|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$105.14
|
|
|
Service Code
|
NDC 60505056001
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.90 |
| Max. Negotiated Rate |
$94.63 |
| Rate for Payer: Cofinity Commercial |
$73.60
|
| Rate for Payer: Cofinity Commercial |
$90.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.60
|
| Rate for Payer: Aetna American Axle |
$68.34
|
| Rate for Payer: Aetna Commercial |
$89.37
|
| Rate for Payer: Aetna Medicare |
$52.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.34
|
| Rate for Payer: BCBS Complete |
$42.06
|
| Rate for Payer: Cash Price |
$84.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.11
|
| Rate for Payer: Healthscope Commercial |
$94.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$73.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.37
|
| Rate for Payer: PHP Commercial |
$89.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.34
|
| Rate for Payer: Priority Health SBD |
$66.24
|
| Rate for Payer: UMR Bronson Commercial |
$38.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.86
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$26.04
|
|
|
Service Code
|
NDC 70756060730
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.46 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna American Axle |
$16.93
|
| Rate for Payer: Aetna Commercial |
$22.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.93
|
| Rate for Payer: Cash Price |
$20.83
|
| Rate for Payer: Cofinity Commercial |
$18.23
|
| Rate for Payer: Cofinity Commercial |
$22.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.83
|
| Rate for Payer: Healthscope Commercial |
$23.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.13
|
| Rate for Payer: PHP Commercial |
$22.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.93
|
| Rate for Payer: Priority Health SBD |
$16.41
|
| Rate for Payer: UMR Bronson Commercial |
$11.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.53
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$25.34
|
|
|
Service Code
|
NDC 64980051505
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$22.81 |
| Rate for Payer: Aetna American Axle |
$16.47
|
| Rate for Payer: Aetna Commercial |
$21.54
|
| Rate for Payer: Aetna Medicare |
$12.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.47
|
| Rate for Payer: BCBS Complete |
$10.14
|
| Rate for Payer: Cash Price |
$20.27
|
| Rate for Payer: Cofinity Commercial |
$17.74
|
| Rate for Payer: Cofinity Commercial |
$21.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.27
|
| Rate for Payer: Healthscope Commercial |
$22.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.54
|
| Rate for Payer: PHP Commercial |
$21.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.47
|
| Rate for Payer: Priority Health SBD |
$15.96
|
| Rate for Payer: UMR Bronson Commercial |
$9.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.00
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$25.34
|
|
|
Service Code
|
NDC 64980051505
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.15 |
| Max. Negotiated Rate |
$22.81 |
| Rate for Payer: Aetna American Axle |
$16.47
|
| Rate for Payer: Aetna Commercial |
$21.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.47
|
| Rate for Payer: Cash Price |
$20.27
|
| Rate for Payer: Cofinity Commercial |
$17.74
|
| Rate for Payer: Cofinity Commercial |
$21.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.27
|
| Rate for Payer: Healthscope Commercial |
$22.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.54
|
| Rate for Payer: PHP Commercial |
$21.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.47
|
| Rate for Payer: Priority Health SBD |
$15.96
|
| Rate for Payer: UMR Bronson Commercial |
$11.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.00
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$45.29
|
|
|
Service Code
|
NDC 64980051501
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.93 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Aetna American Axle |
$29.44
|
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.44
|
| Rate for Payer: Cash Price |
$36.23
|
| Rate for Payer: Cofinity Commercial |
$31.70
|
| Rate for Payer: Cofinity Commercial |
$38.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.23
|
| Rate for Payer: Healthscope Commercial |
$40.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.50
|
| Rate for Payer: PHP Commercial |
$38.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.44
|
| Rate for Payer: Priority Health SBD |
$28.53
|
| Rate for Payer: UMR Bronson Commercial |
$19.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.97
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$85.03
|
|
|
Service Code
|
NDC 00002445401
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.41 |
| Max. Negotiated Rate |
$76.53 |
| Rate for Payer: Aetna American Axle |
$55.27
|
