|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$933.12
|
|
|
Service Code
|
NDC 00032120601
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$410.57 |
| Max. Negotiated Rate |
$839.81 |
| Rate for Payer: Aetna American Axle |
$606.53
|
| Rate for Payer: Aetna Commercial |
$793.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$606.53
|
| Rate for Payer: Cash Price |
$746.50
|
| Rate for Payer: Cofinity Commercial |
$653.18
|
| Rate for Payer: Cofinity Commercial |
$802.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$653.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$746.50
|
| Rate for Payer: Healthscope Commercial |
$839.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$653.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$699.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$793.15
|
| Rate for Payer: PHP Commercial |
$793.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$606.53
|
| Rate for Payer: Priority Health SBD |
$587.87
|
| Rate for Payer: UMR Bronson Commercial |
$410.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$699.84
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
OP
|
$933.12
|
|
|
Service Code
|
NDC 00032120601
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$345.25 |
| Max. Negotiated Rate |
$839.81 |
| Rate for Payer: Aetna American Axle |
$606.53
|
| Rate for Payer: Aetna Commercial |
$793.15
|
| Rate for Payer: Aetna Medicare |
$466.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$606.53
|
| Rate for Payer: BCBS Complete |
$373.25
|
| Rate for Payer: Cash Price |
$746.50
|
| Rate for Payer: Cofinity Commercial |
$653.18
|
| Rate for Payer: Cofinity Commercial |
$802.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$653.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$746.50
|
| Rate for Payer: Healthscope Commercial |
$839.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$653.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$699.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$793.15
|
| Rate for Payer: PHP Commercial |
$793.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$606.53
|
| Rate for Payer: Priority Health SBD |
$587.87
|
| Rate for Payer: UMR Bronson Commercial |
$345.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$699.84
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$2,209.20
|
|
|
Service Code
|
NDC 00032120607
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$972.05 |
| Max. Negotiated Rate |
$1,988.28 |
| Rate for Payer: Aetna American Axle |
$1,435.98
|
| Rate for Payer: Aetna Commercial |
$1,877.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.98
|
| Rate for Payer: Cash Price |
$1,767.36
|
| Rate for Payer: Cofinity Commercial |
$1,546.44
|
| Rate for Payer: Cofinity Commercial |
$1,899.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.36
|
| Rate for Payer: Healthscope Commercial |
$1,988.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.82
|
| Rate for Payer: PHP Commercial |
$1,877.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,435.98
|
| Rate for Payer: Priority Health SBD |
$1,391.80
|
| Rate for Payer: UMR Bronson Commercial |
$972.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.90
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$958.08
|
|
|
Service Code
|
NDC 00032004670
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$421.56 |
| Max. Negotiated Rate |
$862.27 |
| Rate for Payer: Aetna American Axle |
$622.75
|
| Rate for Payer: Aetna Commercial |
$814.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.75
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cofinity Commercial |
$670.66
|
| Rate for Payer: Cofinity Commercial |
$823.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$670.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$766.46
|
| Rate for Payer: Healthscope Commercial |
$862.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$814.37
|
| Rate for Payer: PHP Commercial |
$814.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$622.75
|
| Rate for Payer: Priority Health SBD |
$603.59
|
| Rate for Payer: UMR Bronson Commercial |
$421.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.56
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
OP
|
$958.08
|
|
|
Service Code
|
NDC 00032004670
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$354.49 |
| Max. Negotiated Rate |
$862.27 |
| Rate for Payer: Aetna American Axle |
$622.75
|
| Rate for Payer: Aetna Commercial |
$814.37
|
| Rate for Payer: Aetna Medicare |
$479.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$622.75
|
| Rate for Payer: BCBS Complete |
$383.23
|
| Rate for Payer: Cash Price |
$766.46
|
| Rate for Payer: Cofinity Commercial |
$670.66
|
| Rate for Payer: Cofinity Commercial |
$823.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$670.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$766.46
|
| Rate for Payer: Healthscope Commercial |
$862.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$670.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$718.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$814.37
|
| Rate for Payer: PHP Commercial |
$814.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$622.75
|
| Rate for Payer: Priority Health SBD |
$603.59
|
| Rate for Payer: UMR Bronson Commercial |
$354.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$718.56
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
OP
|
$2,209.20
|
|
|
Service Code
|
NDC 00032120607
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$817.40 |
| Max. Negotiated Rate |
$1,988.28 |
| Rate for Payer: Aetna American Axle |
$1,435.98
|
| Rate for Payer: Aetna Commercial |
$1,877.82
|
| Rate for Payer: Aetna Medicare |
$1,104.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,435.98
|
| Rate for Payer: BCBS Complete |
$883.68
|
| Rate for Payer: Cash Price |
$1,767.36
|
| Rate for Payer: Cofinity Commercial |
$1,546.44
|
| Rate for Payer: Cofinity Commercial |
$1,899.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.36
|
| Rate for Payer: Healthscope Commercial |
$1,988.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,656.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.82
|
| Rate for Payer: PHP Commercial |
$1,877.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,435.98
|
| Rate for Payer: Priority Health SBD |
$1,391.80
|
| Rate for Payer: UMR Bronson Commercial |
$817.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,656.90
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
NDC 09900000103
|
| Hospital Charge Code |
164988
|
|
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
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$73.42
|
|
|
Service Code
|
NDC 00090000239
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna Medicare |
$36.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: BCBS Complete |
$29.37
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.72
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UMR Bronson Commercial |
$27.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 09900000102
|
| Hospital Charge Code |
164988
|
|
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
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 09900000102
|
| Hospital Charge Code |
164988
|
|
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
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$135.60
|
|
|
Service Code
|
NDC 09900000107
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.66 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.14
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$59.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$108.48
|
|
|
Service Code
|
NDC 09900000106
|
| Hospital Charge Code |
164988
|
|
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
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$110.16
|
|
|
Service Code
|
NDC 09900000105
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna American Axle |
$71.60
|
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna Medicare |
$55.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: BCBS Complete |
$44.06
