|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$19.69
|
|
|
Service Code
|
NDC 00641614701
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: Aetna Commercial |
$16.74
|
| Rate for Payer: Aetna Medicare |
$5.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.15
|
| Rate for Payer: BCBS Complete |
$7.88
|
| Rate for Payer: BCBS MAPPO |
$4.92
|
| Rate for Payer: BCBS Trust/PPO |
$16.19
|
| Rate for Payer: BCN Commercial |
$15.31
|
| Rate for Payer: BCN Medicare Advantage |
$4.92
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cofinity Commercial |
$16.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.92
|
| Rate for Payer: Healthscope Commercial |
$17.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.74
|
| Rate for Payer: Nomi Health Commercial |
$16.15
|
| Rate for Payer: PACE Senior Care Partners |
$4.68
|
| Rate for Payer: PACE SWMI |
$4.92
|
| Rate for Payer: PHP Commercial |
$16.74
|
| Rate for Payer: PHP Medicare Advantage |
$4.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.80
|
| Rate for Payer: Priority Health HMO/PPO |
$17.13
|
| Rate for Payer: Priority Health Medicare |
$4.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.19
|
| Rate for Payer: Railroad Medicare Medicare |
$4.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.33
|
| Rate for Payer: UHC Core |
$16.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.92
|
| Rate for Payer: UHC Exchange |
$4.92
|
| Rate for Payer: UHC Medicare Advantage |
$4.92
|
| Rate for Payer: VA VA |
$4.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.77
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$13.75
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Aetna Commercial |
$11.69
|
| Rate for Payer: Aetna Medicare |
$3.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.30
|
| Rate for Payer: BCBS Complete |
$5.50
|
| Rate for Payer: BCBS MAPPO |
$3.44
|
| Rate for Payer: BCBS Trust/PPO |
$11.30
|
| Rate for Payer: BCN Commercial |
$10.69
|
| Rate for Payer: BCN Medicare Advantage |
$3.44
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cofinity Commercial |
$11.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.44
|
| Rate for Payer: Healthscope Commercial |
$12.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.69
|
| Rate for Payer: Nomi Health Commercial |
$11.28
|
| Rate for Payer: PACE Senior Care Partners |
$3.27
|
| Rate for Payer: PACE SWMI |
$3.44
|
| Rate for Payer: PHP Commercial |
$11.69
|
| Rate for Payer: PHP Medicare Advantage |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.94
|
| Rate for Payer: Priority Health HMO/PPO |
$11.96
|
| Rate for Payer: Priority Health Medicare |
$3.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.10
|
| Rate for Payer: UHC Core |
$11.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.44
|
| Rate for Payer: UHC Exchange |
$3.44
|
| Rate for Payer: UHC Medicare Advantage |
$3.44
|
| Rate for Payer: VA VA |
$3.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.31
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$13.75
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Aetna Commercial |
$11.69
|
| Rate for Payer: BCBS Trust/PPO |
$11.22
|
| Rate for Payer: BCN Commercial |
$10.63
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cofinity Commercial |
$11.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.00
|
| Rate for Payer: Healthscope Commercial |
$12.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.69
|
| Rate for Payer: Nomi Health Commercial |
$11.28
|
| Rate for Payer: PHP Commercial |
$11.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.94
|
| Rate for Payer: Priority Health HMO/PPO |
$11.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.10
|
| Rate for Payer: UHC Core |
$11.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.31
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$14.79
|
|
|
Service Code
|
NDC 00409488720
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$13.31 |
| Rate for Payer: Aetna Commercial |
$12.57
|
| Rate for Payer: BCBS Trust/PPO |
$12.07
|
| Rate for Payer: BCN Commercial |
$11.43
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: Cofinity Commercial |
$12.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.83
|
| Rate for Payer: Healthscope Commercial |
$13.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.57
|
| Rate for Payer: Nomi Health Commercial |
$12.13
|
| Rate for Payer: PHP Commercial |
$12.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.61
|
| Rate for Payer: Priority Health HMO/PPO |
$12.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.02
|
| Rate for Payer: UHC Core |