| Rate for Payer: Aetna Commercial |
$72.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.27
|
| Rate for Payer: Cash Price |
$68.02
|
| Rate for Payer: Cofinity Commercial |
$59.52
|
| Rate for Payer: Cofinity Commercial |
$73.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$59.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.02
|
| Rate for Payer: Healthscope Commercial |
$76.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.28
|
| Rate for Payer: PHP Commercial |
$72.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.27
|
| Rate for Payer: Priority Health SBD |
$53.57
|
| Rate for Payer: UMR Bronson Commercial |
$37.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.77
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$8.75
|
|
|
Service Code
|
NDC 55111026379
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna American Axle |
$5.69
|
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.69
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cofinity Commercial |
$6.12
|
| Rate for Payer: Cofinity Commercial |
$7.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.00
|
| Rate for Payer: Healthscope Commercial |
$7.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.44
|
| Rate for Payer: PHP Commercial |
$7.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.69
|
| Rate for Payer: Priority Health SBD |
$5.51
|
| Rate for Payer: UMR Bronson Commercial |
$3.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.56
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$5.62
|
|
|
Service Code
|
NDC 49884032152
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Aetna American Axle |
$3.65
|
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.65
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cofinity Commercial |
$3.93
|
| Rate for Payer: Cofinity Commercial |
$4.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.50
|
| Rate for Payer: Healthscope Commercial |
$5.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.78
|
| Rate for Payer: PHP Commercial |
$4.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.65
|
| Rate for Payer: Priority Health SBD |
$3.54
|
| Rate for Payer: UMR Bronson Commercial |
$2.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.22
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$85.03
|
|
|
Service Code
|
NDC 00002445401
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$76.53 |
| Rate for Payer: Aetna American Axle |
$55.27
|
| Rate for Payer: Aetna Commercial |
$72.28
|
| Rate for Payer: Aetna Medicare |
$42.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.27
|
| Rate for Payer: BCBS Complete |
$34.01
|
| Rate for Payer: Cash Price |
$68.02
|
| Rate for Payer: Cofinity Commercial |
$59.52
|
| Rate for Payer: Cofinity Commercial |
$73.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$59.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.02
|
| Rate for Payer: Healthscope Commercial |
$76.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.28
|
| Rate for Payer: PHP Commercial |
$72.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.27
|
| Rate for Payer: Priority Health SBD |
$53.57
|
| Rate for Payer: UMR Bronson Commercial |
$31.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.77
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$168.34
|
|
|
Service Code
|
NDC 49884032155
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.29 |
| Max. Negotiated Rate |
$151.51 |
| Rate for Payer: Aetna American Axle |
$109.42
|
| Rate for Payer: Aetna Commercial |
$143.09
|
| Rate for Payer: Aetna Medicare |
$84.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.42
|
| Rate for Payer: BCBS Complete |
$67.34
|
| Rate for Payer: Cash Price |
$134.67
|
| Rate for Payer: Cofinity Commercial |
$117.84
|
| Rate for Payer: Cofinity Commercial |
$144.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.67
|
| Rate for Payer: Healthscope Commercial |
$151.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.09
|
| Rate for Payer: PHP Commercial |
$143.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.42
|
| Rate for Payer: Priority Health SBD |
$106.05
|
| Rate for Payer: UMR Bronson Commercial |
$62.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.26
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$169.35
|
|
|
Service Code
|
NDC 59746030732
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.51 |
| Max. Negotiated Rate |
$152.42 |
| Rate for Payer: Aetna American Axle |
$110.08
|
| Rate for Payer: Aetna Commercial |
$143.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.08
|
| Rate for Payer: Cash Price |
$135.48
|
| Rate for Payer: Cofinity Commercial |
$118.54
|
| Rate for Payer: Cofinity Commercial |
$145.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.48
|
| Rate for Payer: Healthscope Commercial |
$152.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.95
|
