|
ISOSOURCE HN CONTINUOUS FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 43900018480
|
| Hospital Charge Code |
168942
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
ISOSOURCE HN CYCLIC FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 43900018480
|
| Hospital Charge Code |
200075
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
ISOSOURCE HN CYCLIC FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 43900018480
|
| Hospital Charge Code |
200075
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: BCBS Complete |
$3.84
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
ISOSOURCE HN INTERMITTENT FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 43900018480
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$4.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: BCBS Complete |
$3.84
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
ISOSOURCE HN INTERMITTENT FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 43900018480
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.24
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.24
|
| Rate for Payer: Priority Health SBD |
$6.05
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$1,223.03
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
10358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$770.51 |
| Max. Negotiated Rate |
$1,100.73 |
| Rate for Payer: Aetna Commercial |
$1,039.58
|
| Rate for Payer: Aetna Commercial |
$2,656.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$794.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,031.67
|
| Rate for Payer: Cash Price |
$978.42
|
| Rate for Payer: Cash Price |
$2,500.51
|
| Rate for Payer: Cofinity Commercial |
$1,051.81
|
| Rate for Payer: Cofinity Commercial |
$2,187.95
|
| Rate for Payer: Cofinity Commercial |
$2,688.05
|
| Rate for Payer: Cofinity Commercial |
$856.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,187.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$856.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$978.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,500.51
|
| Rate for Payer: Healthscope Commercial |
$1,100.73
|
| Rate for Payer: Healthscope Commercial |
$2,813.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,039.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,656.79
|
| Rate for Payer: PHP Commercial |
$1,039.58
|
| Rate for Payer: PHP Commercial |
$2,656.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,031.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$794.97
|
| Rate for Payer: Priority Health SBD |
$1,969.15
|
| Rate for Payer: Priority Health SBD |
$770.51
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$1,223.03
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
10358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$1,100.73 |
| Rate for Payer: Aetna Commercial |
$1,039.58
|
| Rate for Payer: Aetna Commercial |
$2,656.79
|
| Rate for Payer: Aetna Medicare |
$9.08
|
| Rate for Payer: Aetna Medicare |
$9.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$794.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,031.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.91
|
| Rate for Payer: BCBS Complete |
$4.91
|
| Rate for Payer: BCBS Complete |
$4.91
|
| Rate for Payer: BCBS MAPPO |
$8.73
|
| Rate for Payer: BCBS MAPPO |
$8.73
|
| Rate for Payer: BCN Medicare Advantage |
$8.73
|
| Rate for Payer: BCN Medicare Advantage |
$8.73
|
| Rate for Payer: Cash Price |
$2,500.51
|
| Rate for Payer: Cash Price |
$2,500.51
|
| Rate for Payer: Cash Price |
$978.42
|
| Rate for Payer: Cash Price |
$978.42
|
| Rate for Payer: Cofinity Commercial |
$2,187.95
|
| Rate for Payer: Cofinity Commercial |
$2,688.05
|
| Rate for Payer: Cofinity Commercial |
$856.12
|
| Rate for Payer: Cofinity Commercial |
$1,051.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$856.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,500.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$978.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.73
|
| Rate for Payer: Healthscope Commercial |
$1,100.73
|
| Rate for Payer: Healthscope Commercial |
$2,813.08
|
| Rate for Payer: Mclaren Medicaid |
$4.68
|
| Rate for Payer: Mclaren Medicaid |
$4.68
|
| Rate for Payer: Mclaren Medicare |
$8.73
|
| Rate for Payer: Mclaren Medicare |
$8.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.17
|
| Rate for Payer: Meridian Medicaid |
$4.91
|
| Rate for Payer: Meridian Medicaid |
$4.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,039.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,656.79
|
| Rate for Payer: PACE Medicare |
$8.29
|
| Rate for Payer: PACE Medicare |
$8.29
|
| Rate for Payer: PACE SWMI |
$8.73
|
| Rate for Payer: PACE SWMI |
$8.73
|
| Rate for Payer: PHP Commercial |
$2,656.79
|
| Rate for Payer: PHP Commercial |
$1,039.58
|
| Rate for Payer: PHP Medicare Advantage |
$8.73
|
| Rate for Payer: PHP Medicare Advantage |
$8.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,031.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$794.97
|
| Rate for Payer: Priority Health Medicare |
$8.73
|
| Rate for Payer: Priority Health Medicare |
$8.73
|
| Rate for Payer: Priority Health SBD |
$1,969.15
|
| Rate for Payer: Priority Health SBD |
$770.51
|
| Rate for Payer: Railroad Medicare Medicare |
$8.73
|
| Rate for Payer: Railroad Medicare Medicare |
$8.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.73
|
| Rate for Payer: UHC Medicare Advantage |
$8.73
|
| Rate for Payer: UHC Medicare Advantage |
$8.73
|
| Rate for Payer: UHCCP Medicaid |
$4.91
|
| Rate for Payer: UHCCP Medicaid |
