|
NUTRITIONAL TX, KETOGENIC,WHEY 3.4 GRAM-148 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$34.23
|
|
|
Service Code
|
NDC 24359050203
|
| Hospital Charge Code |
198895
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$30.81 |
| Rate for Payer: Aetna American Axle |
$22.25
|
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.25
|
| Rate for Payer: Cash Price |
$27.38
|
| Rate for Payer: Cofinity Advantage |
$23.96
|
| Rate for Payer: Cofinity Commercial |
$29.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.38
|
| Rate for Payer: Healthscope Commercial |
$30.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.67
|
| Rate for Payer: PHP Commercial |
$29.10
|
| Rate for Payer: Priority Health SBD |
$21.56
|
| Rate for Payer: UMR Bronson Commercial |
$15.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.67
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
NDC 70074062716
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$49.95 |
| Rate for Payer: Aetna American Axle |
$36.08
|
| Rate for Payer: Aetna Commercial |
$47.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.08
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cofinity Advantage |
$38.85
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.40
|
| Rate for Payer: Healthscope Commercial |
$49.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.62
|
| Rate for Payer: PHP Commercial |
$47.17
|
| Rate for Payer: Priority Health SBD |
$34.97
|
| Rate for Payer: UMR Bronson Commercial |
$24.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.62
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
NDC 70074062715
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$49.95 |
| Rate for Payer: Aetna American Axle |
$36.08
|
| Rate for Payer: Aetna Commercial |
$47.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.08
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cofinity Advantage |
$38.85
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.40
|
| Rate for Payer: Healthscope Commercial |
$49.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.62
|
| Rate for Payer: PHP Commercial |
$47.17
|
| Rate for Payer: Priority Health SBD |
$34.97
|
| Rate for Payer: UMR Bronson Commercial |
$24.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.62
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
NDC 70074062716
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.54 |
| Max. Negotiated Rate |
$49.95 |
| Rate for Payer: Aetna American Axle |
$36.08
|
| Rate for Payer: Aetna Commercial |
$47.17
|
| Rate for Payer: Aetna Medicare |
$27.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.08
|
| Rate for Payer: BCBS Complete |
$22.20
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cofinity Advantage |
$38.85
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.40
|
| Rate for Payer: Healthscope Commercial |
$49.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.62
|
| Rate for Payer: PHP Commercial |
$47.17
|
| Rate for Payer: Priority Health SBD |
$34.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.08
|
| Rate for Payer: UHC Core |
$28.92
|
| Rate for Payer: UHC Exchange |
$21.81
|
| Rate for Payer: UMR Bronson Commercial |
$20.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.62
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
NDC 70074062715
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.54 |
| Max. Negotiated Rate |
$49.95 |
| Rate for Payer: Aetna American Axle |
$36.08
|
| Rate for Payer: Aetna Commercial |
$47.17
|
| Rate for Payer: Aetna Medicare |
$27.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.08
|
| Rate for Payer: BCBS Complete |
$22.20
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cofinity Advantage |
$38.85
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.40
|
| Rate for Payer: Healthscope Commercial |
$49.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.62
|
| Rate for Payer: PHP Commercial |
$47.17
|
| Rate for Payer: Priority Health SBD |
$34.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.08
|
| Rate for Payer: UHC Core |
$28.92
|
| Rate for Payer: UHC Exchange |
$21.81
|
| Rate for Payer: UMR Bronson Commercial |
$20.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.62
|
|
|
NUT.TX IMPAIRED RENAL FUNCTION, SOY 0.09 GRAM-2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 43900094469
|
| Hospital Charge Code |
173995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Aetna American Axle |
$3.70
|
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.70
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Advantage |
$3.98
|
| Rate for Payer: Cofinity Commercial |
$4.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.27
|
| Rate for Payer: PHP Commercial |
$4.84
|
| Rate for Payer: Priority Health SBD |
$3.58
|
