|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$24.64
|
|
|
Service Code
|
NDC 19903001023
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.70
|
| Rate for Payer: BCBS Complete |
$9.86
|
| Rate for Payer: BCBS MAPPO |
$6.16
|
| Rate for Payer: BCBS Trust/PPO |
$20.26
|
| Rate for Payer: BCN Commercial |
$19.16
|
| Rate for Payer: BCN Medicare Advantage |
$6.16
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.16
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Nomi Health Commercial |
$20.20
|
| Rate for Payer: PACE Senior Care Partners |
$5.85
|
| Rate for Payer: PACE SWMI |
$6.16
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: PHP Medicare Advantage |
$6.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health HMO/PPO |
$21.44
|
| Rate for Payer: Priority Health Medicare |
$6.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.51
|
| Rate for Payer: Railroad Medicare Medicare |
$6.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.68
|
| Rate for Payer: UHC Core |
$20.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.16
|
| Rate for Payer: UHC Exchange |
$6.16
|
| Rate for Payer: UHC Medicare Advantage |
$6.16
|
| Rate for Payer: VA VA |
$6.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS
|
Facility
|
OP
|
$147.80
|
|
|
Service Code
|
CPT 12011
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$140.75 |
| Max. Negotiated Rate |
$147.80 |
| Rate for Payer: BCBS Complete |
$147.80
|
| Rate for Payer: Mclaren Medicaid |
$140.75
|
| Rate for Payer: Meridian Medicaid |
$147.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$140.75
|
| Rate for Payer: UHCCP Medicaid |
$140.75
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$439.34
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$285.57 |
| Max. Negotiated Rate |
$395.41 |
| Rate for Payer: Aetna Commercial |
$373.44
|
| Rate for Payer: BCBS Trust/PPO |
$358.63
|
| Rate for Payer: BCN Commercial |
$339.52
|
| Rate for Payer: Cash Price |
$351.47
|
| Rate for Payer: Cofinity Commercial |
$377.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$351.47
|
| Rate for Payer: Healthscope Commercial |
$395.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$329.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$373.44
|
| Rate for Payer: Nomi Health Commercial |
$360.26
|
| Rate for Payer: PHP Commercial |
$373.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.57
|
| Rate for Payer: Priority Health HMO/PPO |
$382.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$294.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$386.62
|
| Rate for Payer: UHC Core |
$366.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$329.50
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$439.34
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.34 |
| Max. Negotiated Rate |
$395.41 |
| Rate for Payer: Aetna Commercial |
$373.44
|
| Rate for Payer: Aetna Medicare |
$114.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$137.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$137.29
|
| Rate for Payer: BCBS Complete |
$175.74
|
| Rate for Payer: BCBS MAPPO |
$109.84
|
| Rate for Payer: BCBS Trust/PPO |
$361.18
|
| Rate for Payer: BCN Commercial |
$341.59
|
| Rate for Payer: BCN Medicare Advantage |
$109.84
|
| Rate for Payer: Cash Price |
$351.47
|
| Rate for Payer: Cofinity Commercial |
$377.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$351.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$109.84
|
| Rate for Payer: Healthscope Commercial |
$395.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$329.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$115.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$126.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$373.44
|
| Rate for Payer: Nomi Health Commercial |
$360.26
|
| Rate for Payer: PACE Senior Care Partners |
$104.34
|
| Rate for Payer: PACE SWMI |
$109.84
|
| Rate for Payer: PHP Commercial |
$373.44
|
| Rate for Payer: PHP Medicare Advantage |
$109.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.57
|
| Rate for Payer: Priority Health HMO/PPO |
$382.23
|
| Rate for Payer: Priority Health Medicare |
$110.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$294.36
|
| Rate for Payer: Railroad Medicare Medicare |
$109.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$386.62
|
| Rate for Payer: UHC Core |
$366.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$109.84
|
| Rate for Payer: UHC Exchange |
$109.84
|
| Rate for Payer: UHC Medicare Advantage |
$109.84
|
| Rate for Payer: VA VA |
$109.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$329.50
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
IP
|
$1,135.31
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$737.95 |
| Max. Negotiated Rate |
$1,021.78 |
| Rate for Payer: Aetna Commercial |
$965.01
|
| Rate for Payer: BCBS Trust/PPO |
$926.75
|
| Rate for Payer: BCN Commercial |
$877.37
|
| Rate for Payer: Cash Price |
$908.25
|
| Rate for Payer: Cofinity Commercial |
