|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002303
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 00338002303
|
| Hospital Charge Code |
2357
|
|
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: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| 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
|
Facility
|
IP
|
$61.18
|
|
|
Service Code
|
NDC 00338002302
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.92 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna American Axle |
$39.77
|
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health SBD |
$38.54
|
| Rate for Payer: UMR Bronson Commercial |
$26.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
OP
|
$61.18
|
|
|
Service Code
|
NDC 00338002302
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.64 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna American Axle |
$39.77
|
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna Medicare |
$30.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: BCBS Complete |
$24.47
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health SBD |
$38.54
|
| Rate for Payer: UMR Bronson Commercial |
$22.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
IP
|
$61.18
|
|
|
Service Code
|
NDC 00338002302
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.92 |
| Max. Negotiated Rate |
$55.06 |
| Rate for Payer: Aetna American Axle |
$39.77
|
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$55.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: PHP Commercial |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health SBD |
$38.54
|
| Rate for Payer: UMR Bronson Commercial |
$26.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.88
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 00338002303
|
| 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: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| 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 (DOSE REQUIRED)
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002303
|
| Hospital Charge Code |
300135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| 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: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| 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 00338002304
|
| 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: Cofinity Medicare Advantage |
$48.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| 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
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 00338002304
|
| Hospital Charge Code |
300148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Aetna American Axle |
$45.45
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| 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 Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: UMR Bronson Commercial |
$25.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
NDC 00264752020
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna American Axle |
$41.47
|
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.47
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.47
|
| Rate for Payer: Priority Health SBD |
$40.19
|
| Rate for Payer: UMR Bronson Commercial |
$28.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.85
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
OP
|
$63.80
|
|
|
Service Code
|
NDC 00264752020
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.61 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna American Axle |
$41.47
|
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna Medicare |
$31.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.47
|
| Rate for Payer: BCBS Complete |
$25.52
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.47
|
| Rate for Payer: Priority Health SBD |
$40.19
|
| Rate for Payer: UMR Bronson Commercial |
$23.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.85
|
|
|
DEXTROSE 1.2 GRAM/3 ML (40 %) ORAL GEL IN SYRINGE (ORAL USE ONLY)
|
Facility
|
OP
|
$8.03
|
|
|
Service Code
|
NDC 54758000628
|
| Hospital Charge Code |
195245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$7.23 |
| Rate for Payer: Aetna American Axle |
$5.22
|
| Rate for Payer: Aetna Commercial |
$6.83
|
| Rate for Payer: Aetna Medicare |
$4.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.22
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: Cash Price |
$6.42
|
| Rate for Payer: Cofinity Commercial |
$5.62
|
| Rate for Payer: Cofinity Commercial |
$6.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.62
|
| 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 Commercial |
$6.83
|
| Rate for Payer: PHP Commercial |
$6.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.22
|
| Rate for Payer: Priority Health SBD |
$5.06
|
| Rate for Payer: UMR Bronson Commercial |
$2.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.02
|
|
|
DEXTROSE 1.2 GRAM/3 ML (40 %) ORAL GEL IN SYRINGE (ORAL USE ONLY)
|
Facility
|
IP
|
$8.03
|
|
|
Service Code
|
NDC 54758000628
|
| 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: Cofinity Medicare Advantage |
$5.62
|
| 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 Commercial |
$6.83
|
| Rate for Payer: PHP Commercial |
$6.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.22
|
| 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
|
OP
|
$79.75
|
|
|
Service Code
|
NDC 00942064104
|
| Hospital Charge Code |
167293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.51 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna American Axle |
$51.84
|
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Medicare |
$39.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: BCBS Complete |
$31.90
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$55.82
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.82
|
| 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 Commercial |
$67.79
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.84
|
| Rate for Payer: Priority Health SBD |
$50.24
|
| Rate for Payer: UMR Bronson Commercial |
