|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$15.02
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$13.52 |
| Rate for Payer: Aetna American Axle |
$9.76
|
| Rate for Payer: Aetna Commercial |
$12.77
|
| Rate for Payer: Aetna Medicare |
$7.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.76
|
| Rate for Payer: BCBS Complete |
$6.01
|
| Rate for Payer: Cash Price |
$12.02
|
| Rate for Payer: Cofinity Commercial |
$10.51
|
| Rate for Payer: Cofinity Commercial |
$12.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.02
|
| Rate for Payer: Healthscope Commercial |
$13.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.77
|
| Rate for Payer: PHP Commercial |
$12.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.76
|
| Rate for Payer: Priority Health SBD |
$9.46
|
| Rate for Payer: UMR Bronson Commercial |
$5.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.26
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$35.05
|
|
|
Service Code
|
NDC 00574006945
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.97 |
| Max. Negotiated Rate |
$31.54 |
| Rate for Payer: Aetna American Axle |
$22.78
|
| Rate for Payer: Aetna Commercial |
$29.79
|
| Rate for Payer: Aetna Medicare |
$17.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.78
|
| Rate for Payer: BCBS Complete |
$14.02
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Cofinity Commercial |
$24.54
|
| Rate for Payer: Cofinity Commercial |
$30.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.04
|
| Rate for Payer: Healthscope Commercial |
$31.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.79
|
| Rate for Payer: PHP Commercial |
$29.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health SBD |
$22.08
|
| Rate for Payer: UMR Bronson Commercial |
$12.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.29
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$35.05
|
|
|
Service Code
|
NDC 00574006945
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.42 |
| Max. Negotiated Rate |
$31.54 |
| Rate for Payer: PHP Commercial |
$29.79
|
| Rate for Payer: Aetna American Axle |
$22.78
|
| Rate for Payer: Aetna Commercial |
$29.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.78
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Cofinity Commercial |
$24.54
|
| Rate for Payer: Cofinity Commercial |
$30.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.04
|
| Rate for Payer: Healthscope Commercial |
$31.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health SBD |
$22.08
|
| Rate for Payer: UMR Bronson Commercial |
$15.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.29
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$15.02
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$13.52 |
| Rate for Payer: Aetna American Axle |
$9.76
|
| Rate for Payer: Aetna Commercial |
$12.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.76
|
| Rate for Payer: Cash Price |
$12.02
|
| Rate for Payer: Cofinity Commercial |
$10.51
|
| Rate for Payer: Cofinity Commercial |
$12.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.02
|
| Rate for Payer: Healthscope Commercial |
$13.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.77
|
| Rate for Payer: PHP Commercial |
$12.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.76
|
| Rate for Payer: Priority Health SBD |
$9.46
|
| Rate for Payer: UMR Bronson Commercial |
$6.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.26
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 09900001911
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna Medicare |
$1.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| 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 Commercial |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.77
|
| Rate for Payer: UMR Bronson Commercial |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 09900001911
|
| 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: Cofinity Medicare Advantage |
$1.97
|
| 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 Commercial |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| 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
|
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
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$66.99
|
|
|
Service Code
|
NDC 00409664802
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$60.29 |
| Rate for Payer: Aetna American Axle |
$43.54
|
| Rate for Payer: Aetna Commercial |
$56.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.54
|
| Rate for Payer: Cash Price |
$53.59
|
| Rate for Payer: Cofinity Commercial |
$46.89
|
| Rate for Payer: Cofinity Commercial |
$57.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.59
|
| Rate for Payer: Healthscope Commercial |
$60.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.94
|
| Rate for Payer: PHP Commercial |
$56.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.54
|
| Rate for Payer: Priority Health SBD |
$42.20
|
| Rate for Payer: UMR Bronson Commercial |
$29.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.24
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$66.99
|
|
|
Service Code
|
NDC 00409664802
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.79 |
| Max. Negotiated Rate |
$60.29 |
| Rate for Payer: PHP Commercial |
$56.94
|
| Rate for Payer: Aetna American Axle |
$43.54
|
| Rate for Payer: Aetna Commercial |
$56.94
|
| Rate for Payer: Aetna Medicare |
$33.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.54
|
| Rate for Payer: BCBS Complete |
$26.80
|
| Rate for Payer: Cash Price |
$53.59
|
| Rate for Payer: Cofinity Commercial |
$46.89
|
| Rate for Payer: Cofinity Commercial |
$57.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.59
|
| Rate for Payer: Healthscope Commercial |
$60.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.54
|
| Rate for Payer: Priority Health SBD |
$42.20
|