$976.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$908.25
|
| Rate for Payer: Healthscope Commercial |
$1,021.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$851.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$965.01
|
| Rate for Payer: Nomi Health Commercial |
$930.95
|
| Rate for Payer: PHP Commercial |
$965.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$737.95
|
| Rate for Payer: Priority Health HMO/PPO |
$987.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$760.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$999.07
|
| Rate for Payer: UHC Core |
$947.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$851.48
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
OP
|
$1,135.31
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$269.64 |
| Max. Negotiated Rate |
$1,021.78 |
| Rate for Payer: Aetna Commercial |
$965.01
|
| Rate for Payer: Aetna Medicare |
$295.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$354.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$354.78
|
| Rate for Payer: BCBS Complete |
$454.12
|
| Rate for Payer: BCBS MAPPO |
$283.83
|
| Rate for Payer: BCBS Trust/PPO |
$933.34
|
| Rate for Payer: BCN Commercial |
$882.70
|
| Rate for Payer: BCN Medicare Advantage |
$283.83
|
| Rate for Payer: Cash Price |
$908.25
|
| Rate for Payer: Cofinity Commercial |
$976.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$908.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$283.83
|
| Rate for Payer: Healthscope Commercial |
$1,021.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$851.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$298.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$326.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$965.01
|
| Rate for Payer: Nomi Health Commercial |
$930.95
|
| Rate for Payer: PACE Senior Care Partners |
$269.64
|
| Rate for Payer: PACE SWMI |
$283.83
|
| Rate for Payer: PHP Commercial |
$965.01
|
| Rate for Payer: PHP Medicare Advantage |
$283.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$737.95
|
| Rate for Payer: Priority Health HMO/PPO |
$987.72
|
| Rate for Payer: Priority Health Medicare |
$286.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$760.66
|
| Rate for Payer: Railroad Medicare Medicare |
$283.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$999.07
|
| Rate for Payer: UHC Core |
$947.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$283.83
|
| Rate for Payer: UHC Exchange |
$283.83
|
| Rate for Payer: UHC Medicare Advantage |
$283.83
|
| Rate for Payer: VA VA |
$283.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$851.48
|
|
|
SKIN CARE CONSULT
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
HCPCS 00177
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Aetna Medicare |
$13.00
|
| Rate for Payer: BCBS Complete |
$10.40
|
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.90
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.26
|
|
|
Service Code
|
NDC 00409329906
|
| Hospital Charge Code |
7301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$23.63 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: Aetna Medicare |
$6.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.21
|
| Rate for Payer: BCBS Complete |
$10.50
|
| Rate for Payer: BCBS MAPPO |
$6.56
|
| Rate for Payer: BCBS Trust/PPO |
$21.59
|
| Rate for Payer: BCN Commercial |
$20.42
|
| Rate for Payer: BCN Medicare Advantage |
$6.56
|
| Rate for Payer: Cash Price |
$21.01
|
| Rate for Payer: Cofinity Commercial |
$22.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.56
|
| Rate for Payer: Healthscope Commercial |
$23.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.32
|
| Rate for Payer: Nomi Health Commercial |
$21.53
|
| Rate for Payer: PACE Senior Care Partners |
$6.24
|
| Rate for Payer: PACE SWMI |
$6.56
|
| Rate for Payer: PHP Commercial |
$22.32
|
| Rate for Payer: PHP Medicare Advantage |
$6.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.07
|
| Rate for Payer: Priority Health HMO/PPO |
$22.85
|
| Rate for Payer: Priority Health Medicare |
$6.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.59
|
| Rate for Payer: Railroad Medicare Medicare |
$6.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.11
|
| Rate for Payer: UHC Core |
$21.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.56
|
| Rate for Payer: UHC Exchange |
$6.56
|
| Rate for Payer: UHC Medicare Advantage |
$6.56
|
| Rate for Payer: VA VA |
$6.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.70
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.26
|
|
|
Service Code
|
NDC 00409329906
|
| Hospital Charge Code |
7301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.07 |
| Max. Negotiated Rate |
$23.63 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: BCBS Trust/PPO |
$21.44
|
| Rate for Payer: BCN Commercial |
$20.29
|
| Rate for Payer: Cash Price |
$21.01
|
| Rate for Payer: Cofinity Commercial |
$22.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.01
