|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET
|
Facility
|
IP
|
$197.40
|
|
|
Service Code
|
NDC 16500008619
|
| Hospital Charge Code |
17687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Advantage |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.05
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$86.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 16500008619
|
| Hospital Charge Code |
17687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.04 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Advantage |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.05
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.31
|
| Rate for Payer: UHC Core |
$102.85
|
| Rate for Payer: UHC Exchange |
$77.58
|
| Rate for Payer: UMR Bronson Commercial |
$73.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID
|
Facility
|
IP
|
$189.37
|
|
|
Service Code
|
NDC 54629080098
|
| Hospital Charge Code |
175996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.32 |
| Max. Negotiated Rate |
$170.43 |
| Rate for Payer: Aetna American Axle |
$123.09
|
| Rate for Payer: Aetna Commercial |
$160.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.09
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cofinity Advantage |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.50
|
| Rate for Payer: Healthscope Commercial |
$170.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$142.03
|
| Rate for Payer: PHP Commercial |
$160.96
|
| Rate for Payer: Priority Health SBD |
$119.30
|
| Rate for Payer: UMR Bronson Commercial |
$83.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.03
|
|
|
PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID
|
Facility
|
OP
|
$167.09
|
|
|
Service Code
|
NDC 79854008009
|
| Hospital Charge Code |
175996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.82 |
| Max. Negotiated Rate |
$150.38 |
| Rate for Payer: Aetna American Axle |
$108.61
|
| Rate for Payer: Aetna Commercial |
$142.03
|
| Rate for Payer: Aetna Medicare |
$83.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.61
|
| Rate for Payer: BCBS Complete |
$66.84
|
| Rate for Payer: Cash Price |
$133.67
|
| Rate for Payer: Cofinity Advantage |
$116.96
|
| Rate for Payer: Cofinity Commercial |
$143.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.67
|
| Rate for Payer: Healthscope Commercial |
$150.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$133.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.32
|
| Rate for Payer: PHP Commercial |
$142.03
|
| Rate for Payer: Priority Health SBD |
$105.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.61
|
| Rate for Payer: UHC Core |
$87.05
|
| Rate for Payer: UHC Exchange |
$65.67
|
| Rate for Payer: UMR Bronson Commercial |
$61.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.32
|
|
|
PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID
|
Facility
|
IP
|
$10.58
|
|
|
Service Code
|
NDC 09900001851
|
| Hospital Charge Code |
175996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$9.52 |
| Rate for Payer: Aetna American Axle |
$6.88
|
| Rate for Payer: Aetna Commercial |
$8.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.88
|
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Cofinity Advantage |
$7.41
|
| Rate for Payer: Cofinity Commercial |
$9.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.46
|
| Rate for Payer: Healthscope Commercial |
$9.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.93
|
| Rate for Payer: PHP Commercial |
$8.99
|
| Rate for Payer: Priority Health SBD |
$6.67
|
| Rate for Payer: UMR Bronson Commercial |
$4.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.93
|
|
|
PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID
|
Facility
|
IP
|
$167.09
|
|
|
Service Code
|
NDC 79854008009
|
| Hospital Charge Code |
175996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.52 |
| Max. Negotiated Rate |
$150.38 |
| Rate for Payer: Aetna American Axle |
$108.61
|
| Rate for Payer: Aetna Commercial |
$142.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.61
|
| Rate for Payer: Cash Price |
$133.67
|
| Rate for Payer: Cofinity Advantage |
$116.96
|
| Rate for Payer: Cofinity Commercial |
$143.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.67
|
| Rate for Payer: Healthscope Commercial |
$150.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.32
|
| Rate for Payer: PHP Commercial |
$142.03
|
| Rate for Payer: Priority Health SBD |
$105.27
|
| Rate for Payer: UMR Bronson Commercial |
$73.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.32
|
|
|
PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID
|
Facility
|
OP
|
$189.37
|
|
|
Service Code
|
NDC 54629080098
|
| Hospital Charge Code |
175996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.07 |
| Max. Negotiated Rate |
$170.43 |
| Rate for Payer: Aetna American Axle |
$123.09
|
| Rate for Payer: Aetna Commercial |
$160.96
|
| Rate for Payer: Aetna Medicare |
$94.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.09
|
| Rate for Payer: BCBS Complete |
$75.75
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cofinity Advantage |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.50
|
| Rate for Payer: Healthscope Commercial |
$170.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$151.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$142.03
|
| Rate for Payer: PHP Commercial |
$160.96
|
| Rate for Payer: Priority Health SBD |
$119.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.09
|
