|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$3,555.00
|
|
|
Service Code
|
NDC 53436008430
|
| Hospital Charge Code |
176467
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,315.35 |
| Max. Negotiated Rate |
$3,199.50 |
| Rate for Payer: Aetna American Axle |
$2,310.75
|
| Rate for Payer: Aetna Commercial |
$3,021.75
|
| Rate for Payer: Aetna Medicare |
$1,777.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,310.75
|
| Rate for Payer: BCBS Complete |
$1,422.00
|
| Rate for Payer: Cash Price |
$2,844.00
|
| Rate for Payer: Cofinity Commercial |
$2,488.50
|
| Rate for Payer: Cofinity Commercial |
$3,057.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,488.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,844.00
|
| Rate for Payer: Healthscope Commercial |
$3,199.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,488.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,666.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,021.75
|
| Rate for Payer: PHP Commercial |
$3,021.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,310.75
|
| Rate for Payer: Priority Health SBD |
$2,239.65
|
| Rate for Payer: UMR Bronson Commercial |
$1,315.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,666.25
|
|
|
PATISIRAN (LIPID COMPLEX) 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25,441.00
|
|
|
Service Code
|
HCPCS J0222
|
| Hospital Charge Code |
188116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,194.04 |
| Max. Negotiated Rate |
$22,896.90 |
| Rate for Payer: Aetna American Axle |
$16,536.65
|
| Rate for Payer: Aetna Commercial |
$21,624.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16,536.65
|
| Rate for Payer: Cash Price |
$20,352.80
|
| Rate for Payer: Cofinity Commercial |
$17,808.70
|
| Rate for Payer: Cofinity Commercial |
$21,879.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$17,808.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20,352.80
|
| Rate for Payer: Healthscope Commercial |
$22,896.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17,808.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19,080.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21,624.85
|
| Rate for Payer: PHP Commercial |
$21,624.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16,536.65
|
| Rate for Payer: Priority Health SBD |
$16,027.83
|
| Rate for Payer: UMR Bronson Commercial |
$11,194.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19,080.75
|
|
|
PATISIRAN (LIPID COMPLEX) 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$25,441.00
|
|
|
Service Code
|
HCPCS J0222
|
| Hospital Charge Code |
188116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.58 |
| Max. Negotiated Rate |
$22,896.90 |
| Rate for Payer: Aetna American Axle |
$16,536.65
|
| Rate for Payer: Aetna Commercial |
$21,624.85
|
| Rate for Payer: Aetna Medicare |
$103.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16,536.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$124.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$124.96
|
| Rate for Payer: BCBS Complete |
$56.26
|
| Rate for Payer: BCBS MAPPO |
$99.97
|
| Rate for Payer: BCN Medicare Advantage |
$99.97
|
| Rate for Payer: Cash Price |
$20,352.80
|
| Rate for Payer: Cash Price |
$20,352.80
|
| Rate for Payer: Cofinity Commercial |
$21,879.26
|
| Rate for Payer: Cofinity Commercial |
$17,808.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$17,808.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20,352.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$99.97
|
| Rate for Payer: Healthscope Commercial |
$22,896.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17,808.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19,080.75
|
| Rate for Payer: Mclaren Medicaid |
$53.58
|
| Rate for Payer: Mclaren Medicare |
$99.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$104.97
|
| Rate for Payer: Meridian Medicaid |
$56.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$114.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21,624.85
|
| Rate for Payer: PACE Medicare |
$94.97
|
| Rate for Payer: PACE SWMI |
$99.97
|
| Rate for Payer: PHP Commercial |
$21,624.85
|
| Rate for Payer: PHP Medicare Advantage |
$99.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$53.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16,536.65
|
| Rate for Payer: Priority Health Medicare |
$99.97
|
| Rate for Payer: Priority Health SBD |
$16,027.83
|
| Rate for Payer: Railroad Medicare Medicare |
$99.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$99.97
|
| Rate for Payer: UHC Exchange |
$191.05
|
| Rate for Payer: UHC Medicare Advantage |
$99.97
|
| Rate for Payer: UHCCP Medicaid |
$53.58
|
| Rate for Payer: UMR Bronson Commercial |
$9,413.17
|
| Rate for Payer: VA VA |
$99.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19,080.75
|
|
|
PEDIATRIC CHEWABLE MULTIVITAMIN WITH MINERALS TABLET WRAPPER
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 96295012826
|
| Hospital Charge Code |
301519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.69 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna Medicare |
$38.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$28.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
PEDIATRIC CHEWABLE MULTIVITAMIN WITH MINERALS TABLET WRAPPER
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 96295012826
|
| Hospital Charge Code |
301519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
PEDIATRIC COMPLEAT CUSTOM
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 43900014240
|
| Hospital Charge Code |
180159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna American Axle |
$3.90
|
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Aetna Medicare |
$3.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.90
|
| Rate for Payer: BCBS Complete |
$2.40
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cofinity Commercial |
$4.20
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.80
|
| Rate for Payer: Healthscope Commercial |
$5.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.10
|
| Rate for Payer: PHP Commercial |
$5.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.90
|
| Rate for Payer: Priority Health SBD |
$3.78
|
| Rate for Payer: UMR Bronson Commercial |
$2.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.50
|
|
|
PEDIATRIC COMPLEAT CUSTOM
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 43900014240
|
| Hospital Charge Code |
180159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna American Axle |
$3.90
|
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.90
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cofinity Commercial |
$4.20
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.80
|
| Rate for Payer: Healthscope Commercial |
$5.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.10
|
| Rate for Payer: PHP Commercial |
$5.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.90
|
| Rate for Payer: Priority Health SBD |
$3.78
|
