|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
NDC 69230032434
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$21.69 |
| Rate for Payer: Aetna American Axle |
$15.66
|
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.66
|
| Rate for Payer: Cash Price |
$19.28
|
| Rate for Payer: Cofinity Advantage |
$16.87
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.28
|
| Rate for Payer: Healthscope Commercial |
$21.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.07
|
| Rate for Payer: PHP Commercial |
$20.48
|
| Rate for Payer: Priority Health SBD |
$15.18
|
| Rate for Payer: UMR Bronson Commercial |
$10.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.07
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
NDC 69230032434
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.92 |
| Max. Negotiated Rate |
$21.69 |
| Rate for Payer: Aetna American Axle |
$15.66
|
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: Aetna Medicare |
$12.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.66
|
| Rate for Payer: BCBS Complete |
$9.64
|
| Rate for Payer: Cash Price |
$19.28
|
| Rate for Payer: Cofinity Advantage |
$16.87
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.28
|
| Rate for Payer: Healthscope Commercial |
$21.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.07
|
| Rate for Payer: PHP Commercial |
$20.48
|
| Rate for Payer: Priority Health SBD |
$15.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.66
|
| Rate for Payer: UHC Core |
$12.56
|
| Rate for Payer: UHC Exchange |
$9.47
|
| Rate for Payer: UMR Bronson Commercial |
$8.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.07
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$6.42
|
|
|
Service Code
|
NDC 51079030601
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$5.78 |
| Rate for Payer: Aetna American Axle |
$4.17
|
| Rate for Payer: Aetna Commercial |
$5.46
|
| Rate for Payer: Aetna Medicare |
$3.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.17
|
| Rate for Payer: BCBS Complete |
$2.57
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: Cofinity Advantage |
$4.49
|
| Rate for Payer: Cofinity Commercial |
$5.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.14
|
| Rate for Payer: Healthscope Commercial |
$5.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.82
|
| Rate for Payer: PHP Commercial |
$5.46
|
| Rate for Payer: Priority Health SBD |
$4.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.17
|
| Rate for Payer: UHC Core |
$3.34
|
| Rate for Payer: UHC Exchange |
$2.52
|
| Rate for Payer: UMR Bronson Commercial |
$2.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.82
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$69.89
|
|
|
Service Code
|
NDC 68084043098
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.75 |
| Max. Negotiated Rate |
$62.90 |
| Rate for Payer: Aetna American Axle |
$45.43
|
| Rate for Payer: Aetna Commercial |
$59.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.43
|
| Rate for Payer: Cash Price |
$55.91
|
| Rate for Payer: Cofinity Advantage |
$48.92
|
| Rate for Payer: Cofinity Commercial |
$60.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.91
|
| Rate for Payer: Healthscope Commercial |
$62.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.42
|
| Rate for Payer: PHP Commercial |
$59.41
|
| Rate for Payer: Priority Health SBD |
$44.03
|
| Rate for Payer: UMR Bronson Commercial |
$30.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.42
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$54.20
|
|
|
Service Code
|
NDC 41100080676
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.85 |
| Max. Negotiated Rate |
$48.78 |
| Rate for Payer: Aetna American Axle |
$35.23
|
| Rate for Payer: Aetna Commercial |
$46.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.23
|
| Rate for Payer: Cash Price |
$43.36
|
| Rate for Payer: Cofinity Advantage |
$37.94
|
| Rate for Payer: Cofinity Commercial |
$46.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.36
|
| Rate for Payer: Healthscope Commercial |
$48.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$40.65
|
| Rate for Payer: PHP Commercial |
$46.07
|
| Rate for Payer: Priority Health SBD |
$34.15
|
| Rate for Payer: UMR Bronson Commercial |
$23.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.65
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 00904693186
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna American Axle |
$4.15
|
| Rate for Payer: Aetna Commercial |
$5.42
|
| Rate for Payer: Aetna Medicare |
$3.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.15
|
| Rate for Payer: BCBS Complete |
$2.55
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cofinity Advantage |
$4.47
|
| Rate for Payer: Cofinity Commercial |
$5.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.10
|
| Rate for Payer: Healthscope Commercial |
$5.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.79
|
| Rate for Payer: PHP Commercial |
$5.42
|
| Rate for Payer: Priority Health SBD |
$4.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.15
|
| Rate for Payer: UHC Core |
$3.32
|
| Rate for Payer: UHC Exchange |
$2.51
|
| Rate for Payer: UMR Bronson Commercial |
