|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$736.75
|
|
|
Service Code
|
NDC 42858000110
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$324.17 |
| Max. Negotiated Rate |
$663.08 |
| Rate for Payer: Aetna American Axle |
$478.89
|
| Rate for Payer: Aetna Commercial |
$626.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$478.89
|
| Rate for Payer: Cash Price |
$589.40
|
| Rate for Payer: Cofinity Commercial |
$515.72
|
| Rate for Payer: Cofinity Commercial |
$633.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$515.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.40
|
| Rate for Payer: Healthscope Commercial |
$663.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$515.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$552.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.24
|
| Rate for Payer: PHP Commercial |
$626.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$478.89
|
| Rate for Payer: Priority Health SBD |
$464.15
|
| Rate for Payer: UMR Bronson Commercial |
$324.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$552.56
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$5.95
|
|
|
Service Code
|
NDC 00406055223
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna American Axle |
$3.87
|
| Rate for Payer: Aetna Commercial |
$5.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.87
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Cofinity Commercial |
$4.16
|
| Rate for Payer: Cofinity Commercial |
$5.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.76
|
| Rate for Payer: Healthscope Commercial |
$5.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.06
|
| Rate for Payer: PHP Commercial |
$5.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.87
|
| Rate for Payer: Priority Health SBD |
$3.75
|
| Rate for Payer: UMR Bronson Commercial |
$2.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.46
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$325.50
|
|
|
Service Code
|
NDC 00406055201
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.44 |
| Max. Negotiated Rate |
$292.95 |
| Rate for Payer: Aetna American Axle |
$211.58
|
| Rate for Payer: Aetna Commercial |
$276.68
|
| Rate for Payer: Aetna Medicare |
$162.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.58
|
| Rate for Payer: BCBS Complete |
$130.20
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cofinity Commercial |
$227.85
|
| Rate for Payer: Cofinity Commercial |
$279.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.40
|
| Rate for Payer: Healthscope Commercial |
$292.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.68
|
| Rate for Payer: PHP Commercial |
$276.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.58
|
| Rate for Payer: Priority Health SBD |
$205.06
|
| Rate for Payer: UMR Bronson Commercial |
$120.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.12
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$654.50
|
|
|
Service Code
|
NDC 68084035401
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.98 |
| Max. Negotiated Rate |
$589.05 |
| Rate for Payer: Aetna American Axle |
$425.42
|
| Rate for Payer: Aetna Commercial |
$556.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.42
|
| Rate for Payer: Cash Price |
$523.60
|
| Rate for Payer: Cofinity Commercial |
$458.15
|
| Rate for Payer: Cofinity Commercial |
$562.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$458.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$523.60
|
| Rate for Payer: Healthscope Commercial |
$589.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$490.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.32
|
| Rate for Payer: PHP Commercial |
$556.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.42
|
| Rate for Payer: Priority Health SBD |
$412.34
|
| Rate for Payer: UMR Bronson Commercial |
$287.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$490.88
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$595.00
|
|
|
Service Code
|
NDC 00406055262
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.80 |
| Max. Negotiated Rate |
$535.50 |
| Rate for Payer: Aetna American Axle |
$386.75
|
| Rate for Payer: Aetna Commercial |
$505.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.75
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cofinity Commercial |
$416.50
|
| Rate for Payer: Cofinity Commercial |
$511.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.00
|
| Rate for Payer: Healthscope Commercial |
$535.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$505.75
|
| Rate for Payer: PHP Commercial |
$505.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$386.75
|
| Rate for Payer: Priority Health SBD |
$374.85
|
| Rate for Payer: UMR Bronson Commercial |
$261.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.25
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$840.00
|
|
|
Service Code
|
NDC 47781026305
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$369.60 |
| Max. Negotiated Rate |
$756.00 |
| Rate for Payer: Aetna American Axle |
$546.00
|
| Rate for Payer: Aetna Commercial |
