|
NUTREN 2.0 INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 98716006230
|
| Hospital Charge Code |
200084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna American Axle |
$3.09
|
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.09
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health SBD |
$2.99
|
| Rate for Payer: UMR Bronson Commercial |
$2.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
NUTRITIONAL SUPPLEMENT-FIBER ORAL LIQUID
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 43900040722
|
| Hospital Charge Code |
112392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna American Axle |
$13.16
|
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health SBD |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$8.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
NUTRITIONAL SUPPLEMENT-FIBER ORAL LIQUID
|
Facility
|
OP
|
$20.25
|
|
|
Service Code
|
NDC 43900040722
|
| Hospital Charge Code |
112392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna American Axle |
$13.16
|
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna Medicare |
$10.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: BCBS Complete |
$8.10
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health SBD |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$7.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
NUTRITIONAL TX, KETOGENIC,WHEY 3.2 GRAM-149 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$30.63
|
|
|
Service Code
|
NDC 24359050303
|
| Hospital Charge Code |
196979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$27.57 |
| Rate for Payer: Aetna American Axle |
$19.91
|
| Rate for Payer: Aetna Commercial |
$26.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.91
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$21.44
|
| Rate for Payer: Cofinity Commercial |
$26.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.50
|
| Rate for Payer: Healthscope Commercial |
$27.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.04
|
| Rate for Payer: PHP Commercial |
$26.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.91
|
| Rate for Payer: Priority Health SBD |
$19.30
|
| Rate for Payer: UMR Bronson Commercial |
$13.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.97
|
|
|
NUTRITIONAL TX, KETOGENIC,WHEY 3.2 GRAM-149 KCAL/100 ML ORAL LIQUID
|
Facility
|
OP
|
$30.63
|
|
|
Service Code
|
NDC 24359050303
|
| Hospital Charge Code |
196979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$27.57 |
| Rate for Payer: Aetna American Axle |
$19.91
|
| Rate for Payer: Aetna Commercial |
$26.04
|
| Rate for Payer: Aetna Medicare |
$15.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.91
|
| Rate for Payer: BCBS Complete |
$12.25
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$21.44
|
| Rate for Payer: Cofinity Commercial |
$26.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.50
|
| Rate for Payer: Healthscope Commercial |
$27.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.04
|
| Rate for Payer: PHP Commercial |
$26.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.91
|
| Rate for Payer: Priority Health SBD |
$19.30
|
| Rate for Payer: UMR Bronson Commercial |
$11.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.97
|
|
|
NUTRITIONAL TX, KETOGENIC,WHEY 3.4 GRAM-148 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$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 Commercial |
$23.96
|
| Rate for Payer: Cofinity Commercial |
$29.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.96
|
| 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: PHP Commercial |
$29.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.25
|
| 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
|
|
|
NUTRITIONAL TX, KETOGENIC,WHEY 3.4 GRAM-148 KCAL/100 ML ORAL LIQUID
|
Facility
|
OP
|
$34.23
|
|
|
Service Code
|
NDC 24359050203
|
| Hospital Charge Code |
198895
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.67 |
| Max. Negotiated Rate |
$30.81 |
| Rate for Payer: Aetna American Axle |
$22.25
|
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna Medicare |
$17.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.25
|
| Rate for Payer: BCBS Complete |
$13.69
|
| Rate for Payer: Cash Price |
$27.38
|
| Rate for Payer: Cofinity Commercial |
$23.96
|
| Rate for Payer: Cofinity Commercial |
$29.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.96
|
| 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: PHP Commercial |
$29.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.25
|
| Rate for Payer: Priority Health SBD |
$21.56
|
| Rate for Payer: UMR Bronson Commercial |
$12.67
|
| 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
|
$51.80
|
|
|
Service Code
|
NDC 70074062715
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.79 |
| Max. Negotiated Rate |
$46.62 |
| Rate for Payer: Aetna American Axle |
$33.67
|
| Rate for Payer: Aetna Commercial |
$44.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.67
|
| Rate for Payer: Cash Price |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$36.26
|
| Rate for Payer: Cofinity Commercial |
$44.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.44
|
| Rate for Payer: Healthscope Commercial |
$46.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.03
|
| Rate for Payer: PHP Commercial |
$44.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.67
|
| Rate for Payer: Priority Health SBD |
$32.63
|
| Rate for Payer: UMR Bronson Commercial |
$22.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.85
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$51.80
|
|
|
Service Code
|
NDC 70074062716
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.79 |
| Max. Negotiated Rate |
$46.62 |