| Rate for Payer: UHC Core |
$98.66
|
| Rate for Payer: UHC Exchange |
$74.42
|
| Rate for Payer: UMR Bronson Commercial |
$70.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.03
|
|
|
PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID
|
Facility
|
OP
|
$10.58
|
|
|
Service Code
|
NDC 09900001851
|
| Hospital Charge Code |
175996
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.91 |
| Max. Negotiated Rate |
$9.52 |
| Rate for Payer: Aetna American Axle |
$6.88
|
| Rate for Payer: Aetna Commercial |
$8.99
|
| Rate for Payer: Aetna Medicare |
$5.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.88
|
| Rate for Payer: BCBS Complete |
$4.23
|
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Cofinity Advantage |
$7.41
|
| Rate for Payer: Cofinity Commercial |
$9.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.46
|
| Rate for Payer: Healthscope Commercial |
$9.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.93
|
| Rate for Payer: PHP Commercial |
$8.99
|
| Rate for Payer: Priority Health SBD |
$6.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.88
|
| Rate for Payer: UHC Core |
$5.51
|
| Rate for Payer: UHC Exchange |
$4.16
|
| Rate for Payer: UMR Bronson Commercial |
$3.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.93
|
|
|
PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID
|
Facility
|
OP
|
$163.30
|
|
|
Service Code
|
NDC 68176000010
|
| Hospital Charge Code |
176647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.42 |
| Max. Negotiated Rate |
$146.97 |
| Rate for Payer: Aetna American Axle |
$106.14
|
| Rate for Payer: Aetna Commercial |
$138.81
|
| Rate for Payer: Aetna Medicare |
$81.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.14
|
| Rate for Payer: BCBS Complete |
$65.32
|
| Rate for Payer: Cash Price |
$130.64
|
| Rate for Payer: Cofinity Advantage |
$114.31
|
| Rate for Payer: Cofinity Commercial |
$140.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.64
|
| Rate for Payer: Healthscope Commercial |
$146.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$130.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$122.47
|
| Rate for Payer: PHP Commercial |
$138.81
|
| Rate for Payer: Priority Health SBD |
$102.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.14
|
| Rate for Payer: UHC Core |
$85.08
|
| Rate for Payer: UHC Exchange |
$64.18
|
| Rate for Payer: UMR Bronson Commercial |
$60.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.47
|
|
|
PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID
|
Facility
|
IP
|
$163.30
|
|
|
Service Code
|
NDC 68176000010
|
| Hospital Charge Code |
176647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.85 |
| Max. Negotiated Rate |
$146.97 |
| Rate for Payer: Aetna American Axle |
$106.14
|
| Rate for Payer: Aetna Commercial |
$138.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.14
|
| Rate for Payer: Cash Price |
$130.64
|
| Rate for Payer: Cofinity Advantage |
$114.31
|
| Rate for Payer: Cofinity Commercial |
$140.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.64
|
| Rate for Payer: Healthscope Commercial |
$146.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$122.47
|
| Rate for Payer: PHP Commercial |
$138.81
|
| Rate for Payer: Priority Health SBD |
$102.88
|
| Rate for Payer: UMR Bronson Commercial |
$71.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.47
|
|
|
PEDIATRIC MULTIVITAMIN NO.189-FERROUS SULFATE 11 MG/ML ORAL DROPS
|
Facility
|
OP
|
$101.18
|
|
|
Service Code
|
NDC 00087040501
|
| Hospital Charge Code |
194037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.44 |
| Max. Negotiated Rate |
$91.06 |
| Rate for Payer: Aetna American Axle |
$65.77
|
| Rate for Payer: Aetna Commercial |
$86.00
|
| Rate for Payer: Aetna Medicare |
$50.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.77
|
| Rate for Payer: BCBS Complete |
$40.47
|
| Rate for Payer: Cash Price |
$80.94
|
| Rate for Payer: Cofinity Advantage |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.94
|
| Rate for Payer: Healthscope Commercial |
$91.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.89
|
| Rate for Payer: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health SBD |
$63.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.77
|
| Rate for Payer: UHC Core |
$52.71
|
| Rate for Payer: UHC Exchange |
$39.76
|
| Rate for Payer: UMR Bronson Commercial |
$37.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.89
|
|
|
PEDIATRIC MULTIVITAMIN NO.189-FERROUS SULFATE 11 MG/ML ORAL DROPS
|
Facility
|
IP
|
$101.18
|
|
|
Service Code
|
NDC 00087040501
|
| Hospital Charge Code |
194037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$91.06 |
| Rate for Payer: Aetna American Axle |
$65.77
|
| Rate for Payer: Aetna Commercial |
$86.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.77
|
| Rate for Payer: Cash Price |
$80.94
|
| Rate for Payer: Cofinity Advantage |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.94
|
| Rate for Payer: Healthscope Commercial |
$91.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.89
|
| Rate for Payer: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health SBD |
$63.74
|
| Rate for Payer: UMR Bronson Commercial |
$44.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.89
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS
|
Facility
|
OP
|
$101.18
|
|
|
Service Code
|
NDC 00087040203
|
| Hospital Charge Code |
194364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.44 |
| Max. Negotiated Rate |
$91.06 |