$12.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.09
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$14.79
|
|
|
Service Code
|
NDC 00409488720
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$13.31 |
| Rate for Payer: Aetna Commercial |
$12.57
|
| Rate for Payer: Aetna Medicare |
$3.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.62
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS MAPPO |
$3.70
|
| Rate for Payer: BCBS Trust/PPO |
$12.16
|
| Rate for Payer: BCN Commercial |
$11.50
|
| Rate for Payer: BCN Medicare Advantage |
$3.70
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: Cofinity Commercial |
$12.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.70
|
| Rate for Payer: Healthscope Commercial |
$13.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.57
|
| Rate for Payer: Nomi Health Commercial |
$12.13
|
| Rate for Payer: PACE Senior Care Partners |
$3.51
|
| Rate for Payer: PACE SWMI |
$3.70
|
| Rate for Payer: PHP Commercial |
$12.57
|
| Rate for Payer: PHP Medicare Advantage |
$3.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.61
|
| Rate for Payer: Priority Health HMO/PPO |
$12.87
|
| Rate for Payer: Priority Health Medicare |
$3.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.02
|
| Rate for Payer: UHC Core |
$12.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.70
|
| Rate for Payer: UHC Exchange |
$3.70
|
| Rate for Payer: UHC Medicare Advantage |
$3.70
|
| Rate for Payer: VA VA |
$3.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.09
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$19.69
|
|
|
Service Code
|
NDC 00641614710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: Aetna Commercial |
$16.74
|
| Rate for Payer: BCBS Trust/PPO |
$16.07
|
| Rate for Payer: BCN Commercial |
$15.22
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cofinity Commercial |
$16.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.75
|
| Rate for Payer: Healthscope Commercial |
$17.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.74
|
| Rate for Payer: Nomi Health Commercial |
$16.15
|
| Rate for Payer: PHP Commercial |
$16.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.80
|
| Rate for Payer: Priority Health HMO/PPO |
$17.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.33
|
| Rate for Payer: UHC Core |
$16.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.77
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$13.75
|
|
|
Service Code
|
NDC 00409488717
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Aetna Commercial |
$11.69
|
| Rate for Payer: Aetna Medicare |
$3.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.30
|
| Rate for Payer: BCBS Complete |
$5.50
|
| Rate for Payer: BCBS MAPPO |
$3.44
|
| Rate for Payer: BCBS Trust/PPO |
$11.30
|
| Rate for Payer: BCN Commercial |
$10.69
|
| Rate for Payer: BCN Medicare Advantage |
$3.44
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cofinity Commercial |
$11.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.44
|
| Rate for Payer: Healthscope Commercial |
$12.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.69
|
| Rate for Payer: Nomi Health Commercial |
$11.28
|
| Rate for Payer: PACE Senior Care Partners |
$3.27
|
| Rate for Payer: PACE SWMI |
$3.44
|
| Rate for Payer: PHP Commercial |
$11.69
|
| Rate for Payer: PHP Medicare Advantage |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.94
|
| Rate for Payer: Priority Health HMO/PPO |
$11.96
|
| Rate for Payer: Priority Health Medicare |
$3.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.10
|
| Rate for Payer: UHC Core |
$11.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.44
|
| Rate for Payer: UHC Exchange |
$3.44
|
| Rate for Payer: UHC Medicare Advantage |
$3.44
|
| Rate for Payer: VA VA |
$3.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.31
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$19.69
|
|
|
Service Code
|
NDC 00641614701
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: Aetna Commercial |
$16.74
|
| Rate for Payer: BCBS Trust/PPO |
$16.07
|
| Rate for Payer: BCN Commercial |
$15.22
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cofinity Commercial |
$16.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.75
|
| Rate for Payer: Healthscope Commercial |
$17.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.74
|
| Rate for Payer: Nomi Health Commercial |
$16.15
|
| Rate for Payer: PHP Commercial |
$16.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.80
|
| Rate for Payer: Priority Health HMO/PPO |
$17.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.33
|