$2.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.79
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$192.39
|
|
|
Service Code
|
NDC 51079030630
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$173.15 |
| Rate for Payer: Aetna American Axle |
$125.05
|
| Rate for Payer: Aetna Commercial |
$163.53
|
| Rate for Payer: Aetna Medicare |
$96.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.05
|
| Rate for Payer: BCBS Complete |
$76.96
|
| Rate for Payer: Cash Price |
$153.91
|
| Rate for Payer: Cofinity Advantage |
$134.67
|
| Rate for Payer: Cofinity Commercial |
$165.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.91
|
| Rate for Payer: Healthscope Commercial |
$173.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$153.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$144.29
|
| Rate for Payer: PHP Commercial |
$163.53
|
| Rate for Payer: Priority Health SBD |
$121.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.05
|
| Rate for Payer: UHC Core |
$100.24
|
| Rate for Payer: UHC Exchange |
$75.61
|
| Rate for Payer: UMR Bronson Commercial |
$71.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.29
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$520.80
|
|
|
Service Code
|
NDC 00904693181
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.70 |
| Max. Negotiated Rate |
$468.72 |
| Rate for Payer: Aetna American Axle |
$338.52
|
| Rate for Payer: Aetna Commercial |
$442.68
|
| Rate for Payer: Aetna Medicare |
$260.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$338.52
|
| Rate for Payer: BCBS Complete |
$208.32
|
| Rate for Payer: Cash Price |
$416.64
|
| Rate for Payer: Cofinity Advantage |
$364.56
|
| Rate for Payer: Cofinity Commercial |
$447.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.64
|
| Rate for Payer: Healthscope Commercial |
$468.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$364.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$390.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$416.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$390.60
|
| Rate for Payer: PHP Commercial |
$442.68
|
| Rate for Payer: Priority Health SBD |
$328.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$338.52
|
| Rate for Payer: UHC Core |
$271.34
|
| Rate for Payer: UHC Exchange |
$204.67
|
| Rate for Payer: UMR Bronson Commercial |
$192.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$390.60
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$54.20
|
|
|
Service Code
|
NDC 41100080676
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$48.78 |
| Rate for Payer: Aetna American Axle |
$35.23
|
| Rate for Payer: Aetna Commercial |
$46.07
|
| Rate for Payer: Aetna Medicare |
$27.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.23
|
| Rate for Payer: BCBS Complete |
$21.68
|
| Rate for Payer: Cash Price |
$43.36
|
| Rate for Payer: Cofinity Advantage |
$37.94
|
| Rate for Payer: Cofinity Commercial |
$46.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.36
|
| Rate for Payer: Healthscope Commercial |
$48.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$40.65
|
| Rate for Payer: PHP Commercial |
$46.07
|
| Rate for Payer: Priority Health SBD |
$34.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.23
|
| Rate for Payer: UHC Core |
$28.24
|
| Rate for Payer: UHC Exchange |
$21.30
|
| Rate for Payer: UMR Bronson Commercial |
$20.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.65
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$520.80
|
|
|
Service Code
|
NDC 00904693181
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.15 |
| Max. Negotiated Rate |
$468.72 |
| Rate for Payer: Aetna American Axle |
$338.52
|
| Rate for Payer: Aetna Commercial |
$442.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$338.52
|
| Rate for Payer: Cash Price |
$416.64
|
| Rate for Payer: Cofinity Advantage |
$364.56
|
| Rate for Payer: Cofinity Commercial |
$447.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.64
|
| Rate for Payer: Healthscope Commercial |
$468.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$364.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$390.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$390.60
|
| Rate for Payer: PHP Commercial |
$442.68
|
| Rate for Payer: Priority Health SBD |
$328.10
|
| Rate for Payer: UMR Bronson Commercial |
$229.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$390.60
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 00904693186
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna American Axle |
$4.15
|
| Rate for Payer: Aetna Commercial |
$5.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.15
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cofinity Advantage |
$4.47
|
| Rate for Payer: Cofinity Commercial |
$5.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.10
|
| Rate for Payer: Healthscope Commercial |
$5.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.79
|
| Rate for Payer: PHP Commercial |
$5.42
|
| Rate for Payer: Priority Health SBD |
$4.02
|
| Rate for Payer: UMR Bronson Commercial |
$2.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.79
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$192.39
|
|
|
Service Code
|
NDC 51079030630