| Rate for Payer: Aetna American Axle |
$65.77
|
| Rate for Payer: Aetna Commercial |
$86.00
|
| Rate for Payer: Aetna Medicare |
$50.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.77
|
| Rate for Payer: BCBS Complete |
$40.47
|
| Rate for Payer: Cash Price |
$80.94
|
| Rate for Payer: Cofinity Advantage |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.94
|
| Rate for Payer: Healthscope Commercial |
$91.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.89
|
| Rate for Payer: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health SBD |
$63.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.77
|
| Rate for Payer: UHC Core |
$52.71
|
| Rate for Payer: UHC Exchange |
$39.76
|
| Rate for Payer: UMR Bronson Commercial |
$37.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.89
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS
|
Facility
|
IP
|
$101.18
|
|
|
Service Code
|
NDC 00087040203
|
| Hospital Charge Code |
194364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$91.06 |
| Rate for Payer: Aetna American Axle |
$65.77
|
| Rate for Payer: Aetna Commercial |
$86.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.77
|
| Rate for Payer: Cash Price |
$80.94
|
| Rate for Payer: Cofinity Advantage |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.94
|
| Rate for Payer: Healthscope Commercial |
$91.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.89
|
| Rate for Payer: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health SBD |
$63.74
|
| Rate for Payer: UMR Bronson Commercial |
$44.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.89
|
|
|
PEDIATRIC NUTRITION, IRON, LF-FIBER 0.03 GRAM-0.6 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 70074067613
|
| Hospital Charge Code |
120007
|
|
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
|
|
|
PEDIATRIC NUTRITION, IRON, LF-FIBER 0.03 GRAM-0.6 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 70074067613
|
| Hospital Charge Code |
120007
|
|
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
|
|
|
PEDIATRIC NUTRITION, IRON, LF-FIBER 0.03 GRAM-1 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$11.14
|
|
|
Service Code
|
NDC 70074067403
|
| Hospital Charge Code |
119379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna American Axle |
$7.24
|
| Rate for Payer: Aetna Commercial |
$9.47
|
| Rate for Payer: Aetna Medicare |
$5.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.24
|
| Rate for Payer: BCBS Complete |
$4.46
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cofinity Advantage |
$7.80
|
| Rate for Payer: Cofinity Commercial |
$9.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.91
|
| Rate for Payer: Healthscope Commercial |
$10.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.36
|
| Rate for Payer: PHP Commercial |
$9.47
|
| Rate for Payer: Priority Health SBD |
$7.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.24
|
| Rate for Payer: UHC Core |
$5.80
|
| Rate for Payer: UHC Exchange |
$4.38
|
| Rate for Payer: UMR Bronson Commercial |
$4.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.36
|
|
|
PEDIATRIC NUTRITION, IRON, LF-FIBER 0.03 GRAM-1 KCAL/ML ORAL LIQUID
|
Facility
|
OP
|
$11.14
|
|
|
Service Code
|
NDC 70074067404
|
| Hospital Charge Code |
119379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna American Axle |
$7.24
|
| Rate for Payer: Aetna Commercial |
$9.47
|
| Rate for Payer: Aetna Medicare |
$5.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.24
|
| Rate for Payer: BCBS Complete |
$4.46
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cofinity Advantage |
$7.80
|
| Rate for Payer: Cofinity Commercial |
$9.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.91
|
| Rate for Payer: Healthscope Commercial |
$10.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.36
|
| Rate for Payer: PHP Commercial |
$9.47
|
| Rate for Payer: Priority Health SBD |
$7.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.24
|
| Rate for Payer: UHC Core |
$5.80
|
| Rate for Payer: UHC Exchange |
$4.38
|
| Rate for Payer: UMR Bronson Commercial |
$4.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.36
|
|
|
PEDIATRIC NUTRITION, IRON, LF-FIBER 0.03 GRAM-1 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$11.14
|
|
|
Service Code
|
NDC 70074067403
|
| Hospital Charge Code |
119379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna American Axle |
$7.24
|
| Rate for Payer: Aetna Commercial |
$9.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.24
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cofinity Advantage |
$7.80
|
| Rate for Payer: Cofinity Commercial |
$9.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.91
|
| Rate for Payer: Healthscope Commercial |
$10.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.36
|
| Rate for Payer: PHP Commercial |
$9.47
|
| Rate for Payer: Priority Health SBD |
$7.02
|
| Rate for Payer: UMR Bronson Commercial |
$4.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.36
|
|
|
PEDIATRIC NUTRITION, IRON, LF-FIBER 0.03 GRAM-1 KCAL/ML ORAL LIQUID
|
Facility
|
IP
|
$11.14
|
|
|
Service Code
|
NDC 70074067404
|
| Hospital Charge Code |
119379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna American Axle |
$7.24
|
| Rate for Payer: Aetna Commercial |
$9.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.24
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cofinity Advantage |
$7.80
|
| Rate for Payer: Cofinity Commercial |
$9.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.91
|
