|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0023-04
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0023-04
|
| Hospital Charge Code |
300148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
IP
|
$59.82
|
|
|
Service Code
|
NDC 0264-7520-20
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$53.84 |
| Rate for Payer: Aetna American Axle |
$38.88
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cofinity Commercial |
$41.87
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.85
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.87
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: UMR Bronson Commercial |
$26.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.86
|
|
|
DEXTROSE 1.2 GRAM/3 ML (40 %) ORAL GEL IN SYRINGE (ORAL USE ONLY)
|
Facility
|
IP
|
$8.03
|
|
|
Service Code
|
NDC 5475800628
|
| Hospital Charge Code |
195245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$7.23 |
| Rate for Payer: Aetna American Axle |
$5.22
|
| Rate for Payer: Aetna Commercial |
$6.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.22
|
| Rate for Payer: Cash Price |
$6.42
|
| Rate for Payer: Cofinity Commercial |
$5.62
|
| Rate for Payer: Cofinity Commercial |
$6.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.42
|
| Rate for Payer: Healthscope Commercial |
$7.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.83
|
| Rate for Payer: PHP Commercial |
$6.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.62
|
| Rate for Payer: Priority Health SBD |
$5.06
|
| Rate for Payer: UMR Bronson Commercial |
$3.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.02
|
|
|
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN
|
Facility
|
IP
|
$79.75
|
|
|
Service Code
|
NDC 0942-0641-04
|
| Hospital Charge Code |
167293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna American Axle |
$51.84
|
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$55.82
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$55.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.79
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.82
|
| Rate for Payer: Priority Health SBD |
$50.24
|
| Rate for Payer: UMR Bronson Commercial |
$35.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.81
|
|
|
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 800 MG/100 ML SOLN
|
Facility
|
IP
|
$59.82
|
|
|
Service Code
|
NDC 14537-817-75
|
| Hospital Charge Code |
189469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$53.84 |
| Rate for Payer: Aetna American Axle |
$38.88
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cofinity Commercial |
$41.87
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.85
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.87
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: UMR Bronson Commercial |
$26.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.86
|
|
|
DEXTROSE 25% IN WATER BOLUS
|
Facility
|
IP
|
$60.08
|
|
|
Service Code
|
NDC 0409-1775-10
|
| Hospital Charge Code |
150921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.44 |
| Max. Negotiated Rate |
$54.07 |
| Rate for Payer: Aetna American Axle |
$39.05
|
| Rate for Payer: Aetna Commercial |
$51.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.05
|
| Rate for Payer: Cash Price |
$48.06
|
| Rate for Payer: Cofinity Commercial |
$42.06
|
| Rate for Payer: Cofinity Commercial |
$51.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.06
|
| Rate for Payer: Healthscope Commercial |
$54.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.07
|
| Rate for Payer: PHP Commercial |
$51.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.06
|
| Rate for Payer: Priority Health SBD |
$37.85
|
| Rate for Payer: UMR Bronson Commercial |
$26.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.06
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$60.08
|
|
|
Service Code
|
NDC 0409-1775-10
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.44 |
| Max. Negotiated Rate |
$54.07 |
| Rate for Payer: Aetna American Axle |
$39.05
|
| Rate for Payer: Aetna Commercial |
$51.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.05
|
| Rate for Payer: Cash Price |
$48.06
|
| Rate for Payer: Cofinity Commercial |
$42.06
|
| Rate for Payer: Cofinity Commercial |
$51.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.06
|
| Rate for Payer: Healthscope Commercial |
$54.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.07
|
| Rate for Payer: PHP Commercial |
$51.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.06
|
| Rate for Payer: Priority Health SBD |
$37.85
|
| Rate for Payer: UMR Bronson Commercial |
$26.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.06
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$13.17
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$11.85 |
| Rate for Payer: Aetna American Axle |
$8.56
|
| Rate for Payer: Aetna Commercial |
$11.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.56
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$11.33
|
| Rate for Payer: Cofinity Commercial |
$9.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.54
|
| Rate for Payer: Healthscope Commercial |
$11.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.19
|
| Rate for Payer: PHP Commercial |
$11.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.22
|
| Rate for Payer: Priority Health SBD |
$8.30
|
| Rate for Payer: UMR Bronson Commercial |
$5.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.88
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 9900-0019-11
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| Rate for Payer: Priority Health SBD |
$1.77
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$13.17
|
|
|
Service Code
|
NDC 574006915
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$11.85 |
| Rate for Payer: Aetna American Axle |
$8.56
|
| Rate for Payer: Aetna Commercial |
