|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$78.33
|
|
|
Service Code
|
NDC 65219005209
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.98 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna American Axle |
$50.91
|
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: Aetna Medicare |
$39.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.91
|
| Rate for Payer: BCBS Complete |
$31.33
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cofinity Commercial |
$54.83
|
| Rate for Payer: Cofinity Commercial |
$67.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.66
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.58
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.91
|
| Rate for Payer: Priority Health SBD |
$49.35
|
| Rate for Payer: UMR Bronson Commercial |
$28.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.75
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$410.64
|
|
|
Service Code
|
NDC 63323008615
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$180.68 |
| Max. Negotiated Rate |
$369.58 |
| Rate for Payer: Aetna American Axle |
$266.92
|
| Rate for Payer: Aetna Commercial |
$349.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.92
|
| Rate for Payer: Cash Price |
$328.51
|
| Rate for Payer: Cofinity Commercial |
$287.45
|
| Rate for Payer: Cofinity Commercial |
$353.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.51
|
| Rate for Payer: Healthscope Commercial |
$369.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.04
|
| Rate for Payer: PHP Commercial |
$349.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.92
|
| Rate for Payer: Priority Health SBD |
$258.70
|
| Rate for Payer: UMR Bronson Commercial |
$180.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.98
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$410.64
|
|
|
Service Code
|
NDC 63323008615
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$151.94 |
| Max. Negotiated Rate |
$369.58 |
| Rate for Payer: Aetna American Axle |
$266.92
|
| Rate for Payer: Aetna Commercial |
$349.04
|
| Rate for Payer: Aetna Medicare |
$205.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.92
|
| Rate for Payer: BCBS Complete |
$164.26
|
| Rate for Payer: Cash Price |
$328.51
|
| Rate for Payer: Cofinity Commercial |
$287.45
|
| Rate for Payer: Cofinity Commercial |
$353.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.51
|
| Rate for Payer: Healthscope Commercial |
$369.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.04
|
| Rate for Payer: PHP Commercial |
$349.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.92
|
| Rate for Payer: Priority Health SBD |
$258.70
|
| Rate for Payer: UMR Bronson Commercial |
$151.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.98
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$759.80
|
|
|
Service Code
|
NDC 65219005609
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$281.13 |
| Max. Negotiated Rate |
$683.82 |
| Rate for Payer: Aetna American Axle |
$493.87
|
| Rate for Payer: Aetna Commercial |
$645.83
|
| Rate for Payer: Aetna Medicare |
$379.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.87
|
| Rate for Payer: BCBS Complete |
$303.92
|
| Rate for Payer: Cash Price |
$607.84
|
| Rate for Payer: Cofinity Commercial |
$531.86
|
| Rate for Payer: Cofinity Commercial |
$653.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.84
|
| Rate for Payer: Healthscope Commercial |
$683.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.83
|
| Rate for Payer: PHP Commercial |
$645.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.87
|
| Rate for Payer: Priority Health SBD |
$478.67
|
| Rate for Payer: UMR Bronson Commercial |
$281.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.85
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$759.80
|
|
|
Service Code
|
NDC 65219005629
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$334.31 |
| Max. Negotiated Rate |
$683.82 |
| Rate for Payer: Aetna American Axle |
$493.87
|
| Rate for Payer: Aetna Commercial |
$645.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.87
|
| Rate for Payer: Cash Price |
$607.84
|
| Rate for Payer: Cofinity Commercial |
$531.86
|
| Rate for Payer: Cofinity Commercial |
$653.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.84
|
| Rate for Payer: Healthscope Commercial |
$683.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.83
|
| Rate for Payer: PHP Commercial |
$645.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.87
|
| Rate for Payer: Priority Health SBD |
$478.67
|
| Rate for Payer: UMR Bronson Commercial |
$334.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.85
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$77.78
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.22 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna American Axle |
$50.56
|
| Rate for Payer: Aetna Commercial |
$66.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.56
|
| Rate for Payer: Cash Price |
$62.22
|
| Rate for Payer: Cofinity Commercial |
$54.45
|
| Rate for Payer: Cofinity Commercial |
$66.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.22
|
| Rate for Payer: Healthscope Commercial |
$70.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.11
|
| Rate for Payer: PHP Commercial |
$66.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.56
|
| Rate for Payer: Priority Health SBD |
$49.00
|
| Rate for Payer: UMR Bronson Commercial |
$34.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.34
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.45
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.80 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna American Axle |
$129.64
|
| Rate for Payer: Aetna Commercial |
$169.53
|
| Rate for Payer: Aetna Medicare |
$99.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.64
|
| Rate for Payer: BCBS Complete |
$79.78
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$139.62
|
| Rate for Payer: Cofinity Commercial |
$171.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$179.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: PHP Commercial |
$169.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health SBD |
$125.65
|
| Rate for Payer: UMR Bronson Commercial |
$73.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.59
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$78.33
|
|
|
Service Code
|
NDC 65219005229
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.98 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna American Axle |
$50.91
|
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: Aetna Medicare |
$39.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.91
|
| Rate for Payer: BCBS Complete |
$31.33
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cofinity Commercial |
$54.83
|
| Rate for Payer: Cofinity Commercial |
$67.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.66