| Rate for Payer: UMR Bronson Commercial |
$2.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.27
|
|
|
NUT.TX IMPAIRED RENAL FUNCTION, SOY 0.09 GRAM-2 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$6.83
|
|
|
Service Code
|
NDC 43900030609
|
| Hospital Charge Code |
173995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna American Axle |
$4.44
|
| Rate for Payer: Aetna Commercial |
$5.81
|
| Rate for Payer: Aetna Medicare |
$3.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.44
|
| Rate for Payer: BCBS Complete |
$2.73
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$5.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.44
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$2.68
|
| Rate for Payer: UMR Bronson Commercial |
$2.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.12
|
|
|
NUT.TX IMPAIRED RENAL FUNCTION, SOY 0.09 GRAM-2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
NDC 43900030609
|
| 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 Advantage |
$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 Commercial |
$5.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.12
|
| Rate for Payer: PHP Commercial |
$5.81
|
| 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 IMPAIRED RENAL FUNCTION, SOY 0.09 GRAM-2 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 43900094469
|
| Hospital Charge Code |
173995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Aetna American Axle |
$3.70
|
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$2.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.70
|
| Rate for Payer: BCBS Complete |
$2.28
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Advantage |
$3.98
|
| Rate for Payer: Cofinity Commercial |
$4.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.27
|
| Rate for Payer: PHP Commercial |
$4.84
|
| Rate for Payer: Priority Health SBD |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.70
|
| Rate for Payer: UHC Core |
$2.96
|
| Rate for Payer: UHC Exchange |
$2.24
|
| Rate for Payer: UMR Bronson Commercial |
$2.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.27
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 14.4 GRAM-701 KCAL/100 GRAM ORAL POWDR
|
Facility
|
OP
|
$165.39
|
|
|
Service Code
|
NDC 49735001842
|
| Hospital Charge Code |
169193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.19 |
| Max. Negotiated Rate |
$148.85 |
| Rate for Payer: Aetna American Axle |
$107.50
|
| Rate for Payer: Aetna Commercial |
$140.58
|
| Rate for Payer: Aetna Medicare |
$82.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.50
|
| Rate for Payer: BCBS Complete |
$66.16
|
| Rate for Payer: Cash Price |
$132.31
|
| Rate for Payer: Cofinity Advantage |
$115.77
|
| Rate for Payer: Cofinity Commercial |
$142.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.31
|
| Rate for Payer: Healthscope Commercial |
$148.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$132.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$124.04
|
| Rate for Payer: PHP Commercial |
$140.58
|
| Rate for Payer: Priority Health SBD |
$104.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$107.50
|
| Rate for Payer: UHC Core |
$86.17
|
| Rate for Payer: UHC Exchange |
$65.00
|
| Rate for Payer: UMR Bronson Commercial |
$61.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.04
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 14.4 GRAM-701 KCAL/100 GRAM ORAL POWDR
|
Facility
|
IP
|
$165.39
|
|
|
Service Code
|
NDC 49735001842
|
| Hospital Charge Code |
169193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.77 |
| Max. Negotiated Rate |
$148.85 |
| Rate for Payer: Aetna American Axle |
$107.50
|
| Rate for Payer: Aetna Commercial |
$140.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.50
|
| Rate for Payer: Cash Price |
$132.31
|
| Rate for Payer: Cofinity Advantage |
$115.77
|
| Rate for Payer: Cofinity Commercial |
$142.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.31
|
| Rate for Payer: Healthscope Commercial |
$148.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$124.04
|
| Rate for Payer: PHP Commercial |
$140.58
|
| Rate for Payer: Priority Health SBD |
$104.20
|
| Rate for Payer: UMR Bronson Commercial |
$72.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.04
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
OP
|
$29.82
|
|
|
Service Code
|
NDC 49735018796
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna American Axle |
$19.38
|
| Rate for Payer: Aetna Commercial |
$25.35
|
| Rate for Payer: Aetna Medicare |
$14.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.38
|
| Rate for Payer: BCBS Complete |
$11.93
|
| Rate for Payer: Cash Price |
$23.86
|
| Rate for Payer: Cofinity Advantage |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$25.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.86