$714.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$546.00
|
| Rate for Payer: Cash Price |
$672.00
|
| Rate for Payer: Cofinity Commercial |
$588.00
|
| Rate for Payer: Cofinity Commercial |
$722.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$588.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$672.00
|
| Rate for Payer: Healthscope Commercial |
$756.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$588.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$630.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$714.00
|
| Rate for Payer: PHP Commercial |
$714.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$546.00
|
| Rate for Payer: Priority Health SBD |
$529.20
|
| Rate for Payer: UMR Bronson Commercial |
$369.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$630.00
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$5.95
|
|
|
Service Code
|
NDC 00406055223
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna American Axle |
$3.87
|
| Rate for Payer: Aetna Commercial |
$5.06
|
| Rate for Payer: Aetna Medicare |
$2.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.87
|
| Rate for Payer: BCBS Complete |
$2.38
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Cofinity Commercial |
$4.16
|
| Rate for Payer: Cofinity Commercial |
$5.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.76
|
| Rate for Payer: Healthscope Commercial |
$5.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.06
|
| Rate for Payer: PHP Commercial |
$5.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.87
|
| Rate for Payer: Priority Health SBD |
$3.75
|
| Rate for Payer: UMR Bronson Commercial |
$2.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.46
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$654.50
|
|
|
Service Code
|
NDC 68084035411
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.16 |
| Max. Negotiated Rate |
$589.05 |
| Rate for Payer: Aetna American Axle |
$425.42
|
| Rate for Payer: Aetna Commercial |
$556.32
|
| Rate for Payer: Aetna Medicare |
$327.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.42
|
| Rate for Payer: BCBS Complete |
$261.80
|
| Rate for Payer: Cash Price |
$523.60
|
| Rate for Payer: Cofinity Commercial |
$458.15
|
| Rate for Payer: Cofinity Commercial |
$562.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$458.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$523.60
|
| Rate for Payer: Healthscope Commercial |
$589.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$490.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.32
|
| Rate for Payer: PHP Commercial |
$556.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.42
|
| Rate for Payer: Priority Health SBD |
$412.34
|
| Rate for Payer: UMR Bronson Commercial |
$242.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$490.88
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$227.50
|
|
|
Service Code
|
NDC 10702001801
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna American Axle |
$147.88
|
| Rate for Payer: Aetna Commercial |
$193.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.88
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cofinity Commercial |
$159.25
|
| Rate for Payer: Cofinity Commercial |
$195.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.00
|
| Rate for Payer: Healthscope Commercial |
$204.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.38
|
| Rate for Payer: PHP Commercial |
$193.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.88
|
| Rate for Payer: Priority Health SBD |
$143.32
|
| Rate for Payer: UMR Bronson Commercial |
$100.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.62
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$595.00
|
|
|
Service Code
|
NDC 00406055262
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.15 |
| Max. Negotiated Rate |
$535.50 |
| Rate for Payer: Aetna American Axle |
$386.75
|
| Rate for Payer: Aetna Commercial |
$505.75
|
| Rate for Payer: Aetna Medicare |
$297.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.75
|
| Rate for Payer: BCBS Complete |
$238.00
|
| Rate for Payer: Cash Price |
$476.00
|
| Rate for Payer: Cofinity Commercial |
$416.50
|
| Rate for Payer: Cofinity Commercial |
$511.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.00
|
| Rate for Payer: Healthscope Commercial |
$535.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$505.75
|
| Rate for Payer: PHP Commercial |
$505.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$386.75
|
| Rate for Payer: Priority Health SBD |
$374.85
|
| Rate for Payer: UMR Bronson Commercial |
$220.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.25
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
NDC 57664022388
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.72 |
| Max. Negotiated Rate |
$214.20 |
| Rate for Payer: Aetna American Axle |
$154.70
|
| Rate for Payer: Aetna Commercial |
$202.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.70
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cofinity Commercial |
$166.60
|
| Rate for Payer: Cofinity Commercial |