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.58
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.91
|
| Rate for Payer: Priority Health SBD |
$49.35
|
| Rate for Payer: UMR Bronson Commercial |
$28.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.75
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.45
|
|
|
Service Code
|
NDC 00409729511
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.80 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna American Axle |
$129.64
|
| Rate for Payer: Aetna Commercial |
$169.53
|
| Rate for Payer: Aetna Medicare |
$99.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.64
|
| Rate for Payer: BCBS Complete |
$79.78
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$139.62
|
| Rate for Payer: Cofinity Commercial |
$171.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$179.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: PHP Commercial |
$169.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health SBD |
$125.65
|
| Rate for Payer: UMR Bronson Commercial |
$73.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.59
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$199.45
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.76 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna American Axle |
$129.64
|
| Rate for Payer: Aetna Commercial |
$169.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.64
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$139.62
|
| Rate for Payer: Cofinity Commercial |
$171.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$179.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: PHP Commercial |
$169.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health SBD |
$125.65
|
| Rate for Payer: UMR Bronson Commercial |
$87.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.59
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$759.80
|
|
|
Service Code
|
NDC 65219005609
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$334.31 |
| Max. Negotiated Rate |
$683.82 |
| Rate for Payer: Aetna American Axle |
$493.87
|
| Rate for Payer: Aetna Commercial |
$645.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.87
|
| Rate for Payer: Cash Price |
$607.84
|
| Rate for Payer: Cofinity Commercial |
$531.86
|
| Rate for Payer: Cofinity Commercial |
$653.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$531.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.84
|
| Rate for Payer: Healthscope Commercial |
$683.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$531.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$569.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.83
|
| Rate for Payer: PHP Commercial |
$645.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$493.87
|
| Rate for Payer: Priority Health SBD |
$478.67
|
| Rate for Payer: UMR Bronson Commercial |
$334.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$569.85
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$77.78
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna American Axle |
$50.56
|
| Rate for Payer: Aetna Commercial |
$66.11
|
| Rate for Payer: Aetna Medicare |
$38.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.56
|
| Rate for Payer: BCBS Complete |
$31.11
|
| Rate for Payer: Cash Price |
$62.22
|
| Rate for Payer: Cofinity Commercial |
$54.45
|
| Rate for Payer: Cofinity Commercial |
$66.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.22
|
| Rate for Payer: Healthscope Commercial |
$70.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.11
|
| Rate for Payer: PHP Commercial |
$66.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.56
|
| Rate for Payer: Priority Health SBD |
$49.00
|
| Rate for Payer: UMR Bronson Commercial |
$28.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.34
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION (TPN COMPONENT)
|
Facility
|
IP
|
$777.74
|
|
|
Service Code
|
NDC 09900001921
|
| Hospital Charge Code |
301289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$342.21 |
| Max. Negotiated Rate |
$699.97 |
| Rate for Payer: Aetna American Axle |
$505.53
|
| Rate for Payer: Aetna Commercial |
$661.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.53
|
| Rate for Payer: Cash Price |
$622.19
|
| Rate for Payer: Cofinity Commercial |
$544.42
|
| Rate for Payer: Cofinity Commercial |
$668.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$544.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.19
|
| Rate for Payer: Healthscope Commercial |
$699.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.08
|
| Rate for Payer: PHP Commercial |
$661.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$505.53
|
| Rate for Payer: Priority Health SBD |
$489.98
|
| Rate for Payer: UMR Bronson Commercial |
$342.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.30
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION (TPN COMPONENT)
|
Facility
|
OP
|
$777.74
|
|
|
Service Code
|
NDC 09900001921
|
| Hospital Charge Code |
301289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$287.76 |
| Max. Negotiated Rate |
$699.97 |
| Rate for Payer: Aetna American Axle |
$505.53
|
| Rate for Payer: Aetna Commercial |
$661.08
|
| Rate for Payer: Aetna Medicare |
$388.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.53
|
| Rate for Payer: BCBS Complete |
$311.10
|
| Rate for Payer: Cash Price |
$622.19
|
| Rate for Payer: Cofinity Commercial |
$544.42
|
| Rate for Payer: Cofinity Commercial |
$668.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$544.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.19
|
| Rate for Payer: Healthscope Commercial |
$699.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.08
|
| Rate for Payer: PHP Commercial |
$661.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$505.53
|
| Rate for Payer: Priority Health SBD |
$489.98
|
| Rate for Payer: UMR Bronson Commercial |
$287.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.30
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 16500056675
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.78 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna Medicare |
$74.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$54.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
IP
|
$109.98
|
|
|
Service Code
|
NDC 16500004108
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.39 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna American Axle |
$71.49
|
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Commercial |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$76.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.49
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UMR Bronson Commercial |
$48.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
OP
|
$109.98
|
|
|
Service Code
|
NDC 16500004108
