|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$6.72
|
|
|
Service Code
|
NDC 51079-306-01
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Aetna American Axle |
$4.37
|
| Rate for Payer: Aetna Commercial |
$5.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.37
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cofinity Commercial |
$4.70
|
| Rate for Payer: Cofinity Commercial |
$5.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.38
|
| Rate for Payer: Healthscope Commercial |
$6.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.71
|
| Rate for Payer: PHP Commercial |
$5.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.70
|
| Rate for Payer: Priority Health SBD |
$4.23
|
| Rate for Payer: UMR Bronson Commercial |
$2.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.04
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$201.60
|
|
|
Service Code
|
NDC 51079-306-30
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.70 |
| Max. Negotiated Rate |
$181.44 |
| Rate for Payer: Aetna American Axle |
$131.04
|
| Rate for Payer: Aetna Commercial |
$171.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.04
|
| Rate for Payer: Cash Price |
$161.28
|
| Rate for Payer: Cofinity Commercial |
$141.12
|
| Rate for Payer: Cofinity Commercial |
$173.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.28
|
| Rate for Payer: Healthscope Commercial |
$181.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$141.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.36
|
| Rate for Payer: PHP Commercial |
$171.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.12
|
| Rate for Payer: Priority Health SBD |
$127.01
|
| Rate for Payer: UMR Bronson Commercial |
$88.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.20
|
|
|
POLYETHYLENE GLYCOL 3350 238 GRAM ORAL SOLUTION (PEDIATRICS)
|
Facility
|
IP
|
$49.15
|
|
|
Service Code
|
NDC 11523-7234-3
|
| Hospital Charge Code |
300933
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.63 |
| Max. Negotiated Rate |
$44.24 |
| Rate for Payer: Aetna American Axle |
$31.95
|
| Rate for Payer: Aetna Commercial |
$41.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.95
|
| Rate for Payer: Cash Price |
$39.32
|
| Rate for Payer: Cofinity Commercial |
$34.40
|
| Rate for Payer: Cofinity Commercial |
$42.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.32
|
| Rate for Payer: Healthscope Commercial |
$44.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.78
|
| Rate for Payer: PHP Commercial |
$41.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.40
|
| Rate for Payer: Priority Health SBD |
$30.96
|
| Rate for Payer: UMR Bronson Commercial |
$21.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.86
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$261.45
|
|
|
Service Code
|
NDC 0023-7824-10
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.04 |
| Max. Negotiated Rate |
$235.30 |
| Rate for Payer: Aetna American Axle |
$169.94
|
| Rate for Payer: Aetna Commercial |
$222.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.94
|
| Rate for Payer: Cash Price |
$209.16
|
| Rate for Payer: Cofinity Commercial |
$183.02
|
| Rate for Payer: Cofinity Commercial |
$224.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.16
|
| Rate for Payer: Healthscope Commercial |
$235.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$222.23
|
| Rate for Payer: PHP Commercial |
$222.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.02
|
| Rate for Payer: Priority Health SBD |
$164.71
|
| Rate for Payer: UMR Bronson Commercial |
$115.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.09
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$24.30 |
| Rate for Payer: Aetna American Axle |
$17.55
|
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.55
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cofinity Commercial |
$18.90
|
| Rate for Payer: Cofinity Commercial |
$23.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.60
|
| Rate for Payer: Healthscope Commercial |
$24.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.95
|
| Rate for Payer: PHP Commercial |
$22.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.90
|
| Rate for Payer: Priority Health SBD |
$17.01
|
| Rate for Payer: UMR Bronson Commercial |
$11.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.25
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 24208-315-10
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna American Axle |
$22.75
|
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.75
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Commercial |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.00
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.50
|
| Rate for Payer: Priority Health SBD |
$22.05
|
| Rate for Payer: UMR Bronson Commercial |
$15.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$35.46
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$31.91 |
| Rate for Payer: Aetna American Axle |
$23.05
|
| Rate for Payer: Aetna Commercial |
$30.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.05
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$30.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.37