$204.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.40
|
| Rate for Payer: Healthscope Commercial |
$214.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.30
|
| Rate for Payer: PHP Commercial |
$202.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.70
|
| Rate for Payer: Priority Health SBD |
$149.94
|
| Rate for Payer: UMR Bronson Commercial |
$104.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.50
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$227.50
|
|
|
Service Code
|
NDC 10702001801
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.18 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna American Axle |
$147.88
|
| Rate for Payer: Aetna Commercial |
$193.38
|
| Rate for Payer: Aetna Medicare |
$113.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.88
|
| Rate for Payer: BCBS Complete |
$91.00
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cofinity Commercial |
$159.25
|
| Rate for Payer: Cofinity Commercial |
$195.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.00
|
| Rate for Payer: Healthscope Commercial |
$204.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.38
|
| Rate for Payer: PHP Commercial |
$193.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.88
|
| Rate for Payer: Priority Health SBD |
$143.32
|
| Rate for Payer: UMR Bronson Commercial |
$84.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.62
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$654.50
|
|
|
Service Code
|
NDC 68084035401
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.16 |
| Max. Negotiated Rate |
$589.05 |
| Rate for Payer: Aetna American Axle |
$425.42
|
| Rate for Payer: Aetna Commercial |
$556.32
|
| Rate for Payer: Aetna Medicare |
$327.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.42
|
| Rate for Payer: BCBS Complete |
$261.80
|
| Rate for Payer: Cash Price |
$523.60
|
| Rate for Payer: Cofinity Commercial |
$458.15
|
| Rate for Payer: Cofinity Commercial |
$562.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$458.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$523.60
|
| Rate for Payer: Healthscope Commercial |
$589.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$490.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.32
|
| Rate for Payer: PHP Commercial |
$556.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.42
|
| Rate for Payer: Priority Health SBD |
$412.34
|
| Rate for Payer: UMR Bronson Commercial |
$242.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$490.88
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
NDC 57664022388
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.06 |
| Max. Negotiated Rate |
$214.20 |
| Rate for Payer: Aetna American Axle |
$154.70
|
| Rate for Payer: Aetna Commercial |
$202.30
|
| Rate for Payer: Aetna Medicare |
$119.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.70
|
| Rate for Payer: BCBS Complete |
$95.20
|
| Rate for Payer: Cash Price |
$190.40
|
| Rate for Payer: Cofinity Commercial |
$166.60
|
| Rate for Payer: Cofinity Commercial |
$204.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.40
|
| Rate for Payer: Healthscope Commercial |
$214.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.30
|
| Rate for Payer: PHP Commercial |
$202.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.70
|
| Rate for Payer: Priority Health SBD |
$149.94
|
| Rate for Payer: UMR Bronson Commercial |
$88.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.50
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$201.25
|
|
|
Service Code
|
NDC 65162004710
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.55 |
| Max. Negotiated Rate |
$181.12 |
| Rate for Payer: Aetna American Axle |
$130.81
|
| Rate for Payer: Aetna Commercial |
$171.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.81
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cofinity Commercial |
$140.88
|
| Rate for Payer: Cofinity Commercial |
$173.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.00
|
| Rate for Payer: Healthscope Commercial |
$181.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$171.06
|
| Rate for Payer: PHP Commercial |
$171.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.81
|
| Rate for Payer: Priority Health SBD |
$126.79
|
| Rate for Payer: UMR Bronson Commercial |
$88.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.94
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$736.75
|
|
|
Service Code
|
NDC 42858000110
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$272.60 |
| Max. Negotiated Rate |
$663.08 |
| Rate for Payer: Aetna American Axle |
$478.89
|
| Rate for Payer: Aetna Commercial |
$626.24
|
| Rate for Payer: Aetna Medicare |
$368.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$478.89
|
| Rate for Payer: BCBS Complete |
$294.70
|
| Rate for Payer: Cash Price |
$589.40
|
| Rate for Payer: Cofinity Commercial |
$515.72
|
| Rate for Payer: Cofinity Commercial |
$633.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$515.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.40
|