$11.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.56
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$11.33
|
| Rate for Payer: Cofinity Commercial |
$9.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.54
|
| Rate for Payer: Healthscope Commercial |
$11.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.19
|
| Rate for Payer: PHP Commercial |
$11.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.22
|
| Rate for Payer: Priority Health SBD |
$8.30
|
| Rate for Payer: UMR Bronson Commercial |
$5.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.88
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$30.72
|
|
|
Service Code
|
NDC 574006945
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: Aetna American Axle |
$19.97
|
| Rate for Payer: Aetna Commercial |
$26.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.97
|
| Rate for Payer: Cash Price |
$24.58
|
| Rate for Payer: Cofinity Commercial |
$21.50
|
| Rate for Payer: Cofinity Commercial |
$26.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.58
|
| Rate for Payer: Healthscope Commercial |
$27.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.11
|
| Rate for Payer: PHP Commercial |
$26.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.50
|
| Rate for Payer: Priority Health SBD |
$19.35
|
| Rate for Payer: UMR Bronson Commercial |
$13.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.04
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$58.22
|
|
|
Service Code
|
NDC 0409-6648-16
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$52.40 |
| Rate for Payer: Aetna American Axle |
$37.84
|
| Rate for Payer: Aetna Commercial |
$49.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.84
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.75
|
| Rate for Payer: Cofinity Commercial |
$50.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.49
|
| Rate for Payer: PHP Commercial |
$49.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.75
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: UMR Bronson Commercial |
$25.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.66
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$58.22
|
|
|
Service Code
|
NDC 0409-6648-02
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$52.40 |
| Rate for Payer: Aetna American Axle |
$37.84
|
| Rate for Payer: Aetna Commercial |
$49.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.84
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.75
|
| Rate for Payer: Cofinity Commercial |
$50.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.49
|
| Rate for Payer: PHP Commercial |
$49.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.75
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: UMR Bronson Commercial |
$25.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.66
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$58.22
|
|
|
Service Code
|
NDC 0409-6648-02
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.54 |
| Max. Negotiated Rate |
$52.40 |
| Rate for Payer: Aetna American Axle |
$37.84
|
| Rate for Payer: Aetna Commercial |
$49.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.84
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.75
|
| Rate for Payer: Cofinity Commercial |
$50.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.49
|
| Rate for Payer: PHP Commercial |
$49.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.75
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: UMR Bronson Commercial |
$21.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.66
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$58.22
|
|
|
Service Code
|
NDC 0409-6648-16
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.54 |
| Max. Negotiated Rate |
$52.40 |
| Rate for Payer: Aetna American Axle |
$37.84
|
| Rate for Payer: Aetna Commercial |
$49.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.84
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.75
|
| Rate for Payer: Cofinity Commercial |
$50.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.49
|
| Rate for Payer: PHP Commercial |
$49.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.75
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: UMR Bronson Commercial |
$21.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.66
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$47.62
|
|
|
Service Code
|
NDC 76329-3301-1
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$42.86 |
| Rate for Payer: Aetna American Axle |
$30.95
|
| Rate for Payer: Aetna Commercial |
$40.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.95
|
| Rate for Payer: Cash Price |
$38.10
|
| Rate for Payer: Cofinity Commercial |
$33.33
|
| Rate for Payer: Cofinity Commercial |
$40.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.10
|
| Rate for Payer: Healthscope Commercial |
$42.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.48
|
| Rate for Payer: PHP Commercial |
$40.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.33
|
| Rate for Payer: Priority Health SBD |
$30.00
|
| Rate for Payer: UMR Bronson Commercial |
$20.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.72
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$60.30
|
|
|
Service Code
|
NDC 76329-3302-1
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.53 |
| Max. Negotiated Rate |
$54.27 |
| Rate for Payer: Aetna American Axle |
$39.20
|
| Rate for Payer: Aetna Commercial |
$51.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.20
|
| Rate for Payer: Cash Price |
$48.24
|
| Rate for Payer: Cofinity Commercial |
$42.21
|
| Rate for Payer: Cofinity Commercial |
$51.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.24
|
| Rate for Payer: Healthscope Commercial |
$54.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.26
|
| Rate for Payer: PHP Commercial |
$51.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.21
|