| Rate for Payer: UMR Bronson Commercial |
$2.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.50
|
|
|
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 Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| 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: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| 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 Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| 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: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| 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
|
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 Commercial |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.56
|
| 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: PHP Commercial |
$160.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.09
|
| Rate for Payer: Priority Health SBD |
$119.30
|
| 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
|
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 Commercial |
$116.96
|
| Rate for Payer: Cofinity Commercial |
$143.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.96
|
| 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: PHP Commercial |
$142.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.61
|
| 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
|
$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 Commercial |
$116.96
|
| Rate for Payer: Cofinity Commercial |
$143.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.96
|
| 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: PHP Commercial |
$142.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.61
|
| Rate for Payer: Priority Health SBD |
$105.27
|
| 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
|
$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 Commercial |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.56
|
| 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: PHP Commercial |
$160.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.09
|
| 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
|
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 Commercial |
$7.41
|
| Rate for Payer: Cofinity Commercial |
$9.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.41
|
| 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: PHP Commercial |
$8.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.88
|
| 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
|
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 Commercial |
$7.41
|
| Rate for Payer: Cofinity Commercial |
$9.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.41
|
| 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: PHP Commercial |
$8.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.88
|
| Rate for Payer: Priority Health SBD |
$6.67
|
| 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
|
$154.37
|
|
|
Service Code
|
NDC 68176000010
|
| Hospital Charge Code |
176647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.12 |
| Max. Negotiated Rate |
$138.93 |
| Rate for Payer: Aetna American Axle |
$100.34
|
| Rate for Payer: Aetna Commercial |
$131.21
|
| Rate for Payer: Aetna Medicare |
$77.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.34
|
| Rate for Payer: BCBS Complete |
$61.75
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cofinity Commercial |
$108.06
|
| Rate for Payer: Cofinity Commercial |
$132.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.50
|
| Rate for Payer: Healthscope Commercial |
$138.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.21
|
| Rate for Payer: PHP Commercial |
$131.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.34
|
| Rate for Payer: Priority Health SBD |
$97.25
|
| Rate for Payer: UMR Bronson Commercial |
$57.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.78
|
|
|
PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID
|
Facility
|
IP
|
$154.37
|
|
|
Service Code
|
NDC 68176000010
|
| Hospital Charge Code |
176647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.92 |
| Max. Negotiated Rate |
$138.93 |
| Rate for Payer: Aetna American Axle |
$100.34
|
| Rate for Payer: Aetna Commercial |
$131.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.34
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cofinity Commercial |
$108.06
|
| Rate for Payer: Cofinity Commercial |
$132.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.50
|
| Rate for Payer: Healthscope Commercial |
$138.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.21
|
| Rate for Payer: PHP Commercial |
$131.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.34
|
| Rate for Payer: Priority Health SBD |
$97.25
|
| Rate for Payer: UMR Bronson Commercial |
$67.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.78
|
|
|
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 Commercial |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.83
|
| 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: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.77
|
| Rate for Payer: Priority Health SBD |
$63.74
|
| 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 Commercial |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.83
|
| 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: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.77
|
| 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
|
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 Commercial |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.83
|
| 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: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.77
|
| 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 Commercial |
$70.83
|
| Rate for Payer: Cofinity Commercial |
$87.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.83
|
| 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: PHP Commercial |
$86.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.77
|
| Rate for Payer: Priority Health SBD |
$63.74
|
| Rate for Payer: UMR Bronson Commercial |
$37.44
|
| 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 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
|
|
|
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 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
|
|
|
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 Commercial |
$7.80
|
| Rate for Payer: Cofinity Commercial |
$9.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.80
|
| 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: PHP Commercial |
$9.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.24
|
| Rate for Payer: Priority Health SBD |
$7.02
|
| 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 Commercial |
$7.80
|
| Rate for Payer: Cofinity Commercial |
$9.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.80
|
| 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: PHP Commercial |
$9.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.24
|
| 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
|
|