| Rate for Payer: UHC Core |
$16.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.77
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION FOR SOLID FORM MIXTURES
|
Facility
|
IP
|
$18.12
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
301772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$16.31 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: BCBS Trust/PPO |
$14.79
|
| Rate for Payer: BCN Commercial |
$14.00
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cofinity Commercial |
$15.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.50
|
| Rate for Payer: Healthscope Commercial |
$16.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.40
|
| Rate for Payer: Nomi Health Commercial |
$14.86
|
| Rate for Payer: PHP Commercial |
$15.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.78
|
| Rate for Payer: Priority Health HMO/PPO |
$15.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.95
|
| Rate for Payer: UHC Core |
$15.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.59
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION FOR SOLID FORM MIXTURES
|
Facility
|
OP
|
$18.12
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
301772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$16.31 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Aetna Medicare |
$4.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.66
|
| Rate for Payer: BCBS Complete |
$7.25
|
| Rate for Payer: BCBS MAPPO |
$4.53
|
| Rate for Payer: BCBS Trust/PPO |
$14.90
|
| Rate for Payer: BCN Commercial |
$14.09
|
| Rate for Payer: BCN Medicare Advantage |
$4.53
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cofinity Commercial |
$15.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.53
|
| Rate for Payer: Healthscope Commercial |
$16.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.40
|
| Rate for Payer: Nomi Health Commercial |
$14.86
|
| Rate for Payer: PACE Senior Care Partners |
$4.30
|
| Rate for Payer: PACE SWMI |
$4.53
|
| Rate for Payer: PHP Commercial |
$15.40
|
| Rate for Payer: PHP Medicare Advantage |
$4.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.78
|
| Rate for Payer: Priority Health HMO/PPO |
$15.76
|
| Rate for Payer: Priority Health Medicare |
$4.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.14
|
| Rate for Payer: Railroad Medicare Medicare |
$4.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.95
|
| Rate for Payer: UHC Core |
$15.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.53
|
| Rate for Payer: UHC Exchange |
$4.53
|
| Rate for Payer: UHC Medicare Advantage |
$4.53
|
| Rate for Payer: VA VA |
$4.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.59
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$47.85
|
|
|
Service Code
|
NDC 00338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$43.06 |
| Rate for Payer: Aetna Commercial |
$40.67
|
| Rate for Payer: Aetna Medicare |
$12.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14.95
|
| Rate for Payer: BCBS Complete |
$19.14
|
| Rate for Payer: BCBS MAPPO |
$11.96
|
| Rate for Payer: BCBS Trust/PPO |
$39.34
|
| Rate for Payer: BCN Commercial |
$37.20
|
| Rate for Payer: BCN Medicare Advantage |
$11.96
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$41.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.96
|
| Rate for Payer: Healthscope Commercial |
$43.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Nomi Health Commercial |
$39.24
|
| Rate for Payer: PACE Senior Care Partners |
$11.36
|
| Rate for Payer: PACE SWMI |
$11.96
|
| Rate for Payer: PHP Commercial |
$40.67
|
| Rate for Payer: PHP Medicare Advantage |
$11.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.10
|
| Rate for Payer: Priority Health HMO/PPO |
$41.63
|
| Rate for Payer: Priority Health Medicare |
$12.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.06
|
| Rate for Payer: Railroad Medicare Medicare |
$11.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.11
|
| Rate for Payer: UHC Core |
$39.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$11.96
|
| Rate for Payer: UHC Exchange |
$11.96
|
| Rate for Payer: UHC Medicare Advantage |
$11.96
|
| Rate for Payer: VA VA |
$11.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.89
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$47.85
|
|
|
Service Code
|
NDC 00338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.10 |
| Max. Negotiated Rate |
$43.06 |
| Rate for Payer: Aetna Commercial |
$40.67
|
| Rate for Payer: BCBS Trust/PPO |
$39.06
|
| Rate for Payer: BCN Commercial |
$36.98