| Rate for Payer: Priority Health SBD |
$37.99
|
| Rate for Payer: UMR Bronson Commercial |
$26.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.22
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$58.97
|
|
|
Service Code
|
NDC 0409-4902-64
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.95 |
| Max. Negotiated Rate |
$53.07 |
| Rate for Payer: Aetna American Axle |
$38.33
|
| Rate for Payer: Aetna Commercial |
$50.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.33
|
| Rate for Payer: Cash Price |
$47.18
|
| Rate for Payer: Cofinity Commercial |
$41.28
|
| Rate for Payer: Cofinity Commercial |
$50.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.18
|
| Rate for Payer: Healthscope Commercial |
$53.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.12
|
| Rate for Payer: PHP Commercial |
$50.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.28
|
| Rate for Payer: Priority Health SBD |
$37.15
|
| Rate for Payer: UMR Bronson Commercial |
$25.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.23
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$32.04
|
|
|
Service Code
|
NDC 9900-0004-26
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.10 |
| Max. Negotiated Rate |
$28.84 |
| Rate for Payer: Aetna American Axle |
$20.83
|
| Rate for Payer: Aetna Commercial |
$27.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.83
|
| Rate for Payer: Cash Price |
$25.63
|
| Rate for Payer: Cofinity Commercial |
$22.43
|
| Rate for Payer: Cofinity Commercial |
$27.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.63
|
| Rate for Payer: Healthscope Commercial |
$28.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.23
|
| Rate for Payer: PHP Commercial |
$27.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.43
|
| Rate for Payer: Priority Health SBD |
$20.19
|
| Rate for Payer: UMR Bronson Commercial |
$14.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.03
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$57.63
|
|
|
Service Code
|
NDC 0409-7517-16
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.36 |
| Max. Negotiated Rate |
$51.87 |
| Rate for Payer: Aetna American Axle |
$37.46
|
| Rate for Payer: Aetna Commercial |
$48.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.46
|
| Rate for Payer: Cash Price |
$46.10
|
| Rate for Payer: Cofinity Commercial |
$40.34
|
| Rate for Payer: Cofinity Commercial |
$49.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.10
|
| Rate for Payer: Healthscope Commercial |
$51.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$40.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.99
|
| Rate for Payer: PHP Commercial |
$48.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.34
|
| Rate for Payer: Priority Health SBD |
$36.31
|
| Rate for Payer: UMR Bronson Commercial |
$25.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.22
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$58.97
|
|
|
Service Code
|
NDC 0409-4902-34
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.95 |
| Max. Negotiated Rate |
$53.07 |
| Rate for Payer: Aetna American Axle |
$38.33
|
| Rate for Payer: Aetna Commercial |
$50.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.33
|
| Rate for Payer: Cash Price |
$47.18
|
| Rate for Payer: Cofinity Commercial |
$41.28
|
| Rate for Payer: Cofinity Commercial |
$50.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.18
|
| Rate for Payer: Healthscope Commercial |
$53.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.12
|
| Rate for Payer: PHP Commercial |
$50.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.28
|
| Rate for Payer: Priority Health SBD |
$37.15
|
| Rate for Payer: UMR Bronson Commercial |
$25.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.23
|
|
|
DEXTROSE 50% IN WATER (D50W) IV SYRINGE (CODE)
|
Facility
|
IP
|
$118.89
|
|
|
Service Code
|
NDC 0409-7517-16
|
| Hospital Charge Code |
163718
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.31 |
| Max. Negotiated Rate |
$107.00 |
| Rate for Payer: Aetna American Axle |
$77.28
|
| Rate for Payer: Aetna Commercial |
$101.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.28
|
| Rate for Payer: Cash Price |
$95.11
|
| Rate for Payer: Cofinity Commercial |
$102.25
|
| Rate for Payer: Cofinity Commercial |
$83.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.11
|
| Rate for Payer: Healthscope Commercial |
$107.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$101.06
|
| Rate for Payer: PHP Commercial |
$101.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.22
|
| Rate for Payer: Priority Health SBD |
$74.90
|
| Rate for Payer: UMR Bronson Commercial |
$52.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.17
|
|
|
DEXTROSE 50% IN WATER (D50W) IV SYRINGE (CODE)
|
Facility
|
IP
|
$89.84
|
|
|
Service Code
|
NDC 0409-4902-34
|
| Hospital Charge Code |
163718
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.53 |
| Max. Negotiated Rate |
$80.86 |
| Rate for Payer: Aetna American Axle |
$58.40
|
| Rate for Payer: Aetna Commercial |
$76.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.40
|
| Rate for Payer: Cash Price |
$71.87
|
| Rate for Payer: Cofinity Commercial |
$62.89
|
| Rate for Payer: Cofinity Commercial |
$77.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.87
|
| Rate for Payer: Healthscope Commercial |
$80.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.36
|
| Rate for Payer: PHP Commercial |
$76.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.89
|
| Rate for Payer: Priority Health SBD |
$56.60
|
| Rate for Payer: UMR Bronson Commercial |
$39.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.38
|
|
|
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0077-04
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.76 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$30.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