|
| Rate for Payer: Healthscope Commercial |
$31.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.14
|
| Rate for Payer: PHP Commercial |
$30.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.82
|
| Rate for Payer: Priority Health SBD |
$22.34
|
| Rate for Payer: UMR Bronson Commercial |
$15.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.60
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$17.78
|
|
|
Service Code
|
NDC 17478-703-11
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna American Axle |
$11.56
|
| Rate for Payer: Aetna Commercial |
$15.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.56
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cofinity Commercial |
$12.45
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.22
|
| Rate for Payer: Healthscope Commercial |
$16.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.11
|
| Rate for Payer: PHP Commercial |
$15.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.45
|
| Rate for Payer: Priority Health SBD |
$11.20
|
| Rate for Payer: UMR Bronson Commercial |
$7.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.34
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$21.44
|
|
|
Service Code
|
NDC 70594-049-02
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna American Axle |
$13.94
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.94
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cofinity Commercial |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.22
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.01
|
| Rate for Payer: Priority Health SBD |
$13.51
|
| Rate for Payer: UMR Bronson Commercial |
$9.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.08
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$45.44
|
|
|
Service Code
|
NDC 63323-367-11
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$40.90 |
| Rate for Payer: Aetna American Axle |
$29.54
|
| Rate for Payer: Aetna Commercial |
$38.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.54
|
| Rate for Payer: Cash Price |
$36.35
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.35
|
| Rate for Payer: Healthscope Commercial |
$40.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.62
|
| Rate for Payer: PHP Commercial |
$38.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.81
|
| Rate for Payer: Priority Health SBD |
$28.63
|
| Rate for Payer: UMR Bronson Commercial |
$19.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.08
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$45.44
|
|
|
Service Code
|
NDC 63323-367-01
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$40.90 |
| Rate for Payer: Aetna American Axle |
$29.54
|
| Rate for Payer: Aetna Commercial |
$38.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.54
|
| Rate for Payer: Cash Price |
$36.35
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.35
|
| Rate for Payer: Healthscope Commercial |
$40.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.62
|
| Rate for Payer: PHP Commercial |
$38.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.81
|
| Rate for Payer: Priority Health SBD |
$28.63
|
| Rate for Payer: UMR Bronson Commercial |
$19.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.08
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 5199120311
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.05 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.90
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.90
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.81
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$184.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
IP
|
$4.19
|
|
|
Service Code
|
NDC 5199120399
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Aetna American Axle |
$2.72
|
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.72
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cofinity Commercial |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.35
|
| Rate for Payer: Healthscope Commercial |
$3.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.56
|
| Rate for Payer: PHP Commercial |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.93
|
| Rate for Payer: Priority Health SBD |
$2.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.14
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 904539561
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.33 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.70
|
| Rate for Payer: Aetna Commercial |
$195.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.70
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$195.76
|
| Rate for Payer: PHP Commercial |
$195.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.21
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$101.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
POLYSORBATE 80 SOLUTION
|
Facility
|
IP
|
$399.50
|
|
|
Service Code
|
NDC 3877905268
|
| Hospital Charge Code |
6395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.78 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna American Axle |
$259.68
|
| Rate for Payer: Aetna Commercial |
$339.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
| Rate for Payer: Cash Price |