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$41.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$43.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Nomi Health Commercial |
$39.24
|
| Rate for Payer: PHP Commercial |
$40.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.10
|
| Rate for Payer: Priority Health HMO/PPO |
$41.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.11
|
| Rate for Payer: UHC Core |
$39.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.89
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
OP
|
$79.75
|
|
|
Service Code
|
NDC 00338000402
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.94 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Medicare |
$20.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.92
|
| Rate for Payer: BCBS Complete |
$31.90
|
| Rate for Payer: BCBS MAPPO |
$19.94
|
| Rate for Payer: BCBS Trust/PPO |
$65.56
|
| Rate for Payer: BCN Commercial |
$62.01
|
| Rate for Payer: BCN Medicare Advantage |
$19.94
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.94
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Nomi Health Commercial |
$65.40
|
| Rate for Payer: PACE Senior Care Partners |
$18.94
|
| Rate for Payer: PACE SWMI |
$19.94
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: PHP Medicare Advantage |
$19.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.84
|
| Rate for Payer: Priority Health HMO/PPO |
$69.38
|
| Rate for Payer: Priority Health Medicare |
$20.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.43
|
| Rate for Payer: Railroad Medicare Medicare |
$19.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.18
|
| Rate for Payer: UHC Core |
$66.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.94
|
| Rate for Payer: UHC Exchange |
$19.94
|
| Rate for Payer: UHC Medicare Advantage |
$19.94
|
| Rate for Payer: VA VA |
$19.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.81
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
IP
|
$79.75
|
|
|
Service Code
|
NDC 00338000402
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.84 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: BCBS Trust/PPO |
$65.10
|
| Rate for Payer: BCN Commercial |
$61.63
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Nomi Health Commercial |
$65.40
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.84
|
| Rate for Payer: Priority Health HMO/PPO |
$69.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.18
|
| Rate for Payer: UHC Core |
$66.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.81
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
OP
|
$47.85
|
|
|
Service Code
|
NDC 00338000405
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$43.06 |
| Rate for Payer: Aetna Commercial |
$40.67
|
| Rate for Payer: Aetna Medicare |
$12.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14.95
|
| Rate for Payer: BCBS Complete |
$19.14
|
| Rate for Payer: BCBS MAPPO |
$11.96
|
| Rate for Payer: BCBS Trust/PPO |
$39.34
|
| Rate for Payer: BCN Commercial |
$37.20
|
| Rate for Payer: BCN Medicare Advantage |
$11.96
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$41.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.96
|
| Rate for Payer: Healthscope Commercial |
$43.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Nomi Health Commercial |
$39.24
|
| Rate for Payer: PACE Senior Care Partners |
$11.36
|
| Rate for Payer: PACE SWMI |
$11.96
|
| Rate for Payer: PHP Commercial |
$40.67
|
| Rate for Payer: PHP Medicare Advantage |
$11.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.10
|
| Rate for Payer: Priority Health HMO/PPO |
$41.63
|
| Rate for Payer: Priority Health Medicare |
$12.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.06
|
| Rate for Payer: Railroad Medicare Medicare |
$11.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.11
|
| Rate for Payer: UHC Core |
$39.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$11.96
|
| Rate for Payer: UHC Exchange |
$11.96
|
| Rate for Payer: UHC Medicare Advantage |
$11.96
|
| Rate for Payer: VA VA |
$11.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.89
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
IP
|
$47.85
|
|
|
Service Code
|
NDC 00338000405
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.10 |
| Max. Negotiated Rate |
$43.06 |
| Rate for Payer: Aetna Commercial |
$40.67
|
| Rate for Payer: BCBS Trust/PPO |
$39.06
|
| Rate for Payer: BCN Commercial |
$36.98
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$41.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$43.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Nomi Health Commercial |
$39.24
|
| Rate for Payer: PHP Commercial |