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.65 |
| Max. Negotiated Rate |
$173.15 |
| Rate for Payer: Aetna American Axle |
$125.05
|
| Rate for Payer: Aetna Commercial |
$163.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.05
|
| Rate for Payer: Cash Price |
$153.91
|
| Rate for Payer: Cofinity Advantage |
$134.67
|
| Rate for Payer: Cofinity Commercial |
$165.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.91
|
| Rate for Payer: Healthscope Commercial |
$173.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$144.29
|
| Rate for Payer: PHP Commercial |
$163.53
|
| Rate for Payer: Priority Health SBD |
$121.21
|
| Rate for Payer: UMR Bronson Commercial |
$84.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.29
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$6.42
|
|
|
Service Code
|
NDC 51079030601
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$5.78 |
| Rate for Payer: Aetna American Axle |
$4.17
|
| Rate for Payer: Aetna Commercial |
$5.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.17
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: Cofinity Advantage |
$4.49
|
| Rate for Payer: Cofinity Commercial |
$5.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.14
|
| Rate for Payer: Healthscope Commercial |
$5.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.82
|
| Rate for Payer: PHP Commercial |
$5.46
|
| Rate for Payer: Priority Health SBD |
$4.04
|
| Rate for Payer: UMR Bronson Commercial |
$2.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.82
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$69.89
|
|
|
Service Code
|
NDC 68084043098
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.86 |
| Max. Negotiated Rate |
$62.90 |
| Rate for Payer: Aetna American Axle |
$45.43
|
| Rate for Payer: Aetna Commercial |
$59.41
|
| Rate for Payer: Aetna Medicare |
$34.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.43
|
| Rate for Payer: BCBS Complete |
$27.96
|
| Rate for Payer: Cash Price |
$55.91
|
| Rate for Payer: Cofinity Advantage |
$48.92
|
| Rate for Payer: Cofinity Commercial |
$60.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.91
|
| Rate for Payer: Healthscope Commercial |
$62.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.42
|
| Rate for Payer: PHP Commercial |
$59.41
|
| Rate for Payer: Priority Health SBD |
$44.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.43
|
| Rate for Payer: UHC Core |
$36.41
|
| Rate for Payer: UHC Exchange |
$27.47
|
| Rate for Payer: UMR Bronson Commercial |
$25.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.42
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$35.46
|
|
|
Service Code
|
NDC 60758090810
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$31.91 |
| Rate for Payer: Aetna American Axle |
$23.05
|
| Rate for Payer: Aetna Commercial |
$30.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.05
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cofinity Advantage |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$30.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.37
|
| Rate for Payer: Healthscope Commercial |
$31.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.59
|
| Rate for Payer: PHP Commercial |
$30.14
|
| Rate for Payer: Priority Health SBD |
$22.34
|
| Rate for Payer: UMR Bronson Commercial |
$15.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.59
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$17.78
|
|
|
Service Code
|
NDC 17478070311
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna American Axle |
$11.56
|
| Rate for Payer: Aetna Commercial |
$15.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.56
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cofinity Advantage |
$12.45
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.22
|
| Rate for Payer: Healthscope Commercial |
$16.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.34
|
| Rate for Payer: PHP Commercial |
$15.11
|
| Rate for Payer: Priority Health SBD |
$11.20
|
| Rate for Payer: UMR Bronson Commercial |
$7.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.34
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna American Axle |
$22.75
|
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.75
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Advantage |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.00
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.25
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health SBD |
$22.05
|
| Rate for Payer: UMR Bronson Commercial |
$15.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna American Axle |
$22.75
|
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: Aetna Medicare |
$17.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.75
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Advantage |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.00
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.25
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health SBD |
$22.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.75
|
| Rate for Payer: UHC Core |
$18.23
|
| Rate for Payer: UHC Exchange |
$13.76
|
| Rate for Payer: UMR Bronson Commercial |
$12.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
OP
|
$26.15
|
|
|