| Rate for Payer: UMR Bronson Commercial |
$24.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.24
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$66.99
|
|
|
Service Code
|
NDC 00409664816
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$60.29 |
| Rate for Payer: Aetna American Axle |
$43.54
|
| Rate for Payer: Aetna Commercial |
$56.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.54
|
| Rate for Payer: Cash Price |
$53.59
|
| Rate for Payer: Cofinity Commercial |
$46.89
|
| Rate for Payer: Cofinity Commercial |
$57.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.59
|
| Rate for Payer: Healthscope Commercial |
$60.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.94
|
| Rate for Payer: PHP Commercial |
$56.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.54
|
| Rate for Payer: Priority Health SBD |
$42.20
|
| Rate for Payer: UMR Bronson Commercial |
$29.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.24
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$66.99
|
|
|
Service Code
|
NDC 00409664816
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.79 |
| Max. Negotiated Rate |
$60.29 |
| Rate for Payer: Aetna American Axle |
$43.54
|
| Rate for Payer: Aetna Commercial |
$56.94
|
| Rate for Payer: Aetna Medicare |
$33.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.54
|
| Rate for Payer: BCBS Complete |
$26.80
|
| Rate for Payer: Cash Price |
$53.59
|
| Rate for Payer: Cofinity Commercial |
$46.89
|
| Rate for Payer: Cofinity Commercial |
$57.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.59
|
| Rate for Payer: Healthscope Commercial |
$60.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.94
|
| Rate for Payer: PHP Commercial |
$56.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.54
|
| Rate for Payer: Priority Health SBD |
$42.20
|
| Rate for Payer: UMR Bronson Commercial |
$24.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.24
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$66.09
|
|
|
Service Code
|
NDC 76329330201
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.45 |
| Max. Negotiated Rate |
$59.48 |
| Rate for Payer: Aetna American Axle |
$42.96
|
| Rate for Payer: Aetna Commercial |
$56.18
|
| Rate for Payer: Aetna Medicare |
$33.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.96
|
| Rate for Payer: BCBS Complete |
$26.44
|
| Rate for Payer: Cash Price |
$52.87
|
| Rate for Payer: Cofinity Commercial |
$46.26
|
| Rate for Payer: Cofinity Commercial |
$56.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.87
|
| Rate for Payer: Healthscope Commercial |
$59.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.18
|
| Rate for Payer: PHP Commercial |
$56.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.96
|
| Rate for Payer: Priority Health SBD |
$41.64
|
| Rate for Payer: UMR Bronson Commercial |
$24.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.57
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 00409490234
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.33 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna American Axle |
$46.28
|
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health SBD |
$44.86
|
| Rate for Payer: UMR Bronson Commercial |
$31.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$69.65
|
|
|
Service Code
|
NDC 00409751716
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.65 |
| Max. Negotiated Rate |
$62.68 |
| Rate for Payer: Aetna American Axle |
$45.27
|
| Rate for Payer: Aetna Commercial |
$59.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.27
|
| Rate for Payer: Cash Price |
$55.72
|
| Rate for Payer: Cofinity Commercial |
$48.76
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.72
|
| Rate for Payer: Healthscope Commercial |
$62.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.20
|
| Rate for Payer: PHP Commercial |
$59.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.27
|
| Rate for Payer: Priority Health SBD |
$43.88
|
| Rate for Payer: UMR Bronson Commercial |
$30.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.24
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 00409490234
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.34 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna American Axle |
$46.28
|
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna Medicare |
$35.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: BCBS Complete |
$28.48
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health SBD |
$44.86
|
| Rate for Payer: UMR Bronson Commercial |
$26.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 00409490264
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.34 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna American Axle |
$46.28
|
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna Medicare |
$35.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: BCBS Complete |
$28.48
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health SBD |
$44.86
|
| Rate for Payer: UMR Bronson Commercial |
$26.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$32.04
|
|
|
Service Code
|
NDC 09900000426
|
| 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: Cofinity Medicare Advantage |
$22.43
|
| 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 Commercial |
$27.23
|
| Rate for Payer: PHP Commercial |
$27.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.83
|
| 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
|
$47.62
|
|
|
Service Code
|
NDC 76329330101
|
| 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: Cofinity Medicare Advantage |
$33.33
|
| 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 Commercial |
$40.48
|
| Rate for Payer: PHP Commercial |
$40.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.95
|
| 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
|
OP
|
$32.04
|
|
|
Service Code
|
NDC 09900000426