| Rate for Payer: PHP Commercial |
$143.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.08
|
| Rate for Payer: Priority Health SBD |
$106.69
|
| Rate for Payer: UMR Bronson Commercial |
$74.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.01
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$262.30
|
|
|
Service Code
|
NDC 55111026381
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.41 |
| Max. Negotiated Rate |
$236.07 |
| Rate for Payer: Cofinity Commercial |
$183.61
|
| Rate for Payer: Cofinity Commercial |
$225.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.61
|
| Rate for Payer: Aetna American Axle |
$170.50
|
| Rate for Payer: Aetna Commercial |
$222.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.50
|
| Rate for Payer: Cash Price |
$209.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.84
|
| Rate for Payer: Healthscope Commercial |
$236.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.96
|
| Rate for Payer: PHP Commercial |
$222.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.50
|
| Rate for Payer: Priority Health SBD |
$165.25
|
| Rate for Payer: UMR Bronson Commercial |
$115.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.72
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$118.56
|
|
|
Service Code
|
NDC 33342008407
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Aetna American Axle |
$77.06
|
| Rate for Payer: Aetna Commercial |
$100.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.06
|
| Rate for Payer: Cash Price |
$94.85
|
| Rate for Payer: Cofinity Commercial |
$101.96
|
| Rate for Payer: Cofinity Commercial |
$82.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$82.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.85
|
| Rate for Payer: Healthscope Commercial |
$106.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.78
|
| Rate for Payer: PHP Commercial |
$100.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.06
|
| Rate for Payer: Priority Health SBD |
$74.69
|
| Rate for Payer: UMR Bronson Commercial |
$52.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.92
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$118.56
|
|
|
Service Code
|
NDC 33342008407
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.87 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Aetna American Axle |
$77.06
|
| Rate for Payer: Aetna Commercial |
$100.78
|
| Rate for Payer: Aetna Medicare |
$59.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.06
|
| Rate for Payer: BCBS Complete |
$47.42
|
| Rate for Payer: Cash Price |
$94.85
|
| Rate for Payer: Cofinity Commercial |
$101.96
|
| Rate for Payer: Cofinity Commercial |
$82.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$82.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.85
|
| Rate for Payer: Healthscope Commercial |
$106.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.78
|
| Rate for Payer: PHP Commercial |
$100.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.06
|
| Rate for Payer: Priority Health SBD |
$74.69
|
| Rate for Payer: UMR Bronson Commercial |
$43.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.92
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$8.75
|
|
|
Service Code
|
NDC 55111026379
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna American Axle |
$5.69
|
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Aetna Medicare |
$4.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.69
|
| Rate for Payer: BCBS Complete |
$3.50
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cofinity Commercial |
$6.12
|
| Rate for Payer: Cofinity Commercial |
$7.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.00
|
| Rate for Payer: Healthscope Commercial |
$7.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.44
|
| Rate for Payer: PHP Commercial |
$7.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.69
|
| Rate for Payer: Priority Health SBD |
$5.51
|
| Rate for Payer: UMR Bronson Commercial |
$3.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.56
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$262.30
|
|
|
Service Code
|
NDC 55111026381
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.05 |
| Max. Negotiated Rate |
$236.07 |
| Rate for Payer: Aetna American Axle |
$170.50
|
| Rate for Payer: Aetna Commercial |
$222.96
|
| Rate for Payer: Aetna Medicare |
$131.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.50
|
| Rate for Payer: BCBS Complete |
$104.92
|
| Rate for Payer: Cash Price |
$209.84
|
| Rate for Payer: Cofinity Commercial |
$183.61
|
| Rate for Payer: Cofinity Commercial |
$225.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.84
|
| Rate for Payer: Healthscope Commercial |
$236.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.96
|
| Rate for Payer: PHP Commercial |
$222.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.50
|
| Rate for Payer: Priority Health SBD |
