|
NUTREN 2.0 BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 9871606230
|
| Hospital Charge Code |
150720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna American Axle |
$3.09
|
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.09
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health SBD |
$2.99
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
NUTREN 2.0 CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 9871606230
|
| Hospital Charge Code |
168944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna American Axle |
$3.09
|
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.09
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health SBD |
$2.99
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
NUTREN 2.0 CYCLIC FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 9871606230
|
| Hospital Charge Code |
200085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna American Axle |
$3.09
|
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.09
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health SBD |
$2.99
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
NUTREN 2.0 INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 9871606230
|
| Hospital Charge Code |
200084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna American Axle |
$3.09
|
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.09
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health SBD |
$2.99
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
NUTRITIONAL SUPPLEMENT-FIBER ORAL LIQUID
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 4390040722
|
| Hospital Charge Code |
112392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna American Axle |
$13.16
|
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.21
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.18
|
| Rate for Payer: Priority Health SBD |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$8.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
NUTRITIONAL TX, KETOGENIC,WHEY 3.2 GRAM-149 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$30.63
|
|
|
Service Code
|
NDC 2435950303
|
| Hospital Charge Code |
196979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$27.57 |
| Rate for Payer: Aetna American Axle |
$19.91
|
| Rate for Payer: Aetna Commercial |
$26.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.91
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$21.44
|
| Rate for Payer: Cofinity Commercial |
$26.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.50
|
| Rate for Payer: Healthscope Commercial |
$27.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.04
|
| Rate for Payer: PHP Commercial |
$26.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.44
|
| Rate for Payer: Priority Health SBD |
$19.30
|
| Rate for Payer: UMR Bronson Commercial |
$13.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.97
|
|
|
NUTRITIONAL TX, KETOGENIC,WHEY 3.4 GRAM-148 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$32.38
|
|
|
Service Code
|
NDC 2435950203
|
| Hospital Charge Code |
198895
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$29.14 |
| Rate for Payer: Aetna American Axle |
$21.05
|
| Rate for Payer: Aetna Commercial |
$27.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.05
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cofinity Commercial |
$22.67
|
| Rate for Payer: Cofinity Commercial |
$27.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$29.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.52
|
| Rate for Payer: PHP Commercial |
$27.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.67
|
| Rate for Payer: Priority Health SBD |
$20.40
|
| Rate for Payer: UMR Bronson Commercial |
$14.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.28
|
|
|
NUT.TX IMPAIRED RENAL FUNCTION, SOY 0.09 GRAM-2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 4390094469
|
| Hospital Charge Code |
173995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna American Axle |
$2.96
|
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.96
|
| Rate for Payer: Cash Price |
$3.65
|
| Rate for Payer: Cofinity Commercial |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$3.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.65
|
| Rate for Payer: Healthscope Commercial |
$4.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.88
|
| Rate for Payer: PHP Commercial |
$3.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.19
|
| Rate for Payer: Priority Health SBD |
$2.87
|
| Rate for Payer: UMR Bronson Commercial |
$2.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.42
|
|
|
NUT.TX IMPAIRED RENAL FUNCTION, SOY 0.09 GRAM-2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 4390030609
|
| Hospital Charge Code |
173995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Commercial |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.46
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.81
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.78
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UMR Bronson Commercial |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 14.4 GRAM-701 KCAL/100 GRAM ORAL POWDR
|
Facility
|
IP
|
$138.75
|
|
|
Service Code
|
NDC 4973501842
|
| Hospital Charge Code |
169193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.05 |
| Max. Negotiated Rate |
$124.88 |
| Rate for Payer: Aetna American Axle |
$90.19
|
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.19
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cofinity Commercial |
$119.32
|
| Rate for Payer: Cofinity Commercial |
$97.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.00
|
| Rate for Payer: Healthscope Commercial |
$124.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.94
|
| Rate for Payer: PHP Commercial |