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$28.84 |
| Rate for Payer: Aetna American Axle |
$20.83
|
| Rate for Payer: Aetna Commercial |
$27.23
|
| Rate for Payer: Aetna Medicare |
$16.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.83
|
| Rate for Payer: BCBS Complete |
$12.82
|
| Rate for Payer: Cash Price |
$25.63
|
| Rate for Payer: Cofinity Commercial |
$22.43
|
| Rate for Payer: Cofinity Commercial |
$27.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.43
|
| 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 Commercial |
$27.23
|
| Rate for Payer: PHP Commercial |
$27.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.83
|
| Rate for Payer: Priority Health SBD |
$20.19
|
| Rate for Payer: UMR Bronson Commercial |
$11.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.03
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$69.65
|
|
|
Service Code
|
NDC 00409751716
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.77 |
| Max. Negotiated Rate |
$62.68 |
| Rate for Payer: Aetna American Axle |
$45.27
|
| Rate for Payer: Aetna Commercial |
$59.20
|
| Rate for Payer: Aetna Medicare |
$34.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.27
|
| Rate for Payer: BCBS Complete |
$27.86
|
| Rate for Payer: Cash Price |
$55.72
|
| Rate for Payer: Cofinity Commercial |
$48.76
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.72
|
| Rate for Payer: Healthscope Commercial |
$62.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.20
|
| Rate for Payer: PHP Commercial |
$59.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.27
|
| Rate for Payer: Priority Health SBD |
$43.88
|
| Rate for Payer: UMR Bronson Commercial |
$25.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.24
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 00409490264
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.33 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna American Axle |
$46.28
|
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health SBD |
$44.86
|
| Rate for Payer: UMR Bronson Commercial |
$31.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$47.62
|
|
|
Service Code
|
NDC 76329330101
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.62 |
| Max. Negotiated Rate |
$42.86 |
| Rate for Payer: Aetna American Axle |
$30.95
|
| Rate for Payer: Aetna Commercial |
$40.48
|
| Rate for Payer: Aetna Medicare |
$23.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.95
|
| Rate for Payer: BCBS Complete |
$19.05
|
| Rate for Payer: Cash Price |
$38.10
|
| Rate for Payer: Cofinity Commercial |
$33.33
|
| Rate for Payer: Cofinity Commercial |
$40.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$33.33
|
| 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 Commercial |
$40.48
|
| Rate for Payer: PHP Commercial |
$40.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.95
|
| Rate for Payer: Priority Health SBD |
$30.00
|
| Rate for Payer: UMR Bronson Commercial |
$17.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.72
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$66.09
|
|
|
Service Code
|
NDC 76329330201
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.08 |
| Max. Negotiated Rate |
$59.48 |
| Rate for Payer: Aetna American Axle |
$42.96
|
| Rate for Payer: Aetna Commercial |
$56.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.96
|
| Rate for Payer: Cash Price |
$52.87
|
| Rate for Payer: Cofinity Commercial |
$46.26
|
| Rate for Payer: Cofinity Commercial |
$56.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.87
|
| Rate for Payer: Healthscope Commercial |
$59.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.18
|
| Rate for Payer: PHP Commercial |
$56.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.96
|
| Rate for Payer: Priority Health SBD |
$41.64
|
| Rate for Payer: UMR Bronson Commercial |
$29.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.57
|
|
|
DEXTROSE 50% IN WATER (D50W) IV SYRINGE (CODE)
|
Facility
|
OP
|
$108.48
|
|
|
Service Code
|
NDC 00409490234
|
| Hospital Charge Code |
163718
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.14 |
| Max. Negotiated Rate |
$97.63 |
| Rate for Payer: Aetna American Axle |
$70.51
|
| Rate for Payer: Aetna Commercial |
$92.21
|
| Rate for Payer: Aetna Medicare |
$54.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.51
|
| Rate for Payer: BCBS Complete |
$43.39
|
| Rate for Payer: Cash Price |
$86.78
|
| Rate for Payer: Cofinity Commercial |
$75.94
|
| Rate for Payer: Cofinity Commercial |
$93.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.78
|
| Rate for Payer: Healthscope Commercial |
$97.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.21
|
| Rate for Payer: PHP Commercial |
$92.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.51
|
| Rate for Payer: Priority Health SBD |
$68.34
|
| Rate for Payer: UMR Bronson Commercial |
$40.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.36
|
|
|
DEXTROSE 50% IN WATER (D50W) IV SYRINGE (CODE)
|
Facility
|
IP
|
$106.11
|
|
|
Service Code
|
NDC 00409751716
|
| Hospital Charge Code |
163718
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.69 |
| Max. Negotiated Rate |
$95.50 |
| Rate for Payer: Aetna American Axle |
$68.97
|
| Rate for Payer: Aetna Commercial |
$90.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.97
|
| Rate for Payer: Cash Price |
$84.89
|
| Rate for Payer: Cofinity Commercial |
$74.28
|
| Rate for Payer: Cofinity Commercial |
$91.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.89
|
| Rate for Payer: Healthscope Commercial |
$95.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.19
|
| Rate for Payer: PHP Commercial |
$90.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.97
|
| Rate for Payer: Priority Health SBD |
$66.85
|
| Rate for Payer: UMR Bronson Commercial |
$46.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.58
|
|