$29.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.81
|
|
|
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN
|
Facility
|
IP
|
$79.75
|
|
|
Service Code
|
NDC 00942064104
|
| 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: Cofinity Medicare Advantage |
$55.82
|
| 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 Commercial |
$67.79
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.84
|
| 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
|
OP
|
$59.82
|
|
|
Service Code
|
NDC 14537081775
|
| Hospital Charge Code |
189469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.13 |
| Max. Negotiated Rate |
$53.84 |
| Rate for Payer: Aetna American Axle |
$38.88
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Medicare |
$29.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: BCBS Complete |
$23.93
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cofinity Commercial |
$41.87
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.87
|
| 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 Commercial |
$50.85
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.88
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: UMR Bronson Commercial |
$22.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.86
|
|
|
DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 800 MG/100 ML SOLN
|
Facility
|
IP
|
$59.82
|
|
|
Service Code
|
NDC 14537081775
|
| 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: Cofinity Medicare Advantage |
$41.87
|
| 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 Commercial |
$50.85
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.88
|
| 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
|
$72.72
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
150921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$65.45 |
| Rate for Payer: Aetna American Axle |
$47.27
|
| Rate for Payer: Aetna Commercial |
$61.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.27
|
| Rate for Payer: Cash Price |
$58.18
|
| Rate for Payer: Cofinity Commercial |
$50.90
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.18
|
| Rate for Payer: Healthscope Commercial |
$65.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.81
|
| Rate for Payer: PHP Commercial |
$61.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.27
|
| Rate for Payer: Priority Health SBD |
$45.81
|
| Rate for Payer: UMR Bronson Commercial |
$32.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.54
|
|
|
DEXTROSE 25% IN WATER BOLUS
|
Facility
|
OP
|
$72.72
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
150921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.91 |
| Max. Negotiated Rate |
$65.45 |
| Rate for Payer: Aetna American Axle |
$47.27
|
| Rate for Payer: Aetna Commercial |
$61.81
|
| Rate for Payer: Aetna Medicare |
$36.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.27
|
| Rate for Payer: BCBS Complete |
$29.09
|
| Rate for Payer: Cash Price |
$58.18
|
| Rate for Payer: Cofinity Commercial |
$50.90
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.18
|
| Rate for Payer: Healthscope Commercial |
$65.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.81
|
| Rate for Payer: PHP Commercial |
$61.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.27
|
| Rate for Payer: Priority Health SBD |
$45.81
|
| Rate for Payer: UMR Bronson Commercial |
$26.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.54
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$72.72
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$65.45 |
| Rate for Payer: Cash Price |
$58.18
|
| Rate for Payer: Cofinity Commercial |
$50.90
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.90
|
| Rate for Payer: Aetna American Axle |
$47.27
|
| Rate for Payer: Aetna Commercial |
$61.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.18
|
| Rate for Payer: Healthscope Commercial |
$65.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.81
|
| Rate for Payer: PHP Commercial |
$61.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.27
|
| Rate for Payer: Priority Health SBD |
$45.81
|
| Rate for Payer: UMR Bronson Commercial |
$32.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.54
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$72.72
|
|
|
Service Code
|
NDC 00409177510
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.91 |
| Max. Negotiated Rate |
$65.45 |
| Rate for Payer: Aetna American Axle |
$47.27
|
| Rate for Payer: Aetna Commercial |
$61.81
|
| Rate for Payer: Aetna Medicare |
$36.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.27
|
| Rate for Payer: BCBS Complete |
$29.09
|
| Rate for Payer: Cash Price |
$58.18
|
| Rate for Payer: Cofinity Commercial |
$50.90
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.18
|
| Rate for Payer: Healthscope Commercial |
$65.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.81
|
| Rate for Payer: PHP Commercial |
$61.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.27
|
| Rate for Payer: Priority Health SBD |
$45.81
|
| Rate for Payer: UMR Bronson Commercial |
$26.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.54
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$15.19
|
|
|
Service Code
|
NDC 00574006915
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$13.67 |
| Rate for Payer: Aetna American Axle |
$9.87
|
| Rate for Payer: Aetna Commercial |
$12.91
|
| Rate for Payer: Aetna Medicare |
$7.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.87
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cofinity Commercial |
$10.63
|
| Rate for Payer: Cofinity Commercial |
$13.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.15
|
| Rate for Payer: Healthscope Commercial |
$13.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.91
|
| Rate for Payer: PHP Commercial |
$12.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.87
|
| Rate for Payer: Priority Health SBD |
$9.57
|
| Rate for Payer: UMR Bronson Commercial |
$5.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.39
|
|