| Rate for Payer: Healthscope Commercial |
$663.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$515.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$552.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.24
|
| Rate for Payer: PHP Commercial |
$626.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$478.89
|
| Rate for Payer: Priority Health SBD |
$464.15
|
| Rate for Payer: UMR Bronson Commercial |
$272.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$552.56
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
NDC 00904696661
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.17 |
| Max. Negotiated Rate |
$396.90 |
| Rate for Payer: Aetna American Axle |
$286.65
|
| Rate for Payer: Aetna Commercial |
$374.85
|
| Rate for Payer: Aetna Medicare |
$220.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.65
|
| Rate for Payer: BCBS Complete |
$176.40
|
| Rate for Payer: Cash Price |
$352.80
|
| Rate for Payer: Cofinity Commercial |
$308.70
|
| Rate for Payer: Cofinity Commercial |
$379.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.80
|
| Rate for Payer: Healthscope Commercial |
$396.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.85
|
| Rate for Payer: PHP Commercial |
$374.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.65
|
| Rate for Payer: Priority Health SBD |
$277.83
|
| Rate for Payer: UMR Bronson Commercial |
$163.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.75
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$1,218.70
|
|
|
Service Code
|
NDC 00406052362
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$536.23 |
| Max. Negotiated Rate |
$1,096.83 |
| Rate for Payer: Aetna American Axle |
$792.16
|
| Rate for Payer: Aetna Commercial |
$1,035.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$792.16
|
| Rate for Payer: Cash Price |
$974.96
|
| Rate for Payer: Cofinity Commercial |
$1,048.08
|
| Rate for Payer: Cofinity Commercial |
$853.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$853.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$974.96
|
| Rate for Payer: Healthscope Commercial |
$1,096.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$853.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$914.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,035.90
|
| Rate for Payer: PHP Commercial |
$1,035.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$792.16
|
| Rate for Payer: Priority Health SBD |
$767.78
|
| Rate for Payer: UMR Bronson Commercial |
$536.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$914.02
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$277.55
|
|
|
Service Code
|
NDC 50268064615
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.12 |
| Max. Negotiated Rate |
$249.80 |
| Rate for Payer: Aetna American Axle |
$180.41
|
| Rate for Payer: Aetna Commercial |
$235.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.41
|
| Rate for Payer: Cash Price |
$222.04
|
| Rate for Payer: Cofinity Commercial |
$194.28
|
| Rate for Payer: Cofinity Commercial |
$238.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.04
|
| Rate for Payer: Healthscope Commercial |
$249.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.92
|
| Rate for Payer: PHP Commercial |
$235.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.41
|
| Rate for Payer: Priority Health SBD |
$174.86
|
| Rate for Payer: UMR Bronson Commercial |
$122.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.16
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$327.25
|
|
|
Service Code
|
NDC 13107004601
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.99 |
| Max. Negotiated Rate |
$294.52 |
| Rate for Payer: Aetna American Axle |
$212.71
|
| Rate for Payer: Aetna Commercial |
$278.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.71
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Cofinity Commercial |
$229.08
|
| Rate for Payer: Cofinity Commercial |
$281.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$229.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.80
|
| Rate for Payer: Healthscope Commercial |
$294.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.16
|
| Rate for Payer: PHP Commercial |
$278.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.71
|
| Rate for Payer: Priority Health SBD |
$206.17
|
| Rate for Payer: UMR Bronson Commercial |
$143.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.44
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$803.25
|
|
|
Service Code
|
NDC 00406052301
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$353.43 |
| Max. Negotiated Rate |
$722.92 |
| Rate for Payer: Aetna American Axle |
$522.11
|
| Rate for Payer: Aetna Commercial |
$682.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$522.11
|
| Rate for Payer: Cash Price |
$642.60
|
| Rate for Payer: Cofinity Commercial |
$562.28
|
| Rate for Payer: Cofinity Commercial |
$690.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$562.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$642.60
|
| Rate for Payer: Healthscope Commercial |