$40.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.10
|
| Rate for Payer: Priority Health HMO/PPO |
$41.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.11
|
| Rate for Payer: UHC Core |
$39.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.89
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Medicare |
$7.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.69
|
| Rate for Payer: BCBS Complete |
$11.12
|
| Rate for Payer: BCBS MAPPO |
$6.95
|
| Rate for Payer: BCBS Trust/PPO |
$22.85
|
| Rate for Payer: BCN Commercial |
$21.61
|
| Rate for Payer: BCN Medicare Advantage |
$6.95
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.95
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.80
|
| Rate for Payer: PACE Senior Care Partners |
$6.60
|
| Rate for Payer: PACE SWMI |
$6.95
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: PHP Medicare Advantage |
$6.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.07
|
| Rate for Payer: Priority Health HMO/PPO |
$24.19
|
| Rate for Payer: Priority Health Medicare |
$7.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.63
|
| Rate for Payer: Railroad Medicare Medicare |
$6.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.46
|
| Rate for Payer: UHC Core |
$23.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.95
|
| Rate for Payer: UHC Exchange |
$6.95
|
| Rate for Payer: UHC Medicare Advantage |
$6.95
|
| Rate for Payer: VA VA |
$6.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.85
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.07 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: BCBS Trust/PPO |
$22.69
|
| Rate for Payer: BCN Commercial |
$21.48
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.80
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.07
|
| Rate for Payer: Priority Health HMO/PPO |
$24.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.46
|
| Rate for Payer: UHC Core |
$23.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.85
|
|
|
WHITE PETROLATUM EYE OINTMENT WRAPPER
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
301577
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Medicare |
$7.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.69
|
| Rate for Payer: BCBS Complete |
$11.12
|
| Rate for Payer: BCBS MAPPO |
$6.95
|
| Rate for Payer: BCBS Trust/PPO |
$22.85
|
| Rate for Payer: BCN Commercial |
$21.61
|
| Rate for Payer: BCN Medicare Advantage |
$6.95
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.95
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.80
|
| Rate for Payer: PACE Senior Care Partners |
$6.60
|
| Rate for Payer: PACE SWMI |
$6.95
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: PHP Medicare Advantage |
$6.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.07
|
| Rate for Payer: Priority Health HMO/PPO |
$24.19
|
| Rate for Payer: Priority Health Medicare |
$7.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.63
|
| Rate for Payer: Railroad Medicare Medicare |
$6.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.46
|
| Rate for Payer: UHC Core |
$23.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.95
|
| Rate for Payer: UHC Exchange |
$6.95
|
| Rate for Payer: UHC Medicare Advantage |
$6.95
|
| Rate for Payer: VA VA |
$6.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.85
|
|
|
WHITE PETROLATUM EYE OINTMENT WRAPPER
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
301577
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.07 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: BCBS Trust/PPO |
$22.69
|
| Rate for Payer: BCN Commercial |
$21.48
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.80
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.07
|
| Rate for Payer: Priority Health HMO/PPO |
$24.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.46
|
| Rate for Payer: UHC Core |
$23.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.85
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
|
IP
|
$31.82
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Aetna Commercial |
$27.05
|
| Rate for Payer: BCBS Trust/PPO |
$25.97
|
| Rate for Payer: BCN Commercial |
$24.59
|
| Rate for Payer: Cash Price |
$25.46
|
| Rate for Payer: Cofinity Commercial |
$27.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.46
|
| Rate for Payer: Healthscope Commercial |
$28.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.05
|
| Rate for Payer: Nomi Health Commercial |
$26.09
|
| Rate for Payer: PHP Commercial |
$27.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.68
|
| Rate for Payer: Priority Health HMO/PPO |
$27.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.00
