|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 81298965503
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna American Axle |
$18.20
|
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Aetna Medicare |
$14.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.20
|
| Rate for Payer: BCBS Complete |
$11.20
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: Cofinity Commercial |
$19.60
|
| Rate for Payer: Cofinity Commercial |
$24.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.40
|
| Rate for Payer: Healthscope Commercial |
$25.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.80
|
| Rate for Payer: PHP Commercial |
$23.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.20
|
| Rate for Payer: Priority Health SBD |
$17.64
|
| Rate for Payer: UMR Bronson Commercial |
$10.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.00
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 81298965501
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna American Axle |
$18.20
|
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.20
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: Cofinity Commercial |
$19.60
|
| Rate for Payer: Cofinity Commercial |
$24.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.40
|
| Rate for Payer: Healthscope Commercial |
$25.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.80
|
| Rate for Payer: PHP Commercial |
$23.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.20
|
| Rate for Payer: Priority Health SBD |
$17.64
|
| Rate for Payer: UMR Bronson Commercial |
$12.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.00
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$28.25
|
|
|
Service Code
|
NDC 44567064110
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$25.42 |
| Rate for Payer: Aetna American Axle |
$18.36
|
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna Medicare |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: BCBS Complete |
$11.30
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.36
|
| Rate for Payer: Priority Health SBD |
$17.80
|
| Rate for Payer: UMR Bronson Commercial |
$10.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.19
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$28.25
|
|
|
Service Code
|
NDC 44567064101
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$25.42 |
| Rate for Payer: Aetna American Axle |
$18.36
|
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna Medicare |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: BCBS Complete |
$11.30
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.36
|
| Rate for Payer: Priority Health SBD |
$17.80
|
| Rate for Payer: UMR Bronson Commercial |
$10.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.19
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$28.25
|
|
|
Service Code
|
NDC 44567064110
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$25.42 |
| Rate for Payer: Aetna American Axle |
$18.36
|
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.36
|
| Rate for Payer: Priority Health SBD |
$17.80
|
| Rate for Payer: UMR Bronson Commercial |
$12.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.19
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$28.25
|
|
|
Service Code
|
NDC 44567064101
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$25.42 |
| Rate for Payer: Aetna American Axle |
$18.36
|
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.36
|
| Rate for Payer: Priority Health SBD |
$17.80
|
| Rate for Payer: UMR Bronson Commercial |
$12.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.19
|
|
|
NORETHINDRONE ACETATE 5 MG TABLET
|
Facility
|
IP
|
$133.92
|
|
|
Service Code
|
NDC 68462030450
|
| 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 Commercial |
$115.17
|
| Rate for Payer: Cofinity Commercial |
$93.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.74
|
| 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: PHP Commercial |
$113.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.05
|
| 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
|
|
|
NORETHINDRONE ACETATE 5 MG TABLET
|
Facility
|
OP
|
$133.92
|
|
|
Service Code
|
NDC 68462030450
|
| Hospital Charge Code |
10747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.55 |
| Max. Negotiated Rate |
$120.53 |
| Rate for Payer: Aetna American Axle |
$87.05
|
| Rate for Payer: Aetna Commercial |
$113.83
|
| Rate for Payer: Aetna Medicare |
$66.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.05
|
| Rate for Payer: BCBS Complete |
$53.57
|
| Rate for Payer: Cash Price |
$107.14
|
| Rate for Payer: Cofinity Commercial |
$115.17
|
| Rate for Payer: Cofinity Commercial |
$93.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.74
|
| 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: PHP Commercial |
$113.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.05
|
| Rate for Payer: Priority Health SBD |
$84.37
|
| Rate for Payer: UMR Bronson Commercial |
$49.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.44
|
|
|
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 35 MCG TABLET
|
Facility
|
IP
|
$28.18
|
|
|
Service Code
|
NDC 00555901658
|
| Hospital Charge Code |
10749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$25.36 |
| Rate for Payer: Aetna American Axle |
$18.32
|
| Rate for Payer: Aetna Commercial |
$23.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.32
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Cofinity Commercial |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$24.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.54
|
| Rate for Payer: Healthscope Commercial |
$25.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.95
|
| Rate for Payer: PHP Commercial |
$23.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.32
|
| Rate for Payer: Priority Health SBD |
$17.75
|
| Rate for Payer: UMR Bronson Commercial |
$12.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.14
|
|
|
NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 35 MCG TABLET
|
Facility
|
OP
|
$28.18
|
|
|
Service Code
|
NDC 00555901658
|
| Hospital Charge Code |
10749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$25.36 |
| Rate for Payer: Aetna American Axle |
$18.32
|
| Rate for Payer: Aetna Commercial |
$23.95
|
| Rate for Payer: Aetna Medicare |
$14.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.32
|
| Rate for Payer: BCBS Complete |
$11.27
|
| Rate for Payer: Cash Price |
$22.54
|
| Rate for Payer: Cofinity Commercial |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$24.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.54
|
| Rate for Payer: Healthscope Commercial |
$25.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.95
|
| Rate for Payer: PHP Commercial |
$23.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.32
|