|
| Rate for Payer: Healthscope Commercial |
$23.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.32
|
| Rate for Payer: Nomi Health Commercial |
$21.53
|
| Rate for Payer: PHP Commercial |
$22.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.07
|
| Rate for Payer: Priority Health HMO/PPO |
$22.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.11
|
| Rate for Payer: UHC Core |
$21.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.70
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$35.60
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.14 |
| Max. Negotiated Rate |
$32.04 |
| Rate for Payer: Aetna Commercial |
$30.26
|
| Rate for Payer: BCBS Trust/PPO |
$29.06
|
| Rate for Payer: BCN Commercial |
$27.51
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Healthscope Commercial |
$32.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.26
|
| Rate for Payer: Nomi Health Commercial |
$29.19
|
| Rate for Payer: PHP Commercial |
$30.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.14
|
| Rate for Payer: Priority Health HMO/PPO |
$30.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.33
|
| Rate for Payer: UHC Core |
$29.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.70
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$22.70
|
|
|
Service Code
|
NDC 51754500101
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$20.43 |
| Rate for Payer: Aetna Commercial |
$19.30
|
| Rate for Payer: Aetna Medicare |
$5.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.09
|
| Rate for Payer: BCBS Complete |
$9.08
|
| Rate for Payer: BCBS MAPPO |
$5.68
|
| Rate for Payer: BCBS Trust/PPO |
$18.66
|
| Rate for Payer: BCN Commercial |
$17.65
|
| Rate for Payer: BCN Medicare Advantage |
$5.68
|
| Rate for Payer: Cash Price |
$18.16
|
| Rate for Payer: Cofinity Commercial |
$19.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.68
|
| Rate for Payer: Healthscope Commercial |
$20.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.30
|
| Rate for Payer: Nomi Health Commercial |
$18.61
|
| Rate for Payer: PACE Senior Care Partners |
$5.39
|
| Rate for Payer: PACE SWMI |
$5.68
|
| Rate for Payer: PHP Commercial |
$19.30
|
| Rate for Payer: PHP Medicare Advantage |
$5.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.76
|
| Rate for Payer: Priority Health HMO/PPO |
$19.75
|
| Rate for Payer: Priority Health Medicare |
$5.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.21
|
| Rate for Payer: Railroad Medicare Medicare |
$5.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.98
|
| Rate for Payer: UHC Core |
$18.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.68
|
| Rate for Payer: UHC Exchange |
$5.68
|
| Rate for Payer: UHC Medicare Advantage |
$5.68
|
| Rate for Payer: VA VA |
$5.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.02
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.70
|
|
|
Service Code
|
NDC 51754500101
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$20.43 |
| Rate for Payer: Aetna Commercial |
$19.30
|
| Rate for Payer: BCBS Trust/PPO |
$18.53
|
| Rate for Payer: BCN Commercial |
$17.54
|
| Rate for Payer: Cash Price |
$18.16
|
| Rate for Payer: Cofinity Commercial |
$19.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.16
|
| Rate for Payer: Healthscope Commercial |
$20.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.30
|
| Rate for Payer: Nomi Health Commercial |
$18.61
|
| Rate for Payer: PHP Commercial |
$19.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.76
|
| Rate for Payer: Priority Health HMO/PPO |
$19.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.98
|
| Rate for Payer: UHC Core |
$18.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.02
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$35.60
|
|
|
Service Code
|
NDC 00409662522
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.14 |
| Max. Negotiated Rate |
$32.04 |
| Rate for Payer: Aetna Commercial |
$30.26
|
| Rate for Payer: BCBS Trust/PPO |
$29.06
|
| Rate for Payer: BCN Commercial |
$27.51
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Healthscope Commercial |
$32.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.26
|
| Rate for Payer: Nomi Health Commercial |
$29.19
|
| Rate for Payer: PHP Commercial |
$30.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.14
|
| Rate for Payer: Priority Health HMO/PPO |
$30.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.33
|
| Rate for Payer: UHC Core |
$29.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.70
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$35.60
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$32.04 |
| Rate for Payer: Aetna Commercial |
$30.26
|
| Rate for Payer: Aetna Medicare |
$9.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.12
|
| Rate for Payer: BCBS Complete |
$14.24
|
| Rate for Payer: BCBS MAPPO |
$8.90
|
| Rate for Payer: BCBS Trust/PPO |
$29.27
|
| Rate for Payer: BCN Commercial |
$27.68
|