$117.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.12
|
| Rate for Payer: Priority Health SBD |
$87.41
|
| Rate for Payer: UMR Bronson Commercial |
$61.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.06
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$21.05
|
|
|
Service Code
|
NDC 4973513054
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$18.94 |
| Rate for Payer: Aetna American Axle |
$13.68
|
| Rate for Payer: Aetna Commercial |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.68
|
| Rate for Payer: Cash Price |
$16.84
|
| Rate for Payer: Cofinity Commercial |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$18.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.84
|
| Rate for Payer: Healthscope Commercial |
$18.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.89
|
| Rate for Payer: PHP Commercial |
$17.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.74
|
| Rate for Payer: Priority Health SBD |
$13.26
|
| Rate for Payer: UMR Bronson Commercial |
$9.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.79
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$27.19
|
|
|
Service Code
|
NDC 4973518796
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.96 |
| Max. Negotiated Rate |
$24.47 |
| Rate for Payer: Aetna American Axle |
$17.67
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.11
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.03
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: UMR Bronson Commercial |
$11.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$17.82
|
|
|
Service Code
|
NDC 45802-059-35
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna American Axle |
$11.58
|
| Rate for Payer: Aetna Commercial |
$15.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.58
|
| Rate for Payer: Cash Price |
$14.26
|
| Rate for Payer: Cofinity Commercial |
$12.47
|
| Rate for Payer: Cofinity Commercial |
$15.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.26
|
| Rate for Payer: Healthscope Commercial |
$16.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.15
|
| Rate for Payer: PHP Commercial |
$15.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.47
|
| Rate for Payer: Priority Health SBD |
$11.23
|
| Rate for Payer: UMR Bronson Commercial |
$7.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.36
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$28.41
|
|
|
Service Code
|
NDC 51672-1289-1
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$25.57 |
| Rate for Payer: Aetna American Axle |
$18.47
|
| Rate for Payer: Aetna Commercial |
$24.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.47
|
| Rate for Payer: Cash Price |
$22.73
|
| Rate for Payer: Cofinity Commercial |
$24.43
|
| Rate for Payer: Cofinity Commercial |
$19.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.73
|
| Rate for Payer: Healthscope Commercial |
$25.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.15
|
| Rate for Payer: PHP Commercial |
$24.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.89
|
| Rate for Payer: Priority Health SBD |
$17.90
|
| Rate for Payer: UMR Bronson Commercial |
$12.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.31
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$12.63
|
|
|
Service Code
|
NDC 0713-0686-15
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$11.37 |
| Rate for Payer: Aetna American Axle |
$8.21
|
| Rate for Payer: Aetna Commercial |
$10.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.21
|
| Rate for Payer: Cash Price |
$10.10
|
| Rate for Payer: Cofinity Commercial |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$8.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.10
|
| Rate for Payer: Healthscope Commercial |
$11.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.74
|
| Rate for Payer: PHP Commercial |
$10.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.84
|
| Rate for Payer: Priority Health SBD |
$7.96
|
| Rate for Payer: UMR Bronson Commercial |
$5.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.47
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$45.57
|
|
|
Service Code
|
NDC 0168-0007-15
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Aetna American Axle |
$29.62
|
| Rate for Payer: Aetna Commercial |
$38.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.62
|
| Rate for Payer: Cash Price |
$36.46
|
| Rate for Payer: Cofinity Commercial |
$31.90
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.46
|
| Rate for Payer: Healthscope Commercial |
$41.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.73
|
| Rate for Payer: PHP Commercial |
$38.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.90
|
| Rate for Payer: Priority Health SBD |
$28.71
|
| Rate for Payer: UMR Bronson Commercial |
$20.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.18
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$45.10
|
|
|
Service Code
|
NDC 45802-048-35
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.84 |
| Max. Negotiated Rate |
$40.59 |
| Rate for Payer: Aetna American Axle |
$29.32
|
| Rate for Payer: Aetna Commercial |
$38.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.32
|
| Rate for Payer: Cash Price |
$36.08
|
| Rate for Payer: Cofinity Commercial |
$31.57
|
| Rate for Payer: Cofinity Commercial |
$38.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.08
|
| Rate for Payer: Healthscope Commercial |
$40.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.34
|
| Rate for Payer: PHP Commercial |
$38.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.57
|
| Rate for Payer: Priority Health SBD |
$28.41
|
| Rate for Payer: UMR Bronson Commercial |
$19.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.82
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$67.62
|
|
|
Service Code
|