$4.91
|
| Rate for Payer: VA VA |
$8.73
|
| Rate for Payer: VA VA |
$8.73
|
|
|
ITRACONAZOLE 100 MG CAPSULE
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
NDC 67877045430
|
| Hospital Charge Code |
10364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.20 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna Commercial |
$121.55
|
| Rate for Payer: Aetna Medicare |
$71.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.95
|
| Rate for Payer: BCBS Complete |
$57.20
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Cofinity Commercial |
$100.10
|
| Rate for Payer: Cofinity Commercial |
$122.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$100.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.40
|
| Rate for Payer: Healthscope Commercial |
$128.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.55
|
| Rate for Payer: PHP Commercial |
$121.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.95
|
| Rate for Payer: Priority Health SBD |
$90.09
|
|
|
ITRACONAZOLE 100 MG CAPSULE
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
NDC 67877045430
|
| Hospital Charge Code |
10364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.09 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna Commercial |
$121.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.95
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Cofinity Commercial |
$100.10
|
| Rate for Payer: Cofinity Commercial |
$122.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$100.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.40
|
| Rate for Payer: Healthscope Commercial |
$128.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.55
|
| Rate for Payer: PHP Commercial |
$121.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.95
|
| Rate for Payer: Priority Health SBD |
$90.09
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$1,181.60
|
|
|
Service Code
|
NDC 50458029515
|
| Hospital Charge Code |
19928
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$472.64 |
| Max. Negotiated Rate |
$1,063.44 |
| Rate for Payer: Aetna Commercial |
$1,004.36
|
| Rate for Payer: Aetna Medicare |
$590.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.04
|
| Rate for Payer: BCBS Complete |
$472.64
|
| Rate for Payer: Cash Price |
$945.28
|
| Rate for Payer: Cofinity Commercial |
$1,016.18
|
| Rate for Payer: Cofinity Commercial |
$827.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$827.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.28
|
| Rate for Payer: Healthscope Commercial |
$1,063.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,004.36
|
| Rate for Payer: PHP Commercial |
$1,004.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$768.04
|
| Rate for Payer: Priority Health SBD |
$744.41
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$1,181.60
|
|
|
Service Code
|
NDC 50458029515
|
| Hospital Charge Code |
19928
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$744.41 |
| Max. Negotiated Rate |
$1,063.44 |
| Rate for Payer: Aetna Commercial |
$1,004.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.04
|
| Rate for Payer: Cash Price |
$945.28
|
| Rate for Payer: Cofinity Commercial |
$1,016.18
|
| Rate for Payer: Cofinity Commercial |
$827.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$827.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.28
|
| Rate for Payer: Healthscope Commercial |
$1,063.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,004.36
|
| Rate for Payer: PHP Commercial |
$1,004.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$768.04
|
| Rate for Payer: Priority Health SBD |
$744.41
|
|
|
IXABEPILONE 15 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$9,045.38
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
88652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.62 |
| Max. Negotiated Rate |
$8,140.84 |
| Rate for Payer: Aetna Commercial |
$7,688.57
|
| Rate for Payer: Aetna Medicare |
$144.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,879.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$174.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$174.01
|
| Rate for Payer: BCBS Complete |
$78.35
|
| Rate for Payer: BCBS MAPPO |
$139.21
|
| Rate for Payer: BCN Medicare Advantage |
$139.21
|
| Rate for Payer: Cash Price |
$7,236.30
|
| Rate for Payer: Cash Price |
$7,236.30
|
| Rate for Payer: Cofinity Commercial |
$6,331.77
|
| Rate for Payer: Cofinity Commercial |
$7,779.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,331.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,236.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$139.21
|
| Rate for Payer: Healthscope Commercial |
$8,140.84
|
| Rate for Payer: Mclaren Medicaid |
$74.62
|
| Rate for Payer: Mclaren Medicare |
$139.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$146.17
|
| Rate for Payer: Meridian Medicaid |
$78.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$160.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,688.57
|
| Rate for Payer: PACE Medicare |
$132.25
|
| Rate for Payer: PACE SWMI |
$139.21
|
| Rate for Payer: PHP Commercial |
$7,688.57
|
| Rate for Payer: PHP Medicare Advantage |
$139.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$74.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,879.50
|
| Rate for Payer: Priority Health Medicare |
$139.21
|
| Rate for Payer: Priority Health SBD |
$5,698.59
|
| Rate for Payer: Railroad Medicare Medicare |
$139.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$391.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$139.21
|
| Rate for Payer: UHC Medicare Advantage |