$319.60
|
| Rate for Payer: Cofinity Commercial |
$279.65
|
| Rate for Payer: Cofinity Commercial |
$343.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.60
|
| Rate for Payer: Healthscope Commercial |
$359.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$279.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$299.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.58
|
| Rate for Payer: PHP Commercial |
$339.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.65
|
| Rate for Payer: Priority Health SBD |
$251.68
|
| Rate for Payer: UMR Bronson Commercial |
$175.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$299.62
|
|
|
POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 0023-0506-50
|
| Hospital Charge Code |
112480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.34
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION
|
Facility
|
IP
|
$1,832.13
|
|
|
Service Code
|
NDC 10122-510-01
|
| Hospital Charge Code |
27047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$806.14 |
| Max. Negotiated Rate |
$1,648.92 |
| Rate for Payer: Aetna American Axle |
$1,190.88
|
| Rate for Payer: Aetna Commercial |
$1,557.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,190.88
|
| Rate for Payer: Cash Price |
$1,465.70
|
| Rate for Payer: Cofinity Commercial |
$1,282.49
|
| Rate for Payer: Cofinity Commercial |
$1,575.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,465.70
|
| Rate for Payer: Healthscope Commercial |
$1,648.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,282.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,374.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,557.31
|
| Rate for Payer: PHP Commercial |
$1,557.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,282.49
|
| Rate for Payer: Priority Health SBD |
$1,154.24
|
| Rate for Payer: UMR Bronson Commercial |
$806.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,374.10
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3,337.77
|
|
|
Service Code
|
NDC 0254-2045-02
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,468.62 |
| Max. Negotiated Rate |
$3,003.99 |
| Rate for Payer: Aetna American Axle |
$2,169.55
|
| Rate for Payer: Aetna Commercial |
$2,837.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,169.55
|
| Rate for Payer: Cash Price |
$2,670.22
|
| Rate for Payer: Cofinity Commercial |
$2,336.44
|
| Rate for Payer: Cofinity Commercial |
$2,870.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,670.22
|
| Rate for Payer: Healthscope Commercial |
$3,003.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,336.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,503.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,837.10
|
| Rate for Payer: PHP Commercial |
$2,837.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,336.44
|
| Rate for Payer: Priority Health SBD |
$2,102.80
|
| Rate for Payer: UMR Bronson Commercial |
$1,468.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,503.33
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$14,148.73
|
|
|
Service Code
|
NDC 0085-4324-02
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,235.03 |
| Max. Negotiated Rate |
$12,733.86 |
| Rate for Payer: Aetna American Axle |
$9,196.67
|
| Rate for Payer: Aetna Commercial |
$12,026.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,196.67
|
| Rate for Payer: BCBS Complete |
$5,659.49
|
| Rate for Payer: Cash Price |
$11,318.98
|
| Rate for Payer: Cofinity Commercial |
$12,167.91
|
| Rate for Payer: Cofinity Commercial |
$9,904.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,318.98
|
| Rate for Payer: Healthscope Commercial |
$12,733.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,904.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,611.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,026.42
|
| Rate for Payer: PHP Commercial |
$12,026.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,904.11
|
| Rate for Payer: Priority Health SBD |
$8,913.70
|
| Rate for Payer: UMR Bronson Commercial |
$5,235.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,611.55
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$1,548.45
|
|
|
Service Code
|
NDC 70748-258-07
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$681.32 |
| Max. Negotiated Rate |
$1,393.60 |
| Rate for Payer: Aetna American Axle |
$1,006.49
|
| Rate for Payer: Aetna Commercial |
$1,316.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,006.49
|
| Rate for Payer: Cash Price |
$1,238.76
|
| Rate for Payer: Cofinity Commercial |
$1,083.92
|
| Rate for Payer: Cofinity Commercial |
$1,331.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,238.76
|
| Rate for Payer: Healthscope Commercial |
$1,393.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,083.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,161.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,316.18
|
| Rate for Payer: PHP Commercial |
$1,316.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.92
|
| Rate for Payer: Priority Health SBD |
$975.52
|
| Rate for Payer: UMR Bronson Commercial |
$681.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,161.34
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$14,148.73
