial |
$86.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.98
|
| Rate for Payer: PHP Commercial |
$81.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.69
|
| Rate for Payer: Priority Health SBD |
$60.76
|
| Rate for Payer: UMR Bronson Commercial |
$35.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.34
|
|
|
NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE
|
Facility
|
OP
|
$289.34
|
|
|
Service Code
|
NDC 45802008902
|
| Hospital Charge Code |
182298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.06 |
| Max. Negotiated Rate |
$260.41 |
| Rate for Payer: Aetna American Axle |
$188.07
|
| Rate for Payer: Aetna Commercial |
$245.94
|
| Rate for Payer: Aetna Medicare |
$144.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.07
|
| Rate for Payer: BCBS Complete |
$115.74
|
| Rate for Payer: Cash Price |
$231.47
|
| Rate for Payer: Cofinity Commercial |
$202.54
|
| Rate for Payer: Cofinity Commercial |
$248.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.47
|
| Rate for Payer: Healthscope Commercial |
$260.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.94
|
| Rate for Payer: PHP Commercial |
$245.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.07
|
| Rate for Payer: Priority Health SBD |
$182.28
|
| Rate for Payer: UMR Bronson Commercial |
$107.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.00
|
|
|
NIFEDIPINE 10 MG CAPSULE
|
Facility
|
IP
|
$382.08
|
|
|
Service Code
|
NDC 00904722961
|
| Hospital Charge Code |
5558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.12 |
| Max. Negotiated Rate |
$343.87 |
| Rate for Payer: Aetna American Axle |
$248.35
|
| Rate for Payer: Aetna Commercial |
$324.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.35
|
| Rate for Payer: Cash Price |
$305.66
|
| Rate for Payer: Cofinity Commercial |
$267.46
|
| Rate for Payer: Cofinity Commercial |
$328.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$267.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.66
|
| Rate for Payer: Healthscope Commercial |
$343.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$267.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$286.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.77
|
| Rate for Payer: PHP Commercial |
$324.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.35
|
| Rate for Payer: Priority Health SBD |
$240.71
|
| Rate for Payer: UMR Bronson Commercial |
$168.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.56
|
|
|
NIFEDIPINE 10 MG CAPSULE
|
Facility
|
OP
|
$3.49
|
|
|
Service Code
|
NDC 68084002211
|
| Hospital Charge Code |
5558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Aetna American Axle |
$2.27
|
| Rate for Payer: Aetna Commercial |
$2.97
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.27
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: Cash Price |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$3.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.79
|
| Rate for Payer: Healthscope Commercial |
$3.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.97
|
| Rate for Payer: PHP Commercial |
$2.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.27
|
| Rate for Payer: Priority Health SBD |
$2.20
|
| Rate for Payer: UMR Bronson Commercial |
$1.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.62
|
|