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.60
|
| Rate for Payer: Priority Health SBD |
$69.40
|
| Rate for Payer: UMR Bronson Commercial |
$40.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.62
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$73.44
|
|
|
Service Code
|
NDC 09900000104
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.31 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Commercial |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.42
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.74
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UMR Bronson Commercial |
$32.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$73.44
|
|
|
Service Code
|
NDC 09900000104
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna Medicare |
$36.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: BCBS Complete |
$29.38
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Commercial |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.42
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.74
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UMR Bronson Commercial |
$27.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$108.48
|
|
|
Service Code
|
NDC 09900000106
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.73 |
| Max. Negotiated Rate |
$97.63 |
| Rate for Payer: Aetna American Axle |
$70.51
|
| Rate for Payer: Aetna Commercial |
$92.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.51
|
| 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 |
$47.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.36
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$135.60
|
|
|
Service Code
|
NDC 09900000107
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.17 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna Medicare |
$67.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: BCBS Complete |
$54.24
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.14
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$50.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$73.42
|
|
|
Service Code
|
NDC 00090000239
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.72
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UMR Bronson Commercial |
$32.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
IP
|
$110.16
|
|
|
Service Code
|
NDC 09900000105
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.47 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna American Axle |
$71.60
|
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.60
|
| Rate for Payer: Priority Health SBD |
$69.40
|
| Rate for Payer: UMR Bronson Commercial |
$48.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.62
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$63.80
|
|
|
Service Code
|
NDC 09900000103
|
| Hospital Charge Code |
164988
|
|
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
|
|
|
LIPID (FAT EMULSION 20%) NEONATAL SYRINGE CUSTOM
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
NDC 00338051909
|
| Hospital Charge Code |
164988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.68 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna American Axle |
$301.60
|
| Rate for Payer: Aetna Commercial |
$394.40
|
| Rate for Payer: Aetna Medicare |
$232.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$301.60
|
| Rate for Payer: BCBS Complete |
$185.60
|
| Rate for Payer: Cash Price |
$371.20
|
| Rate for Payer: Cofinity Commercial |
$324.80
|
| Rate for Payer: Cofinity Commercial |
$399.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.20
|
| Rate for Payer: Healthscope Commercial |
$417.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$324.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$348.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$394.40
|
| Rate for Payer: PHP Commercial |
$394.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.60
|
| Rate for Payer: Priority Health SBD |
$292.32
|
| Rate for Payer: UMR Bronson Commercial |
$171.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$348.00
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417010110
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,467.76 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna Medicare |
$1,983.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: BCBS Complete |
$1,586.77
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Commercial |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,776.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,371.89
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,578.50
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UMR Bronson Commercial |
$1,467.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
OP
|
$480.90
|
|
|
Service Code
|
NDC 43547060210
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.93 |
| Max. Negotiated Rate |
$432.81 |
| Rate for Payer: Aetna American Axle |
$312.58
|
| Rate for Payer: Aetna Commercial |
$408.76
|
| Rate for Payer: Aetna Medicare |
$240.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.58
|
| Rate for Payer: BCBS Complete |
$192.36
|
| Rate for Payer: Cash Price |
$384.72
|
| Rate for Payer: Cofinity Commercial |
$336.63
|
| Rate for Payer: Cofinity Commercial |
$413.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$336.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$384.72
|
| Rate for Payer: Healthscope Commercial |
$432.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$336.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$360.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$408.76
|
| Rate for Payer: PHP Commercial |
$408.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.58
|
| Rate for Payer: Priority Health SBD |
$302.97
|
| Rate for Payer: UMR Bronson Commercial |
$177.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$360.68
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3,966.93
|
|
|
Service Code
|
NDC 59417010110
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,745.45 |
| Max. Negotiated Rate |
$3,570.24 |
| Rate for Payer: Aetna American Axle |
$2,578.50
|
| Rate for Payer: Aetna Commercial |
$3,371.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,578.50
|
| Rate for Payer: Cash Price |
$3,173.54
|
| Rate for Payer: Cofinity Commercial |
$2,776.85
|
| Rate for Payer: Cofinity Commercial |
$3,411.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,776.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,173.54
|
| Rate for Payer: Healthscope Commercial |
$3,570.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,776.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,975.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,371.89
|
| Rate for Payer: PHP Commercial |
$3,371.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,578.50
|
| Rate for Payer: Priority Health SBD |
$2,499.17
|
| Rate for Payer: UMR Bronson Commercial |
$1,745.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,975.20
|
|
|
LISDEXAMFETAMINE 10 MG CAPSULE
|
Facility
|
IP
|
$1,201.90
|
|
|
Service Code
|
NDC 00527466137
|
| Hospital Charge Code |
173697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$528.84 |
| Max. Negotiated Rate |
$1,081.71 |
| Rate for Payer: Aetna American Axle |
$781.24
|
| Rate for Payer: Aetna Commercial |
$1,021.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.24
|
| Rate for Payer: Cash Price |
$961.52
|
| Rate for Payer: Cofinity Commercial |
$1,033.63
|
| Rate for Payer: Cofinity Commercial |
$841.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$841.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$961.52
|
| Rate for Payer: Healthscope Commercial |
$1,081.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$841.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$901.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,021.62
|
| Rate for Payer: PHP Commercial |
$1,021.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$781.24
|
| Rate for Payer: Priority Health SBD |
$757.20
|
| Rate for Payer: UMR Bronson Commercial |
$528.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$901.42
|
|