| Rate for Payer: BCN Medicare Advantage |
$8.90
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.90
|
| Rate for Payer: Healthscope Commercial |
$32.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.26
|
| Rate for Payer: Nomi Health Commercial |
$29.19
|
| Rate for Payer: PACE Senior Care Partners |
$8.46
|
| Rate for Payer: PACE SWMI |
$8.90
|
| Rate for Payer: PHP Commercial |
$30.26
|
| Rate for Payer: PHP Medicare Advantage |
$8.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.14
|
| Rate for Payer: Priority Health HMO/PPO |
$30.97
|
| Rate for Payer: Priority Health Medicare |
$8.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.85
|
| Rate for Payer: Railroad Medicare Medicare |
$8.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.33
|
| Rate for Payer: UHC Core |
$29.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.90
|
| Rate for Payer: UHC Exchange |
$8.90
|
| Rate for Payer: UHC Medicare Advantage |
$8.90
|
| Rate for Payer: VA VA |
$8.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.70
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23.81
|
|
|
Service Code
|
NDC 51754500105
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$21.43 |
| Rate for Payer: Aetna Commercial |
$20.24
|
| Rate for Payer: Aetna Medicare |
$6.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.44
|
| Rate for Payer: BCBS Complete |
$9.52
|
| Rate for Payer: BCBS MAPPO |
$5.95
|
| Rate for Payer: BCBS Trust/PPO |
$19.57
|
| Rate for Payer: BCN Commercial |
$18.51
|
| Rate for Payer: BCN Medicare Advantage |
$5.95
|
| Rate for Payer: Cash Price |
$19.05
|
| Rate for Payer: Cofinity Commercial |
$20.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.95
|
| Rate for Payer: Healthscope Commercial |
$21.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.24
|
| Rate for Payer: Nomi Health Commercial |
$19.52
|
| Rate for Payer: PACE Senior Care Partners |
$5.65
|
| Rate for Payer: PACE SWMI |
$5.95
|
| Rate for Payer: PHP Commercial |
$20.24
|
| Rate for Payer: PHP Medicare Advantage |
$5.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.48
|
| Rate for Payer: Priority Health HMO/PPO |
$20.71
|
| Rate for Payer: Priority Health Medicare |
$6.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.95
|
| Rate for Payer: Railroad Medicare Medicare |
$5.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.95
|
| Rate for Payer: UHC Core |
$19.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.95
|
| Rate for Payer: UHC Exchange |
$5.95
|
| Rate for Payer: UHC Medicare Advantage |
$5.95
|
| Rate for Payer: VA VA |
$5.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.86
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.81
|
|
|
Service Code
|
NDC 51754500105
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.48 |
| Max. Negotiated Rate |
$21.43 |
| Rate for Payer: Aetna Commercial |
$20.24
|
| Rate for Payer: BCBS Trust/PPO |
$19.44
|
| Rate for Payer: BCN Commercial |
$18.40
|
| Rate for Payer: Cash Price |
$19.05
|
| Rate for Payer: Cofinity Commercial |
$20.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.05
|
| Rate for Payer: Healthscope Commercial |
$21.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.24
|
| Rate for Payer: Nomi Health Commercial |
$19.52
|
| Rate for Payer: PHP Commercial |
$20.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.48
|
| Rate for Payer: Priority Health HMO/PPO |
$20.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.95
|
| Rate for Payer: UHC Core |
$19.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.86
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$35.60
|
|
|
Service Code
|
NDC 00409662522
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$32.04 |
| Rate for Payer: Aetna Commercial |
$30.26
|
| Rate for Payer: Aetna Medicare |
$9.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.12
|
| Rate for Payer: BCBS Complete |
$14.24
|
| Rate for Payer: BCBS MAPPO |
$8.90
|
| Rate for Payer: BCBS Trust/PPO |
$29.27
|
| Rate for Payer: BCN Commercial |
$27.68
|
| Rate for Payer: BCN Medicare Advantage |
$8.90
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$30.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.90
|
| Rate for Payer: Healthscope Commercial |
$32.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.26
|
| Rate for Payer: Nomi Health Commercial |
$29.19
|
| Rate for Payer: PACE Senior Care Partners |
$8.46
|
| Rate for Payer: PACE SWMI |
$8.90
|
| Rate for Payer: PHP Commercial |
$30.26
|
| Rate for Payer: PHP Medicare Advantage |
$8.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.14
|
| Rate for Payer: Priority Health HMO/PPO |
$30.97
|
| Rate for Payer: Priority Health Medicare |
$8.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.85
|
| Rate for Payer: Railroad Medicare Medicare |
$8.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.33
|
| Rate for Payer: UHC Core |
$29.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.90
|
| Rate for Payer: UHC Exchange |
$8.90
|