$139.21
|
| Rate for Payer: UHCCP Medicaid |
$78.38
|
| Rate for Payer: VA VA |
$139.21
|
|
|
IXABEPILONE 15 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$9,045.38
|
|
|
Service Code
|
HCPCS J9207
|
| Hospital Charge Code |
88652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,698.59 |
| Max. Negotiated Rate |
$8,140.84 |
| Rate for Payer: Aetna Commercial |
$7,688.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,879.50
|
| Rate for Payer: Cash Price |
$7,236.30
|
| Rate for Payer: Cofinity Commercial |
$6,331.77
|
| Rate for Payer: Cofinity Commercial |
$7,779.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,331.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,236.30
|
| Rate for Payer: Healthscope Commercial |
$8,140.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,688.57
|
| Rate for Payer: PHP Commercial |
$7,688.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,879.50
|
| Rate for Payer: Priority Health SBD |
$5,698.59
|
|
|
J-TIP NEEDLE FREE INJECTOR 0.25 ML
|
Facility
|
IP
|
$3.99
|
|
|
Service Code
|
NDC 09900000400
|
| Hospital Charge Code |
163515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.59 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.59
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$3.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.19
|
| Rate for Payer: Healthscope Commercial |
$3.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.59
|
| Rate for Payer: Priority Health SBD |
$2.51
|
|
|
J-TIP NEEDLE FREE INJECTOR 0.25 ML
|
Facility
|
OP
|
$3.99
|
|
|
Service Code
|
NDC 09900000400
|
| Hospital Charge Code |
163515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.59 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Aetna Medicare |
$2.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.59
|
| Rate for Payer: BCBS Complete |
$1.60
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$3.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.19
|
| Rate for Payer: Healthscope Commercial |
$3.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.59
|
| Rate for Payer: Priority Health SBD |
$2.51
|
|
|
KATE FARMS BOLUS FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.63 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS BOLUS FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.16 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna Medicare |
$31.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: BCBS Complete |
$25.16
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS CONTINUOUS FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.16 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna Medicare |
$31.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: BCBS Complete |
$25.16
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS CONTINUOUS FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.63 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS CYCLIC FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.16 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna Medicare |
$31.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: BCBS Complete |
$25.16
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS CYCLIC FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.63 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS INTERMITTENT FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.63 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KATE FARMS INTERMITTENT FEED LIQUID 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$62.90
|
|
|
Service Code
|
NDC 09900001990
|
| Hospital Charge Code |
301453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.16 |
| Max. Negotiated Rate |
$56.61 |
| Rate for Payer: Aetna Commercial |
$53.47
|
| Rate for Payer: Aetna Medicare |
$31.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.88
|
| Rate for Payer: BCBS Complete |
$25.16
|
| Rate for Payer: Cash Price |
$50.32
|
| Rate for Payer: Cofinity Commercial |
$44.03
|
| Rate for Payer: Cofinity Commercial |
$54.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.32
|
| Rate for Payer: Healthscope Commercial |
$56.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.47
|
| Rate for Payer: PHP Commercial |
$53.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.88
|
| Rate for Payer: Priority Health SBD |
$39.63
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
IP
|
$38.63
|
|
|
Service Code
|
NDC 00409205105
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.34 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.11
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: Cofinity Commercial |
$33.22
|
| Rate for Payer: Cofinity Commercial |
$27.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.90
|
| Rate for Payer: Healthscope Commercial |
$34.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health SBD |
$24.34
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
OP
|
$38.65
|
|
|
Service Code
|
NDC 00409004010
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.46 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: Aetna Medicare |
$19.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.12
|
| Rate for Payer: BCBS Complete |
$15.46
|
| Rate for Payer: Cash Price |
$30.92
|
| Rate for Payer: Cofinity Commercial |
$27.05
|
| Rate for Payer: Cofinity Commercial |
$33.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.92
|
| Rate for Payer: Healthscope Commercial |
$34.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: PHP Commercial |
$32.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.12
|
| Rate for Payer: Priority Health SBD |
$24.35
|
|