| Rate for Payer: Healthscope Commercial |
$10.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.36
|
| Rate for Payer: PHP Commercial |
$9.47
|
| Rate for Payer: Priority Health SBD |
$7.02
|
| Rate for Payer: UMR Bronson Commercial |
$4.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.36
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
OP
|
$1,411.79
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$408.52 |
| Max. Negotiated Rate |
$2,526.00 |
| Rate for Payer: Aetna American Axle |
$917.66
|
| Rate for Payer: Aetna Commercial |
$1,200.02
|
| Rate for Payer: Aetna Medicare |
$812.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$917.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$976.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$976.38
|
| Rate for Payer: BCBS Complete |
$428.98
|
| Rate for Payer: BCBS MAPPO |
$781.10
|
| Rate for Payer: BCBS Trust/PPO |
$1,217.72
|
| Rate for Payer: BCN Commercial |
$1,217.72
|
| Rate for Payer: BCN Medicare Advantage |
$781.10
|
| Rate for Payer: Cash Price |
$1,129.43
|
| Rate for Payer: Cash Price |
$1,129.43
|
| Rate for Payer: Cofinity Advantage |
$988.25
|
| Rate for Payer: Cofinity Commercial |
$1,214.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,129.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$781.10
|
| Rate for Payer: Healthscope Commercial |
$1,270.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$988.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,058.84
|
| Rate for Payer: Mclaren Medicaid |
$781.10
|
| Rate for Payer: Mclaren Medicare |
$781.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$820.15
|
| Rate for Payer: Meridian Medicaid |
$820.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$898.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$859.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,200.02
|
| Rate for Payer: Nomi Health Commercial |
$2,343.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,058.84
|
| Rate for Payer: PACE Medicare |
$742.04
|
| Rate for Payer: PACE SWMI |
$781.10
|
| Rate for Payer: PHP Commercial |
$1,200.02
|
| Rate for Payer: PHP Medicare Advantage |
$781.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$408.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$2,526.00
|
| Rate for Payer: Priority Health Medicare |
$781.10
|
| Rate for Payer: Priority Health SBD |
$889.43
|
| Rate for Payer: Priority Health Tiered Network |
$2,020.80
|
| Rate for Payer: Railroad Medicare Medicare |
$781.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$917.66
|
| Rate for Payer: UHC Core |
$735.54
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$781.10
|
| Rate for Payer: UHC Exchange |
$554.83
|
| Rate for Payer: UHC Medicaid |
$408.52
|
| Rate for Payer: UHCCP Medicaid |
$408.52
|
| Rate for Payer: UMR Bronson Commercial |
$522.36
|
| Rate for Payer: VA VA |
$781.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,058.84
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
IP
|
$1,411.79
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$621.19 |
| Max. Negotiated Rate |
$1,270.61 |
| Rate for Payer: Aetna American Axle |
$917.66
|
| Rate for Payer: Aetna Commercial |
$1,200.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$917.66
|
| Rate for Payer: Cash Price |
$1,129.43
|
| Rate for Payer: Cofinity Advantage |
$988.25
|
| Rate for Payer: Cofinity Commercial |
$1,214.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,129.43
|
| Rate for Payer: Healthscope Commercial |
$1,270.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$988.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,058.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,200.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,058.84
|
| Rate for Payer: PHP Commercial |
$1,200.02
|
| Rate for Payer: Priority Health SBD |
$889.43
|
| Rate for Payer: UMR Bronson Commercial |
$621.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,058.84
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna American Axle |
$36.40
|
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.40
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Advantage |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.00
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health SBD |
$35.28
|
| Rate for Payer: UMR Bronson Commercial |
$24.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna American Axle |
$45.50
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna Medicare |
$35.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: BCBS Complete |
$28.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Advantage |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.50
|
| Rate for Payer: UHC Core |
$36.47
|
| Rate for Payer: UHC Exchange |
$27.51
|
| Rate for Payer: UMR Bronson Commercial |
$25.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.50
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 10572010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna American Axle |
$45.50
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna Medicare |
$35.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: BCBS Complete |
$28.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Advantage |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.50
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.50
|
| Rate for Payer: UHC Core |
$36.47
|
| Rate for Payer: UHC Exchange |
$27.51
|
| Rate for Payer: UMR Bronson Commercial |
$25.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.50
|
|