| Rate for Payer: Priority Health SBD |
$17.75
|
| Rate for Payer: UMR Bronson Commercial |
$10.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.14
|
|
|
NORGESTIMATE-ETHINYL ESTRADIOL 0.18 MG/0.215MG/0.25MG-35 MCG(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 Commercial |
$65.30
|
| Rate for Payer: Cofinity Commercial |
$80.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.30
|
| 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: PHP Commercial |
$79.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.63
|
| 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
|
|
|
NORGESTIMATE-ETHINYL ESTRADIOL 0.18 MG/0.215MG/0.25MG-35 MCG(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 Commercial |
$65.30
|
| Rate for Payer: Cofinity Commercial |
$80.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.30
|
| 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: PHP Commercial |
$79.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.63
|
| Rate for Payer: Priority Health SBD |
$58.77
|
| Rate for Payer: UMR Bronson Commercial |
$34.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69.96
|
|
|
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 |
$382.82 |
| 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 Commercial |
$297.74
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$382.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.48
|
| 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
|
$270.25
|
|
|
Service Code
|
NDC 00093081001
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.99 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna American Axle |
$175.66
|
| Rate for Payer: Aetna Commercial |
$229.71
|
| Rate for Payer: Aetna Medicare |
$135.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.66
|
| Rate for Payer: BCBS Complete |
$108.10
|
| Rate for Payer: Cash Price |
$216.20
|
| Rate for Payer: Cofinity Commercial |
$189.18
|
| Rate for Payer: Cofinity Commercial |
$232.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$189.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.20
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.71
|
| Rate for Payer: PHP Commercial |
$229.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.66
|
| Rate for Payer: Priority Health SBD |
$170.26
|
| Rate for Payer: UMR Bronson Commercial |
$99.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.69
|
|
|
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 |
$382.82 |
| 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 Commercial |
$297.74
|
| Rate for Payer: Cofinity Commercial |
$365.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$382.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: PHP Commercial |
$361.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.48
|
| Rate for Payer: Priority Health SBD |
$267.97
|
| 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
|
$270.25
|
|
|
Service Code
|
NDC 00093081001
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.91 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna American Axle |
$175.66
|
| Rate for Payer: Aetna Commercial |
$229.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.66
|
| Rate for Payer: Cash Price |
$216.20
|
| Rate for Payer: Cofinity Commercial |
$189.18
|
| Rate for Payer: Cofinity Commercial |
$232.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$189.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.20
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.71
|
| Rate for Payer: PHP Commercial |
$229.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.66
|
| Rate for Payer: Priority Health SBD |
$170.26
|
| Rate for Payer: UMR Bronson Commercial |
$118.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.69
|
|
|
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 Commercial |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.56
|
| 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: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.17
|
| 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
|
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 |
$113.98
|
| 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 Commercial |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.56
|
| 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: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.17
|
| Rate for Payer: Priority Health SBD |
$143.61
|
| 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 Commercial |
$196.91
|
| Rate for Payer: Cofinity Commercial |
$241.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.91
|
| 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 |
$210.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: PHP Commercial |
$239.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.84
|
| 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 |
$210.98
|
|
|
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 Commercial |
$196.91
|
| Rate for Payer: Cofinity Commercial |
$241.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.91
|
| 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 |
$210.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: PHP Commercial |
$239.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.84
|
| Rate for Payer: Priority Health SBD |
$177.22
|
| Rate for Payer: UMR Bronson Commercial |
$104.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.98
|
|
|
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 Commercial |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$177.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.76
|
| 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: PHP Commercial |
$175.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.42
|
| Rate for Payer: Priority Health SBD |
$130.28
|
| 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
|
$321.95
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.12 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna Medicare |
$160.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$119.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$141.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
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 Commercial |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$177.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.76
|
| 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: PHP Commercial |
$175.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.42
|
| 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
|
|
|
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 Commercial |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.78
|
| 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: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.44
|
| 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
|
|