|
| Rate for Payer: Healthscope Commercial |
$26.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.36
|
| Rate for Payer: PHP Commercial |
$25.35
|
| Rate for Payer: Priority Health SBD |
$18.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.38
|
| Rate for Payer: UHC Core |
$15.54
|
| Rate for Payer: UHC Exchange |
$11.72
|
| Rate for Payer: UMR Bronson Commercial |
$11.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.36
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
OP
|
$25.44
|
|
|
Service Code
|
NDC 49735013054
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna Medicare |
$12.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: BCBS Complete |
$10.18
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cofinity Advantage |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.08
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.54
|
| Rate for Payer: UHC Core |
$13.25
|
| Rate for Payer: UHC Exchange |
$10.00
|
| Rate for Payer: UMR Bronson Commercial |
$9.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$25.44
|
|
|
Service Code
|
NDC 49735013054
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cofinity Advantage |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.08
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: UMR Bronson Commercial |
$11.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$29.82
|
|
|
Service Code
|
NDC 49735018796
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna American Axle |
$19.38
|
| Rate for Payer: Aetna Commercial |
$25.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.38
|
| Rate for Payer: Cash Price |
$23.86
|
| Rate for Payer: Cofinity Advantage |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$25.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.86
|
| Rate for Payer: Healthscope Commercial |
$26.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.36
|
| Rate for Payer: PHP Commercial |
$25.35
|
| Rate for Payer: Priority Health SBD |
$18.79
|
| Rate for Payer: UMR Bronson Commercial |
$13.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.36
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$18.16
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna American Axle |
$11.80
|
| Rate for Payer: Aetna Commercial |
$15.44
|
| Rate for Payer: Aetna Medicare |
$9.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.80
|
| Rate for Payer: BCBS Complete |
$7.26
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Cofinity Advantage |
$12.71
|
| Rate for Payer: Cofinity Commercial |
$15.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.53
|
| Rate for Payer: Healthscope Commercial |
$16.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.62
|
| Rate for Payer: PHP Commercial |
$15.44
|
| Rate for Payer: Priority Health SBD |
$11.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.80
|
| Rate for Payer: UHC Core |
$9.46
|
| Rate for Payer: UHC Exchange |
$7.14
|
| Rate for Payer: UMR Bronson Commercial |
$6.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.62
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$18.16
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna American Axle |
$11.80
|
| Rate for Payer: Aetna Commercial |
$15.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.80
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Cofinity Advantage |
$12.71
|
| Rate for Payer: Cofinity Commercial |
$15.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.53
|
| Rate for Payer: Healthscope Commercial |
$16.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.62
|
| Rate for Payer: PHP Commercial |
$15.44
|
| Rate for Payer: Priority Health SBD |
$11.44
|
| Rate for Payer: UMR Bronson Commercial |
$7.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.62
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$28.41
|
|
|
Service Code
|
NDC 51672128901
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$25.57 |
| Rate for Payer: Aetna American Axle |
$18.47
|
| Rate for Payer: Aetna Commercial |
$24.15
|
| Rate for Payer: Aetna Medicare |
$14.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.47
|
| Rate for Payer: BCBS Complete |
$11.36
|
| Rate for Payer: Cash Price |
$22.73
|
| Rate for Payer: Cofinity Advantage |
$19.89
|
| Rate for Payer: Cofinity Commercial |
$24.43
|
| 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: MI Amish Medical Board Commercial |
$22.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.31
|
| Rate for Payer: PHP Commercial |
$24.15
|
| Rate for Payer: Priority Health SBD |
$17.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.47
|
| Rate for Payer: UHC Core |
$14.80
|
| Rate for Payer: UHC Exchange |
$11.17
|
| Rate for Payer: UMR Bronson Commercial |