$165.25
|
| Rate for Payer: UMR Bronson Commercial |
$97.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.72
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$5.65
|
|
|
Service Code
|
NDC 59746030712
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$5.08 |
| Rate for Payer: Aetna American Axle |
$3.67
|
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.67
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cofinity Commercial |
$3.96
|
| Rate for Payer: Cofinity Commercial |
$4.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.52
|
| Rate for Payer: Healthscope Commercial |
$5.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.80
|
| Rate for Payer: PHP Commercial |
$4.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.67
|
| Rate for Payer: Priority Health SBD |
$3.56
|
| Rate for Payer: UMR Bronson Commercial |
$2.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.24
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$168.34
|
|
|
Service Code
|
NDC 49884032155
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.07 |
| Max. Negotiated Rate |
$151.51 |
| Rate for Payer: Aetna American Axle |
$109.42
|
| Rate for Payer: Aetna Commercial |
$143.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.42
|
| Rate for Payer: Cash Price |
$134.67
|
| Rate for Payer: Cofinity Commercial |
$117.84
|
| Rate for Payer: Cofinity Commercial |
$144.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.67
|
| Rate for Payer: Healthscope Commercial |
$151.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.09
|
| Rate for Payer: PHP Commercial |
$143.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.42
|
| Rate for Payer: Priority Health SBD |
$106.05
|
| Rate for Payer: UMR Bronson Commercial |
$74.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.26
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$169.35
|
|
|
Service Code
|
NDC 59746030732
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.66 |
| Max. Negotiated Rate |
$152.42 |
| Rate for Payer: Aetna American Axle |
$110.08
|
| Rate for Payer: Aetna Commercial |
$143.95
|
| Rate for Payer: Aetna Medicare |
$84.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.08
|
| Rate for Payer: BCBS Complete |
$67.74
|
| Rate for Payer: Cash Price |
$135.48
|
| Rate for Payer: Cofinity Commercial |
$118.54
|
| Rate for Payer: Cofinity Commercial |
$145.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.48
|
| Rate for Payer: Healthscope Commercial |
$152.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.95
|
| Rate for Payer: PHP Commercial |
$143.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.08
|
| Rate for Payer: Priority Health SBD |
$106.69
|
| Rate for Payer: UMR Bronson Commercial |
$62.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.01
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$5.62
|
|
|
Service Code
|
NDC 49884032152
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Aetna American Axle |
$3.65
|
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: Aetna Medicare |
$2.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.65
|
| Rate for Payer: BCBS Complete |
$2.25
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cofinity Commercial |
$3.93
|
| Rate for Payer: Cofinity Commercial |
$4.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.50
|
| Rate for Payer: Healthscope Commercial |
$5.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.78
|
| Rate for Payer: PHP Commercial |
$4.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.65
|
| Rate for Payer: Priority Health SBD |
$3.54
|
| Rate for Payer: UMR Bronson Commercial |
$2.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.22
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$5.65
|
|
|
Service Code
|
NDC 59746030712
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$5.08 |
| Rate for Payer: Aetna American Axle |
$3.67
|
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Aetna Medicare |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.67
|
| Rate for Payer: BCBS Complete |
$2.26
|
| Rate for Payer: Cash Price |
$4.52
|
| Rate for Payer: Cofinity Commercial |
$3.96
|
| Rate for Payer: Cofinity Commercial |
$4.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.52
|
| Rate for Payer: Healthscope Commercial |
$5.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.80
|
| Rate for Payer: PHP Commercial |
$4.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.67
|
| Rate for Payer: Priority Health SBD |
$3.56
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.24
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$113.84
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$102.46 |
| Rate for Payer: Aetna American Axle |
$74.00
|
| Rate for Payer: Aetna American Axle |
$35.03
|
| Rate for Payer: Aetna Commercial |
$45.81
|
| Rate for Payer: Aetna Commercial |
$96.76
|
| Rate for Payer: Aetna Medicare |