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.69 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna American Axle |
$71.49
|
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna Medicare |
$54.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: BCBS Complete |
$43.99
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Commercial |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$76.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.49
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UMR Bronson Commercial |
$40.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 16500056675
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
POVIDONE (BULK) K-30 POWDER
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
NDC 51552132305
|
| Hospital Charge Code |
23281
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$233.10 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Aetna American Axle |
$409.50
|
| Rate for Payer: Aetna Commercial |
$535.50
|
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.50
|
| Rate for Payer: BCBS Complete |
$252.00
|
| Rate for Payer: Cash Price |
$504.00
|
| Rate for Payer: Cofinity Commercial |
$441.00
|
| Rate for Payer: Cofinity Commercial |
$541.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$441.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.00
|
| Rate for Payer: Healthscope Commercial |
$567.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$441.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$472.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$535.50
|
| Rate for Payer: PHP Commercial |
$535.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$409.50
|
| Rate for Payer: Priority Health SBD |
$396.90
|
| Rate for Payer: UMR Bronson Commercial |
$233.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$472.50
|
|
|
POVIDONE (BULK) K-30 POWDER
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
NDC 51552132305
|
| Hospital Charge Code |
23281
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$277.20 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Aetna American Axle |
$409.50
|
| Rate for Payer: Aetna Commercial |
$535.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.50
|
| Rate for Payer: Cash Price |
$504.00
|
| Rate for Payer: Cofinity Commercial |
$441.00
|
| Rate for Payer: Cofinity Commercial |
$541.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$441.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.00
|
| Rate for Payer: Healthscope Commercial |
$567.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$441.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$472.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$535.50
|
| Rate for Payer: PHP Commercial |
$535.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$409.50
|
| Rate for Payer: Priority Health SBD |
$396.90
|
| Rate for Payer: UMR Bronson Commercial |
$277.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$472.50
|
|
|
POVIDONE-IODINE 0.3 % VAGINAL SOLUTION
|
Facility
|
IP
|
$16.03
|
|
|
Service Code
|
NDC 41608008743
|
| Hospital Charge Code |
12799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Aetna American Axle |
$10.42
|
| Rate for Payer: Aetna Commercial |
$13.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.42
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Commercial |
$11.22
|
| Rate for Payer: Cofinity Commercial |
$13.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.63
|
| Rate for Payer: PHP Commercial |
$13.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.42
|
| Rate for Payer: Priority Health SBD |
$10.10
|
| Rate for Payer: UMR Bronson Commercial |
$7.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
|
POVIDONE-IODINE 0.3 % VAGINAL SOLUTION
|
Facility
|
OP
|
$16.03
|
|
|
Service Code
|
NDC 41608008743
|
| Hospital Charge Code |
12799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Aetna American Axle |
$10.42
|
| Rate for Payer: Aetna Commercial |
$13.63
|
| Rate for Payer: Aetna Medicare |
$8.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.42
|
| Rate for Payer: BCBS Complete |
$6.41
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Commercial |
$11.22
|
| Rate for Payer: Cofinity Commercial |
$13.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.63
|
| Rate for Payer: PHP Commercial |
$13.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.42
|
| Rate for Payer: Priority Health SBD |
$10.10
|
| Rate for Payer: UMR Bronson Commercial |
$5.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$21.29
|
|
|
Service Code
|
NDC 00395232516
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna American Axle |
$13.84
|
| Rate for Payer: Aetna Commercial |
$18.10
|
| Rate for Payer: Aetna Medicare |
$10.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.84
|
| Rate for Payer: BCBS Complete |
$8.52
|
| Rate for Payer: Cash Price |
$17.03
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$18.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.03
|
| Rate for Payer: Healthscope Commercial |
$19.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.10
|
| Rate for Payer: PHP Commercial |
$18.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.84
|
| Rate for Payer: Priority Health SBD |
$13.41
|
| Rate for Payer: UMR Bronson Commercial |
$7.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.97
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$13.81
|
|
|
Service Code
|
NDC 00904110309
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna American Axle |
$8.98
|
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.98
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cofinity Commercial |
$11.88
|
| Rate for Payer: Cofinity Commercial |
$9.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.05
|
| Rate for Payer: Healthscope Commercial |
$12.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.74
|
| Rate for Payer: PHP Commercial |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.98
|
| Rate for Payer: Priority Health SBD |
$8.70
|
| Rate for Payer: UMR Bronson Commercial |
$6.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.36
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$21.29
|
|
|
Service Code
|
NDC 00395232516
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna American Axle |
$13.84
|
| Rate for Payer: Aetna Commercial |
$18.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.84
|
| Rate for Payer: Cash Price |
$17.03
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$18.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.03
|
| Rate for Payer: Healthscope Commercial |
$19.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.10
|
| Rate for Payer: PHP Commercial |
$18.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.84
|
| Rate for Payer: Priority Health SBD |
$13.41
|
| Rate for Payer: UMR Bronson Commercial |
$9.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.97
|
|