|
|
|
Service Code
|
NDC 0085-4324-02
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,225.44 |
| Max. Negotiated Rate |
$12,733.86 |
| Rate for Payer: Aetna American Axle |
$9,196.67
|
| Rate for Payer: Aetna Commercial |
$12,026.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,196.67
|
| Rate for Payer: Cash Price |
$11,318.98
|
| Rate for Payer: Cofinity Commercial |
$12,167.91
|
| Rate for Payer: Cofinity Commercial |
$9,904.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,318.98
|
| Rate for Payer: Healthscope Commercial |
$12,733.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,904.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,611.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,026.42
|
| Rate for Payer: PHP Commercial |
$12,026.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,904.11
|
| Rate for Payer: Priority Health SBD |
$8,913.70
|
| Rate for Payer: UMR Bronson Commercial |
$6,225.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,611.55
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4,689.98
|
|
|
Service Code
|
NDC 60687-523-21
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,063.59 |
| Max. Negotiated Rate |
$4,220.98 |
| Rate for Payer: Aetna American Axle |
$3,048.49
|
| Rate for Payer: Aetna Commercial |
$3,986.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,048.49
|
| Rate for Payer: Cash Price |
$3,751.98
|
| Rate for Payer: Cofinity Commercial |
$3,282.99
|
| Rate for Payer: Cofinity Commercial |
$4,033.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,751.98
|
| Rate for Payer: Healthscope Commercial |
$4,220.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,282.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,517.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,986.48
|
| Rate for Payer: PHP Commercial |
$3,986.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,282.99
|
| Rate for Payer: Priority Health SBD |
$2,954.69
|
| Rate for Payer: UMR Bronson Commercial |
$2,063.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,517.48
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$156.34
|
|
|
Service Code
|
NDC 60687-523-11
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.79 |
| Max. Negotiated Rate |
$140.71 |
| Rate for Payer: Aetna American Axle |
$101.62
|
| Rate for Payer: Aetna Commercial |
$132.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.62
|
| Rate for Payer: Cash Price |
$125.07
|
| Rate for Payer: Cofinity Commercial |
$134.45
|
| Rate for Payer: Cofinity Commercial |
$109.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.07
|
| Rate for Payer: Healthscope Commercial |
$140.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$132.89
|
| Rate for Payer: PHP Commercial |
$132.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.44
|
| Rate for Payer: Priority Health SBD |
$98.49
|
| Rate for Payer: UMR Bronson Commercial |
$68.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.26
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$3,337.77
|
|
|
Service Code
|
NDC 0254-2045-02
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,234.97 |
| Max. Negotiated Rate |
$3,003.99 |
| Rate for Payer: Aetna American Axle |
$2,169.55
|
| Rate for Payer: Aetna Commercial |
$2,837.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,169.55
|
| Rate for Payer: BCBS Complete |
$1,335.11
|
| Rate for Payer: Cash Price |
$2,670.22
|
| Rate for Payer: Cofinity Commercial |
$2,870.48
|
| Rate for Payer: Cofinity Commercial |
$2,336.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,670.22
|
| Rate for Payer: Healthscope Commercial |
$3,003.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,336.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,503.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,837.10
|
| Rate for Payer: PHP Commercial |
$2,837.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,336.44
|
| Rate for Payer: Priority Health SBD |
$2,102.80
|
| Rate for Payer: UMR Bronson Commercial |
$1,234.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,503.33
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$4,953.38
|
|
|
Service Code
|
NDC 0085-1328-01
|
| Hospital Charge Code |
77371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,179.49 |
| Max. Negotiated Rate |
$4,458.04 |
| Rate for Payer: Aetna American Axle |
$3,219.70
|
| Rate for Payer: Aetna Commercial |
$4,210.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,219.70
|
| Rate for Payer: Cash Price |
$3,962.70
|
| Rate for Payer: Cofinity Commercial |
$4,259.91
|
| Rate for Payer: Cofinity Commercial |
$3,467.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,962.70
|
| Rate for Payer: Healthscope Commercial |
$4,458.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,467.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,715.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,210.37
|
| Rate for Payer: PHP Commercial |
$4,210.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,467.37
|
| Rate for Payer: Priority Health SBD |
$3,120.63
|
| Rate for Payer: UMR Bronson Commercial |
$2,179.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,715.04
|
|