$722.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$562.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$602.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$682.76
|
| Rate for Payer: PHP Commercial |
$682.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$522.11
|
| Rate for Payer: Priority Health SBD |
$506.05
|
| Rate for Payer: UMR Bronson Commercial |
$353.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$602.44
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$1,218.70
|
|
|
Service Code
|
NDC 00406052362
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$450.92 |
| Max. Negotiated Rate |
$1,096.83 |
| Rate for Payer: Aetna American Axle |
$792.16
|
| Rate for Payer: Aetna Commercial |
$1,035.90
|
| Rate for Payer: Aetna Medicare |
$609.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$792.16
|
| Rate for Payer: BCBS Complete |
$487.48
|
| Rate for Payer: Cash Price |
$974.96
|
| Rate for Payer: Cofinity Commercial |
$1,048.08
|
| Rate for Payer: Cofinity Commercial |
$853.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$853.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$974.96
|
| Rate for Payer: Healthscope Commercial |
$1,096.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$853.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$914.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,035.90
|
| Rate for Payer: PHP Commercial |
$1,035.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$792.16
|
| Rate for Payer: Priority Health SBD |
$767.78
|
| Rate for Payer: UMR Bronson Commercial |
$450.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$914.02
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$760.90
|
|
|
Service Code
|
NDC 00904709561
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.80 |
| Max. Negotiated Rate |
$684.81 |
| Rate for Payer: Aetna American Axle |
$494.58
|
| Rate for Payer: Aetna Commercial |
$646.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$494.58
|
| Rate for Payer: Cash Price |
$608.72
|
| Rate for Payer: Cofinity Commercial |
$532.63
|
| Rate for Payer: Cofinity Commercial |
$654.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$532.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$608.72
|
| Rate for Payer: Healthscope Commercial |
$684.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$532.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$570.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$646.76
|
| Rate for Payer: PHP Commercial |
$646.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$494.58
|
| Rate for Payer: Priority Health SBD |
$479.37
|
| Rate for Payer: UMR Bronson Commercial |
$334.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$570.68
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$803.25
|
|
|
Service Code
|
NDC 00406052301
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$297.20 |
| Max. Negotiated Rate |
$722.92 |
| Rate for Payer: Aetna American Axle |
$522.11
|
| Rate for Payer: Aetna Commercial |
$682.76
|
| Rate for Payer: Aetna Medicare |
$401.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$522.11
|
| Rate for Payer: BCBS Complete |
$321.30
|
| Rate for Payer: Cash Price |
$642.60
|
| Rate for Payer: Cofinity Commercial |
$562.28
|
| Rate for Payer: Cofinity Commercial |
$690.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$562.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$642.60
|
| Rate for Payer: Healthscope Commercial |
$722.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$562.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$602.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$682.76
|
| Rate for Payer: PHP Commercial |
$682.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$522.11
|
| Rate for Payer: Priority Health SBD |
$506.05
|
| Rate for Payer: UMR Bronson Commercial |
$297.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$602.44
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$760.90
|
|
|
Service Code
|
NDC 00904709561
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.53 |
| Max. Negotiated Rate |
$684.81 |
| Rate for Payer: Aetna American Axle |
$494.58
|
| Rate for Payer: Aetna Commercial |
$646.76
|
| Rate for Payer: Aetna Medicare |
$380.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$494.58
|
| Rate for Payer: BCBS Complete |
$304.36
|
| Rate for Payer: Cash Price |
$608.72
|
| Rate for Payer: Cofinity Commercial |
$532.63
|
| Rate for Payer: Cofinity Commercial |
$654.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$532.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$608.72
|
| Rate for Payer: Healthscope Commercial |
$684.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$532.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$570.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$646.76
|
| Rate for Payer: PHP Commercial |
$646.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$494.58
|
| Rate for Payer: Priority Health SBD |
$479.37
|
| Rate for Payer: UMR Bronson Commercial |
$281.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$570.68
|
|