| Rate for Payer: UHC Medicare Advantage |
$8.90
|
| Rate for Payer: VA VA |
$8.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.70
|
|
|
SODIUM BICARBONATE 2485 MG-CITRIC ACID 1949 MG (PICOT) POWDER PACKET
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 64613004562
|
| Hospital Charge Code |
301795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: BCBS Trust/PPO |
$3.59
|
| Rate for Payer: BCN Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: Cofinity Commercial |
$3.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.52
|
| Rate for Payer: Healthscope Commercial |
$3.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.74
|
| Rate for Payer: Nomi Health Commercial |
$3.61
|
| Rate for Payer: PHP Commercial |
$3.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.86
|
| Rate for Payer: Priority Health HMO/PPO |
$3.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.87
|
| Rate for Payer: UHC Core |
$3.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.30
|
|
|
SODIUM BICARBONATE 2485 MG-CITRIC ACID 1949 MG (PICOT) POWDER PACKET
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 64613004562
|
| Hospital Charge Code |
301795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Medicare |
$1.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.38
|
| Rate for Payer: BCBS Complete |
$1.76
|
| Rate for Payer: BCBS MAPPO |
$1.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.62
|
| Rate for Payer: BCN Commercial |
$3.42
|
| Rate for Payer: BCN Medicare Advantage |
$1.10
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: Cofinity Commercial |
$3.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.10
|
| Rate for Payer: Healthscope Commercial |
$3.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.74
|
| Rate for Payer: Nomi Health Commercial |
$3.61
|
| Rate for Payer: PACE Senior Care Partners |
$1.04
|
| Rate for Payer: PACE SWMI |
$1.10
|
| Rate for Payer: PHP Commercial |
$3.74
|
| Rate for Payer: PHP Medicare Advantage |
$1.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.86
|
| Rate for Payer: Priority Health HMO/PPO |
$3.83
|
| Rate for Payer: Priority Health Medicare |
$1.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.95
|
| Rate for Payer: Railroad Medicare Medicare |
$1.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.87
|
| Rate for Payer: UHC Core |
$3.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.10
|
| Rate for Payer: UHC Exchange |
$1.10
|
| Rate for Payer: UHC Medicare Advantage |
$1.10
|
| Rate for Payer: VA VA |
$1.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.30
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
|
OP
|
$265.55
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.07 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna Commercial |
$225.72
|
| Rate for Payer: Aetna Medicare |
$69.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$82.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$82.98
|
| Rate for Payer: BCBS Complete |
$106.22
|
| Rate for Payer: BCBS MAPPO |
$66.39
|
| Rate for Payer: BCBS Trust/PPO |
$218.31
|
| Rate for Payer: BCN Commercial |
$206.47
|
| Rate for Payer: BCN Medicare Advantage |
$66.39
|
| Rate for Payer: Cash Price |
$212.44
|
| Rate for Payer: Cofinity Commercial |
$228.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$66.39
|
| Rate for Payer: Healthscope Commercial |
$239.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$69.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.72
|
| Rate for Payer: Nomi Health Commercial |
$217.75
|
| Rate for Payer: PACE Senior Care Partners |
$63.07
|
| Rate for Payer: PACE SWMI |
$66.39
|
| Rate for Payer: PHP Commercial |
$225.72
|
| Rate for Payer: PHP Medicare Advantage |
$66.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.61
|
| Rate for Payer: Priority Health HMO/PPO |
$231.03
|
| Rate for Payer: Priority Health Medicare |
$67.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$177.92
|
| Rate for Payer: Railroad Medicare Medicare |
$66.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$233.68
|
| Rate for Payer: UHC Core |
$221.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$66.39
|
| Rate for Payer: UHC Exchange |
$66.39
|
| Rate for Payer: UHC Medicare Advantage |
$66.39
|
| Rate for Payer: VA VA |
$66.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.16
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
|
IP
|
$265.55
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.61 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna Commercial |
$225.72
|
| Rate for Payer: BCBS Trust/PPO |
$216.77
|
| Rate for Payer: BCN Commercial |
$205.22
|
| Rate for Payer: Cash Price |
$212.44
|
| Rate for Payer: Cofinity Commercial |
$228.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Healthscope Commercial |
$239.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.72
|
| Rate for Payer: Nomi Health Commercial |
$217.75
|
| Rate for Payer: PHP Commercial |
$225.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.61