$56.92
|
| Rate for Payer: Aetna Medicare |
$26.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.03
|
| Rate for Payer: BCBS Complete |
$21.56
|
| Rate for Payer: BCBS Complete |
$45.54
|
| Rate for Payer: BCBS Trust/PPO |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.46
|
| Rate for Payer: BCN Commercial |
$2.46
|
| Rate for Payer: BCN Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Cash Price |
$91.07
|
| Rate for Payer: Cash Price |
$91.07
|
| Rate for Payer: Cofinity Commercial |
$46.35
|
| Rate for Payer: Cofinity Commercial |
$79.69
|
| Rate for Payer: Cofinity Commercial |
$37.72
|
| Rate for Payer: Cofinity Commercial |
$97.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$79.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.07
|
| Rate for Payer: Healthscope Commercial |
$48.50
|
| Rate for Payer: Healthscope Commercial |
$102.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$85.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$96.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.81
|
| Rate for Payer: PHP Commercial |
$96.76
|
| Rate for Payer: PHP Commercial |
$45.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.03
|
| Rate for Payer: Priority Health SBD |
$33.95
|
| Rate for Payer: Priority Health SBD |
$71.72
|
| Rate for Payer: UMR Bronson Commercial |
$42.12
|
| Rate for Payer: UMR Bronson Commercial |
$19.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$85.38
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$113.84
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.09 |
| Max. Negotiated Rate |
$102.46 |
| Rate for Payer: Aetna American Axle |
$74.00
|
| Rate for Payer: Aetna American Axle |
$35.03
|
| Rate for Payer: Aetna Commercial |
$96.76
|
| Rate for Payer: Aetna Commercial |
$45.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.03
|
| Rate for Payer: Cash Price |
$91.07
|
| Rate for Payer: Cash Price |
$43.11
|
| Rate for Payer: Cofinity Commercial |
$46.35
|
| Rate for Payer: Cofinity Commercial |
$37.72
|
| Rate for Payer: Cofinity Commercial |
$79.69
|
| Rate for Payer: Cofinity Commercial |
$97.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$79.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.11
|
| Rate for Payer: Healthscope Commercial |
$102.46
|
| Rate for Payer: Healthscope Commercial |
$48.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$85.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$96.76
|
| Rate for Payer: PHP Commercial |
$45.81
|
| Rate for Payer: PHP Commercial |
$96.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.03
|
| Rate for Payer: Priority Health SBD |
$71.72
|
| Rate for Payer: Priority Health SBD |
$33.95
|
| Rate for Payer: UMR Bronson Commercial |
$50.09
|
| Rate for Payer: UMR Bronson Commercial |
$23.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$85.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.42
|
|
|
OLANZAPINE 10 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
NDC 00002759701
|
| Hospital Charge Code |
200122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.96 |
| Max. Negotiated Rate |
$187.20 |
| Rate for Payer: Aetna American Axle |
$135.20
|
| Rate for Payer: Aetna Commercial |
$176.80
|
| Rate for Payer: Aetna Medicare |
$104.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.20
|
| Rate for Payer: BCBS Complete |
$83.20
|
| Rate for Payer: Cash Price |
$166.40
|
| Rate for Payer: Cofinity Commercial |
$145.60
|
| Rate for Payer: Cofinity Commercial |
$178.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$145.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$187.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.80
|
| Rate for Payer: PHP Commercial |
$176.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.20
|
| Rate for Payer: Priority Health SBD |
$131.04
|
| Rate for Payer: UMR Bronson Commercial |
$76.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.00
|
|
|
OLANZAPINE 10 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$155.89
|
|
|
Service Code
|
NDC 00517095501
|
| Hospital Charge Code |
200122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.59 |
| Max. Negotiated Rate |
$140.30 |
| Rate for Payer: Aetna American Axle |
$101.33
|
| Rate for Payer: Aetna Commercial |
$132.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.33
|
| Rate for Payer: Cash Price |
$124.71
|
| Rate for Payer: Cofinity Commercial |
$109.12
|
| Rate for Payer: Cofinity Commercial |
$134.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.71
|
| Rate for Payer: Healthscope Commercial |
$140.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.51
|
| Rate for Payer: PHP Commercial |
$132.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.33
|
| Rate for Payer: Priority Health SBD |
$98.21
|
| Rate for Payer: UMR Bronson Commercial |
$68.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.92
|
|