Service Code
|
NDC 61314062810
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna American Axle |
$17.00
|
| Rate for Payer: Aetna Commercial |
$22.23
|
| Rate for Payer: Aetna Medicare |
$13.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.00
|
| Rate for Payer: BCBS Complete |
$10.46
|
| Rate for Payer: Cash Price |
$20.92
|
| Rate for Payer: Cofinity Advantage |
$18.30
|
| Rate for Payer: Cofinity Commercial |
$22.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.92
|
| Rate for Payer: Healthscope Commercial |
$23.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.61
|
| Rate for Payer: PHP Commercial |
$22.23
|
| Rate for Payer: Priority Health SBD |
$16.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.00
|
| Rate for Payer: UHC Core |
$13.62
|
| Rate for Payer: UHC Exchange |
$10.28
|
| Rate for Payer: UMR Bronson Commercial |
$9.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.61
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
OP
|
$35.46
|
|
|
Service Code
|
NDC 60758090810
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$31.91 |
| Rate for Payer: Aetna American Axle |
$23.05
|
| Rate for Payer: Aetna Commercial |
$30.14
|
| Rate for Payer: Aetna Medicare |
$17.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.05
|
| Rate for Payer: BCBS Complete |
$14.18
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cofinity Advantage |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$30.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.37
|
| Rate for Payer: Healthscope Commercial |
$31.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.59
|
| Rate for Payer: PHP Commercial |
$30.14
|
| Rate for Payer: Priority Health SBD |
$22.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.05
|
| Rate for Payer: UHC Core |
$18.47
|
| Rate for Payer: UHC Exchange |
$13.94
|
| Rate for Payer: UMR Bronson Commercial |
$13.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.59
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$26.15
|
|
|
Service Code
|
NDC 61314062810
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$23.54 |
| Rate for Payer: Aetna American Axle |
$17.00
|
| Rate for Payer: Aetna Commercial |
$22.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.00
|
| Rate for Payer: Cash Price |
$20.92
|
| Rate for Payer: Cofinity Advantage |
$18.30
|
| Rate for Payer: Cofinity Commercial |
$22.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.92
|
| Rate for Payer: Healthscope Commercial |
$23.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.61
|
| Rate for Payer: PHP Commercial |
$22.23
|
| Rate for Payer: Priority Health SBD |
$16.47
|
| Rate for Payer: UMR Bronson Commercial |
$11.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.61
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
OP
|
$17.78
|
|
|
Service Code
|
NDC 17478070311
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna American Axle |
$11.56
|
| Rate for Payer: Aetna Commercial |
$15.11
|
| Rate for Payer: Aetna Medicare |
$8.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.56
|
| Rate for Payer: BCBS Complete |
$7.11
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cofinity Advantage |
$12.45
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.22
|
| Rate for Payer: Healthscope Commercial |
$16.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.34
|
| Rate for Payer: PHP Commercial |
$15.11
|
| Rate for Payer: Priority Health SBD |
$11.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.56
|
| Rate for Payer: UHC Core |
$9.26
|
| Rate for Payer: UHC Exchange |
$6.99
|
| Rate for Payer: UMR Bronson Commercial |
$6.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.34
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$20.70
|
|
|
Service Code
|
NDC 70594004902
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Aetna American Axle |
$13.46
|
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Advantage |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.53
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: UMR Bronson Commercial |
$9.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.53
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$20.70
|
|
|
Service Code
|
NDC 70594004902
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.66 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Aetna American Axle |
$13.46
|
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna Medicare |
$10.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Advantage |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.53
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.46
|
| Rate for Payer: UHC Core |
$10.78
|
| Rate for Payer: UHC Exchange |
$8.14
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.53
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 51991020311
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.05 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.89
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.89
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Advantage |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$313.73
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$184.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.73
|
|