|
| Rate for Payer: Priority Health HMO/PPO |
$231.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$177.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$233.68
|
| Rate for Payer: UHC Core |
$221.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.16
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
|
IP
|
$159.80
|
|
|
Service Code
|
NDC 00223172101
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.87 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: BCBS Trust/PPO |
$130.44
|
| Rate for Payer: BCN Commercial |
$123.49
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.83
|
| Rate for Payer: Nomi Health Commercial |
$131.04
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.87
|
| Rate for Payer: Priority Health HMO/PPO |
$139.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$107.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$140.62
|
| Rate for Payer: UHC Core |
$133.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
|
OP
|
$159.80
|
|
|
Service Code
|
NDC 00223172101
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.95 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: Aetna Medicare |
$41.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$49.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$49.94
|
| Rate for Payer: BCBS Complete |
$63.92
|
| Rate for Payer: BCBS MAPPO |
$39.95
|
| Rate for Payer: BCBS Trust/PPO |
$131.37
|
| Rate for Payer: BCN Commercial |
$124.24
|
| Rate for Payer: BCN Medicare Advantage |
$39.95
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.95
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$41.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.83
|
| Rate for Payer: Nomi Health Commercial |
$131.04
|
| Rate for Payer: PACE Senior Care Partners |
$37.95
|
| Rate for Payer: PACE SWMI |
$39.95
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: PHP Medicare Advantage |
$39.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.87
|
| Rate for Payer: Priority Health HMO/PPO |
$139.03
|
| Rate for Payer: Priority Health Medicare |
$40.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$107.07
|
| Rate for Payer: Railroad Medicare Medicare |
$39.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$140.62
|
| Rate for Payer: UHC Core |
$133.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.95
|
| Rate for Payer: UHC Exchange |
$39.95
|
| Rate for Payer: UHC Medicare Advantage |
$39.95
|
| Rate for Payer: VA VA |
$39.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$72.32
|
|
|
Service Code
|
NDC 00409663724
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.18 |
| Max. Negotiated Rate |
$65.09 |
| Rate for Payer: Aetna Commercial |
$61.47
|
| Rate for Payer: Aetna Medicare |
$18.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.60
|
| Rate for Payer: BCBS Complete |
$28.93
|
| Rate for Payer: BCBS MAPPO |
$18.08
|
| Rate for Payer: BCBS Trust/PPO |
$59.45
|
| Rate for Payer: BCN Commercial |
$56.23
|
| Rate for Payer: BCN Medicare Advantage |
$18.08
|
| Rate for Payer: Cash Price |
$57.86
|
| Rate for Payer: Cofinity Commercial |
$62.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.08
|
| Rate for Payer: Healthscope Commercial |
$65.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.47
|
| Rate for Payer: Nomi Health Commercial |
$59.30
|
| Rate for Payer: PACE Senior Care Partners |
$17.18
|
| Rate for Payer: PACE SWMI |
$18.08
|
| Rate for Payer: PHP Commercial |
$61.47
|
| Rate for Payer: PHP Medicare Advantage |
$18.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.01
|
| Rate for Payer: Priority Health HMO/PPO |
$62.92
|
| Rate for Payer: Priority Health Medicare |
$18.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$48.45
|
| Rate for Payer: Railroad Medicare Medicare |
$18.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.64
|
| Rate for Payer: UHC Core |
$60.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.08
|
| Rate for Payer: UHC Exchange |
$18.08
|
| Rate for Payer: UHC Medicare Advantage |
$18.08
|
| Rate for Payer: VA VA |
$18.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.24
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$66.75
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.39 |
| Max. Negotiated Rate |
$60.08 |
| Rate for Payer: Aetna Commercial |
$56.74
|
| Rate for Payer: BCBS Trust/PPO |
$54.49
|
| Rate for Payer: BCN Commercial |
$51.58
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cofinity Commercial |
$57.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.40
|
| Rate for Payer: Healthscope Commercial |
$60.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.74
|
| Rate for Payer: Nomi Health Commercial |
$54.74
|
| Rate for Payer: PHP Commercial |
$56.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.39
|
| Rate for Payer: Priority Health HMO/PPO |
$58.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.74
|
| Rate for Payer: UHC Core |
$55.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.06
|
|