|
| Rate for Payer: UHC Core |
$26.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.86
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
|
OP
|
$31.82
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Aetna Commercial |
$27.05
|
| Rate for Payer: Aetna Medicare |
$8.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.94
|
| Rate for Payer: BCBS Complete |
$12.73
|
| Rate for Payer: BCBS MAPPO |
$7.96
|
| Rate for Payer: BCBS Trust/PPO |
$26.16
|
| Rate for Payer: BCN Commercial |
$24.74
|
| Rate for Payer: BCN Medicare Advantage |
$7.96
|
| Rate for Payer: Cash Price |
$25.46
|
| Rate for Payer: Cofinity Commercial |
$27.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.96
|
| Rate for Payer: Healthscope Commercial |
$28.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.05
|
| Rate for Payer: Nomi Health Commercial |
$26.09
|
| Rate for Payer: PACE Senior Care Partners |
$7.56
|
| Rate for Payer: PACE SWMI |
$7.96
|
| Rate for Payer: PHP Commercial |
$27.05
|
| Rate for Payer: PHP Medicare Advantage |
$7.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.68
|
| Rate for Payer: Priority Health HMO/PPO |
$27.68
|
| Rate for Payer: Priority Health Medicare |
$8.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.32
|
| Rate for Payer: Railroad Medicare Medicare |
$7.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.00
|
| Rate for Payer: UHC Core |
$26.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.96
|
| Rate for Payer: UHC Exchange |
$7.96
|
| Rate for Payer: UHC Medicare Advantage |
$7.96
|
| Rate for Payer: VA VA |
$7.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.86
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM
|
Facility
|
OP
|
$12.88
|
|
|
Service Code
|
NDC 61924017804
|
| Hospital Charge Code |
11371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna Medicare |
$3.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.02
|
| Rate for Payer: BCBS Complete |
$5.15
|
| Rate for Payer: BCBS MAPPO |
$3.22
|
| Rate for Payer: BCBS Trust/PPO |
$10.59
|
| Rate for Payer: BCN Commercial |
$10.01
|
| Rate for Payer: BCN Medicare Advantage |
$3.22
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Nomi Health Commercial |
$10.56
|
| Rate for Payer: PACE Senior Care Partners |
$3.06
|
| Rate for Payer: PACE SWMI |
$3.22
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: PHP Medicare Advantage |
$3.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.37
|
| Rate for Payer: Priority Health HMO/PPO |
$11.21
|
| Rate for Payer: Priority Health Medicare |
$3.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.63
|
| Rate for Payer: Railroad Medicare Medicare |
$3.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.33
|
| Rate for Payer: UHC Core |
$10.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.22
|
| Rate for Payer: UHC Exchange |
$3.22
|
| Rate for Payer: UHC Medicare Advantage |
$3.22
|
| Rate for Payer: VA VA |
$3.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.66
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM
|
Facility
|
IP
|
$12.88
|
|
|
Service Code
|
NDC 61924017804
|
| Hospital Charge Code |
11371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: BCBS Trust/PPO |
$10.51
|
| Rate for Payer: BCN Commercial |
$9.95
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Nomi Health Commercial |
$10.56
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.37
|
| Rate for Payer: Priority Health HMO/PPO |
$11.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.33
|
| Rate for Payer: UHC Core |
$10.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.66
|
|
|
ZAFIRLUKAST 20 MG TABLET
|
Facility
|
IP
|
$296.26
|
|
|
Service Code
|
NDC 68084005921
|
| Hospital Charge Code |
17960
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$266.63 |
| Rate for Payer: Aetna Commercial |
$251.82
|
| Rate for Payer: BCBS Trust/PPO |
$241.84
|
| Rate for Payer: BCN Commercial |
$228.95
|
| Rate for Payer: Cash Price |
$237.01
|
| Rate for Payer: Cofinity Commercial |
$254.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$237.01
|
| Rate for Payer: Healthscope Commercial |
$266.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$251.82
|
| Rate for Payer: Nomi Health Commercial |
$242.93
|
| Rate for Payer: PHP Commercial |
$251.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.57
|
| Rate for Payer: Priority Health HMO/PPO |
$257.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$198.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$260.71
|
| Rate for Payer: UHC Core |
$247.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.20
|
|