NDC 45802-048-11
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$60.86 |
| Rate for Payer: Aetna American Axle |
$43.95
|
| Rate for Payer: Aetna Commercial |
$57.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.95
|
| Rate for Payer: Cash Price |
$54.10
|
| Rate for Payer: Cofinity Commercial |
$47.33
|
| Rate for Payer: Cofinity Commercial |
$58.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.10
|
| Rate for Payer: Healthscope Commercial |
$60.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.48
|
| Rate for Payer: PHP Commercial |
$57.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.33
|
| Rate for Payer: Priority Health SBD |
$42.60
|
| Rate for Payer: UMR Bronson Commercial |
$29.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.72
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.46
|
|
|
Service Code
|
NDC 68094-599-61
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: Aetna American Axle |
$3.55
|
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.55
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cofinity Commercial |
$3.82
|
| Rate for Payer: Cofinity Commercial |
$4.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.37
|
| Rate for Payer: Healthscope Commercial |
$4.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.64
|
| Rate for Payer: PHP Commercial |
$4.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.82
|
| Rate for Payer: Priority Health SBD |
$3.44
|
| Rate for Payer: UMR Bronson Commercial |
$2.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.10
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$10.92
|
|
|
Service Code
|
NDC 68094-599-59
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Aetna American Axle |
$7.10
|
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.10
|
| Rate for Payer: Cash Price |
$8.74
|
| Rate for Payer: Cofinity Commercial |
$7.64
|
| Rate for Payer: Cofinity Commercial |
$9.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.74
|
| Rate for Payer: Healthscope Commercial |
$9.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.28
|
| Rate for Payer: PHP Commercial |
$9.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.64
|
| Rate for Payer: Priority Health SBD |
$6.88
|
| Rate for Payer: UMR Bronson Commercial |
$4.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.19
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 0904-7276-41
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna American Axle |
$2.55
|
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.55
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cofinity Commercial |
$2.75
|
| Rate for Payer: Cofinity Commercial |
$3.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.14
|
| Rate for Payer: Healthscope Commercial |
$3.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.34
|
| Rate for Payer: PHP Commercial |
$3.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.48
|
| Rate for Payer: UMR Bronson Commercial |
$1.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.95
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.10
|
|
|
Service Code
|
NDC 0121-4785-05
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna American Axle |
$3.32
|
| Rate for Payer: Aetna Commercial |
$4.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.32
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Cofinity Commercial |
$3.57
|
| Rate for Payer: Cofinity Commercial |
$4.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.08
|
| Rate for Payer: Healthscope Commercial |
$4.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.34
|
| Rate for Payer: PHP Commercial |
$4.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: Priority Health SBD |
$3.21
|
| Rate for Payer: UMR Bronson Commercial |
$2.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.82
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 66689-037-01
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna American Axle |
$3.57
|
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.57
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$4.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.67
|
| Rate for Payer: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.84
|
| Rate for Payer: Priority Health SBD |
$3.46
|
| Rate for Payer: UMR Bronson Commercial |
$2.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.12
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$94.37
|
|
|
Service Code
|
NDC 0121-0868-16
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.52 |
| Max. Negotiated Rate |
$84.93 |
| Rate for Payer: Aetna American Axle |
$61.34
|
| Rate for Payer: Aetna Commercial |
$80.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.34
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cofinity Commercial |
$66.06
|
| Rate for Payer: Cofinity Commercial |
$81.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.50
|
| Rate for Payer: Healthscope Commercial |
$84.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$80.21
|
| Rate for Payer: PHP Commercial |
$80.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.06
|
| Rate for Payer: Priority Health SBD |
$59.45
|
| Rate for Payer: UMR Bronson Commercial |
$41.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.78
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 66689-037-50
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna American Axle |
$3.57
|
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.57
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$4.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.67
|
| Rate for Payer: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.84
|
| Rate for Payer: Priority Health SBD |
$3.46
|
| Rate for Payer: UMR Bronson Commercial |
$2.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.12
|
|