$10.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.31
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
IP
|
$28.41
|
|
|
Service Code
|
NDC 51672128901
|
| 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 Advantage |
$19.89
|
| Rate for Payer: Cofinity Commercial |
$24.43
|
| 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 Commercial |
$24.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.31
|
| Rate for Payer: PHP Commercial |
$24.15
|
| 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
|
$68.36
|
|
|
Service Code
|
NDC 45802004811
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.08 |
| Max. Negotiated Rate |
$61.52 |
| Rate for Payer: Aetna American Axle |
$44.43
|
| Rate for Payer: Aetna Commercial |
$58.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.43
|
| Rate for Payer: Cash Price |
$54.69
|
| Rate for Payer: Cofinity Advantage |
$47.85
|
| Rate for Payer: Cofinity Commercial |
$58.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.69
|
| Rate for Payer: Healthscope Commercial |
$61.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.27
|
| Rate for Payer: PHP Commercial |
$58.11
|
| Rate for Payer: Priority Health SBD |
$43.07
|
| Rate for Payer: UMR Bronson Commercial |
$30.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.27
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$13.03
|
|
|
Service Code
|
NDC 00713068615
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$11.73 |
| Rate for Payer: Aetna American Axle |
$8.47
|
| Rate for Payer: Aetna Commercial |
$11.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.47
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cofinity Advantage |
$9.12
|
| Rate for Payer: Cofinity Commercial |
$11.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.42
|
| Rate for Payer: Healthscope Commercial |
$11.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.77
|
| Rate for Payer: PHP Commercial |
$11.08
|
| Rate for Payer: Priority Health SBD |
$8.21
|
| Rate for Payer: UMR Bronson Commercial |
$5.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.77
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$45.57
|
|
|
Service Code
|
NDC 45802004835
|
| 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 Advantage |
$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 Commercial |
$38.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.18
|
| Rate for Payer: PHP Commercial |
$38.73
|
| 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
|
OP
|
$13.03
|
|
|
Service Code
|
NDC 00713068615
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.82 |
| Max. Negotiated Rate |
$11.73 |
| Rate for Payer: Aetna American Axle |
$8.47
|
| Rate for Payer: Aetna Commercial |
$11.08
|
| Rate for Payer: Aetna Medicare |
$6.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.47
|
| Rate for Payer: BCBS Complete |
$5.21
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cofinity Advantage |
$9.12
|
| Rate for Payer: Cofinity Commercial |
$11.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.42
|
| Rate for Payer: Healthscope Commercial |
$11.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.77
|
| Rate for Payer: PHP Commercial |
$11.08
|
| Rate for Payer: Priority Health SBD |
$8.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.47
|
| Rate for Payer: UHC Core |
$6.79
|
| Rate for Payer: UHC Exchange |
$5.12
|
| Rate for Payer: UMR Bronson Commercial |
$4.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.77
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT
|
Facility
|
IP
|
$45.57
|
|
|
Service Code
|
NDC 00168000715
|
| 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 Advantage |
$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 Commercial |
$38.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.18
|
| Rate for Payer: PHP Commercial |
$38.73
|
| 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
|
OP
|
$45.57
|
|
|
Service Code
|
NDC 00168000715
|
| Hospital Charge Code |
5750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.86 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Aetna American Axle |
$29.62
|
| Rate for Payer: Aetna Commercial |
$38.73
|
| Rate for Payer: Aetna Medicare |
$22.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.62
|
| Rate for Payer: BCBS Complete |
$18.23
|
| Rate for Payer: Cash Price |
$36.46
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$36.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.18
|
| Rate for Payer: PHP Commercial |
$38.73
|
| Rate for Payer: Priority Health SBD |
$28.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.62
|
| Rate for Payer: UHC Core |
$23.74
|
| Rate for Payer: UHC Exchange |
$17.91
|
| Rate for Payer: UMR Bronson Commercial |
$16.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.18
|
|