| Rate for Payer: Aetna American Axle |
$33.67
|
| Rate for Payer: Aetna Commercial |
$44.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.67
|
| Rate for Payer: Cash Price |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$36.26
|
| Rate for Payer: Cofinity Commercial |
$44.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.44
|
| Rate for Payer: Healthscope Commercial |
$46.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.03
|
| Rate for Payer: PHP Commercial |
$44.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.67
|
| Rate for Payer: Priority Health SBD |
$32.63
|
| Rate for Payer: UMR Bronson Commercial |
$22.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.85
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$51.80
|
|
|
Service Code
|
NDC 70074062715
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$46.62 |
| Rate for Payer: Aetna American Axle |
$33.67
|
| Rate for Payer: Aetna Commercial |
$44.03
|
| Rate for Payer: Aetna Medicare |
$25.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.67
|
| Rate for Payer: BCBS Complete |
$20.72
|
| Rate for Payer: Cash Price |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$36.26
|
| Rate for Payer: Cofinity Commercial |
$44.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.44
|
| Rate for Payer: Healthscope Commercial |
$46.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.03
|
| Rate for Payer: PHP Commercial |
$44.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.67
|
| Rate for Payer: Priority Health SBD |
$32.63
|
| Rate for Payer: UMR Bronson Commercial |
$19.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.85
|
|
|
NUT.TX IMPAIRED DIGESTIVE FXN-FIBER 0.08 GRAM-1.2 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$51.80
|
|
|
Service Code
|
NDC 70074062716
|
| Hospital Charge Code |
120015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$46.62 |
| Rate for Payer: Aetna American Axle |
$33.67
|
| Rate for Payer: Aetna Commercial |
$44.03
|
| Rate for Payer: Aetna Medicare |
$25.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.67
|
| Rate for Payer: BCBS Complete |
$20.72
|
| Rate for Payer: Cash Price |
$41.44
|
| Rate for Payer: Cofinity Commercial |
$36.26
|
| Rate for Payer: Cofinity Commercial |
$44.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.44
|
| Rate for Payer: Healthscope Commercial |
$46.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.03
|
| Rate for Payer: PHP Commercial |
$44.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.67
|
| Rate for Payer: Priority Health SBD |
$32.63
|
| Rate for Payer: UMR Bronson Commercial |
$19.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.85
|
|
|
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 Commercial |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.78
|
| 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: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.44
|
| Rate for Payer: Priority Health SBD |
$4.30
|
| 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
|
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 |
$2.84
|
| 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 Commercial |
$3.98
|
| Rate for Payer: Cofinity Commercial |
$4.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.98
|
| 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: PHP Commercial |
$4.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: Priority Health SBD |
$3.58
|
| Rate for Payer: UMR Bronson Commercial |
$2.11
|
| 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
|
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 Commercial |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$5.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.78
|
| 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: PHP Commercial |
$5.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.44
|
| 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
|
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 Commercial |
$3.98
|
| Rate for Payer: Cofinity Commercial |
$4.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.98
|
| 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: PHP Commercial |
$4.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| 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,KETOGENIC,MILK BASED-SOY 14.4 GRAM-701 KCAL/100 GRAM ORAL POWDR
|
Facility
|
IP
|
$138.75
|
|
|
Service Code
|
NDC 49735001842
|
| Hospital Charge Code |
169193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.05 |
| Max. Negotiated Rate |
$124.88 |
| Rate for Payer: Aetna American Axle |
$90.19
|
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.19
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cofinity Commercial |
$119.32
|
| Rate for Payer: Cofinity Commercial |
$97.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.00
|
| Rate for Payer: Healthscope Commercial |
$124.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.94
|
| Rate for Payer: PHP Commercial |
$117.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.19
|
| Rate for Payer: Priority Health SBD |
$87.41
|
| Rate for Payer: UMR Bronson Commercial |
$61.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.06
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 14.4 GRAM-701 KCAL/100 GRAM ORAL POWDR
|
Facility
|
OP
|
$138.75
|
|
|
Service Code
|
NDC 49735001842
|
| Hospital Charge Code |
169193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.34 |
| Max. Negotiated Rate |
$124.88 |
| Rate for Payer: Aetna American Axle |
$90.19
|
| Rate for Payer: Aetna Commercial |
$117.94
|
| Rate for Payer: Aetna Medicare |
$69.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.19
|
| Rate for Payer: BCBS Complete |
$55.50
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cofinity Commercial |
$119.32
|
| Rate for Payer: Cofinity Commercial |
$97.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.00
|
| Rate for Payer: Healthscope Commercial |
$124.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.94
|
| Rate for Payer: PHP Commercial |
$117.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.19
|
| Rate for Payer: Priority Health SBD |
$87.41
|
| Rate for Payer: UMR Bronson Commercial |
$51.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.06
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
OP
|
$22.80
|
|
|
Service Code
|
NDC 49735013054
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Aetna American Axle |
$14.82
|
| Rate for Payer: Aetna Commercial |
$19.38
|
| Rate for Payer: Aetna Medicare |
$11.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.82
|
| Rate for Payer: BCBS Complete |
$9.12
|
| Rate for Payer: Cash Price |
$18.24
|
| Rate for Payer: Cofinity Commercial |
$15.96
|
| Rate for Payer: Cofinity Commercial |
$19.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.24
|
| Rate for Payer: Healthscope Commercial |
$20.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.38
|
| Rate for Payer: PHP Commercial |
$19.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.82
|
| Rate for Payer: Priority Health SBD |
$14.36
|
| Rate for Payer: UMR Bronson Commercial |
$8.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.10
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$22.80
|
|
|
Service Code
|
NDC 49735013054
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Aetna American Axle |
$14.82
|
| Rate for Payer: Aetna Commercial |
$19.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.82
|
| Rate for Payer: Cash Price |
$18.24
|
| Rate for Payer: Cofinity Commercial |
$15.96
|
| Rate for Payer: Cofinity Commercial |
$19.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.24
|
| Rate for Payer: Healthscope Commercial |
$20.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.38
|
| Rate for Payer: PHP Commercial |
$19.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.82
|
| Rate for Payer: Priority Health SBD |
$14.36
|
| Rate for Payer: UMR Bronson Commercial |
$10.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.10
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
IP
|
$27.19
|
|
|
Service Code
|
NDC 49735018796
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.96 |
| Max. Negotiated Rate |
$24.47 |
| Rate for Payer: Aetna American Axle |
$17.67
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: UMR Bronson Commercial |
$11.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
|
|
NUT.TX,KETOGENIC,MILK BASED-SOY 3.09 GRAM-150 KCAL/100 ML ORAL LIQUID
|
Facility
|
OP
|
$27.19
|
|
|
Service Code
|
NDC 49735018796
|
| Hospital Charge Code |
119530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$24.47 |
| Rate for Payer: Aetna American Axle |
$17.67
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Medicare |
$13.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: UMR Bronson Commercial |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
|
|
NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM
|
Facility
|
OP
|
$18.09
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$16.28 |
| Rate for Payer: Aetna American Axle |
$11.76
|
| Rate for Payer: Aetna Commercial |
$15.38
|
| Rate for Payer: Aetna Medicare |
$9.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.76
|
| Rate for Payer: BCBS Complete |
$7.24
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cofinity Commercial |
$12.66
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.47
|
| Rate for Payer: Healthscope Commercial |
$16.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.38
|
| Rate for Payer: PHP Commercial |
$15.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.76
|
| Rate for Payer: Priority Health SBD |
$11.40
|
| Rate for Payer: UMR Bronson Commercial |
$6.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.57
|
|
|
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 |
$14.20
|
| 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 Commercial |
$19.89
|
| Rate for Payer: Cofinity Commercial |
$24.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.73
|
| Rate for Payer: Healthscope Commercial |
$25.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.15
|
| Rate for Payer: PHP Commercial |
$24.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.47
|
| Rate for Payer: Priority Health SBD |
$17.90
|
| 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 Commercial |
$19.89
|
| Rate for Payer: Cofinity Commercial |
$24.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.73
|
| Rate for Payer: Healthscope Commercial |
$25.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.15
|
| Rate for Payer: PHP Commercial |
$24.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.47
|
| 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 CREAM
|
Facility
|
IP
|
$18.09
|
|
|
Service Code
|
NDC 45802005935
|
| Hospital Charge Code |
5749
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$16.28 |
| Rate for Payer: Aetna American Axle |
$11.76
|
| Rate for Payer: Aetna Commercial |
$15.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.76
|
| Rate for Payer: Cash Price |
$14.47
|
| Rate for Payer: Cofinity Commercial |
$12.66
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.47
|
| Rate for Payer: Healthscope Commercial |
$16.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.38
|
| Rate for Payer: PHP Commercial |
$15.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.76
|
| Rate for Payer: Priority Health SBD |
$11.40
|
| Rate for Payer: UMR Bronson Commercial |
$7.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.57
|
|
