|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION (TPN COMPONENT)
|
Facility
|
IP
|
$777.74
|
|
|
Service Code
|
NDC 09900001921
|
| Hospital Charge Code |
301289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$342.21 |
| Max. Negotiated Rate |
$699.97 |
| Rate for Payer: Aetna American Axle |
$505.53
|
| Rate for Payer: Aetna Commercial |
$661.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.53
|
| Rate for Payer: Cash Price |
$622.19
|
| Rate for Payer: Cofinity Advantage |
$544.42
|
| Rate for Payer: Cofinity Commercial |
$668.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.19
|
| Rate for Payer: Healthscope Commercial |
$699.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$583.30
|
| Rate for Payer: PHP Commercial |
$661.08
|
| Rate for Payer: Priority Health SBD |
$489.98
|
| Rate for Payer: UMR Bronson Commercial |
$342.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.30
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
IP
|
$109.98
|
|
|
Service Code
|
NDC 16500004108
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.39 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna American Axle |
$71.49
|
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Advantage |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UMR Bronson Commercial |
$48.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
OP
|
$109.98
|
|
|
Service Code
|
NDC 16500004108
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.69 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna American Axle |
$71.49
|
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: Aetna Medicare |
$54.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.49
|
| Rate for Payer: BCBS Complete |
$43.99
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Advantage |
$76.99
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$87.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health SBD |
$69.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.49
|
| Rate for Payer: UHC Core |
$57.30
|
| Rate for Payer: UHC Exchange |
$43.22
|
| Rate for Payer: UMR Bronson Commercial |
$40.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 16500056675
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Advantage |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.04
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 16500056675
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.78 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna Medicare |
$74.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Advantage |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.04
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.23
|
| Rate for Payer: UHC Core |
$77.13
|
| Rate for Payer: UHC Exchange |
$58.18
|
| Rate for Payer: UMR Bronson Commercial |
$54.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
POVIDONE (BULK) K-30 POWDER
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
NDC 51552132305
|
| Hospital Charge Code |
23281
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$277.20 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Aetna American Axle |
$409.50
|
| Rate for Payer: Aetna Commercial |
$535.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.50
|
| Rate for Payer: Cash Price |
$504.00
|
| Rate for Payer: Cofinity Advantage |
$441.00
|
| Rate for Payer: Cofinity Commercial |
$541.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.00
|
| Rate for Payer: Healthscope Commercial |
$567.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$441.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$472.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$535.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$472.50
|
| Rate for Payer: PHP Commercial |
$535.50
|
| Rate for Payer: Priority Health SBD |
$396.90
|
| Rate for Payer: UMR Bronson Commercial |
$277.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$472.50
|
|
|
POVIDONE (BULK) K-30 POWDER
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
NDC 51552132305
|
| Hospital Charge Code |
23281
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$233.10 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Aetna American Axle |
$409.50
|
| Rate for Payer: Aetna Commercial |
$535.50
|
| Rate for Payer: Aetna Medicare |
$315.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.50
|
| Rate for Payer: BCBS Complete |
$252.00
|
| Rate for Payer: Cash Price |
$504.00
|
| Rate for Payer: Cofinity Advantage |
$441.00
|
| Rate for Payer: Cofinity Commercial |
$541.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.00
|
| Rate for Payer: Healthscope Commercial |
$567.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$441.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$472.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$504.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$535.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$472.50
|
| Rate for Payer: PHP Commercial |
$535.50
|
| Rate for Payer: Priority Health SBD |
$396.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$409.50
|
| Rate for Payer: UHC Core |
$328.23
|
| Rate for Payer: UHC Exchange |
$247.59
|
| Rate for Payer: UMR Bronson Commercial |
$233.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$472.50
|
|
|
POVIDONE-IODINE 0.3 % VAGINAL SOLUTION
|
Facility
|
IP
|
$16.03
|
|
|
Service Code
|
NDC 41608008743
|
| Hospital Charge Code |
12799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Aetna American Axle |
$10.42
|
| Rate for Payer: Aetna Commercial |
$13.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.42
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Advantage |
$11.22
|
| Rate for Payer: Cofinity Commercial |
$13.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.02
|
| Rate for Payer: PHP Commercial |
$13.63
|
| Rate for Payer: Priority Health SBD |
$10.10
|
| Rate for Payer: UMR Bronson Commercial |
$7.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
|
POVIDONE-IODINE 0.3 % VAGINAL SOLUTION
|
Facility
|
OP
|
$16.03
|
|
|
Service Code
|
NDC 41608008743
|
| Hospital Charge Code |
12799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Aetna American Axle |
$10.42
|
| Rate for Payer: Aetna Commercial |
$13.63
|
| Rate for Payer: Aetna Medicare |
$8.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.42
|
| Rate for Payer: BCBS Complete |
$6.41
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Advantage |
$11.22
|
| Rate for Payer: Cofinity Commercial |
$13.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.02
|
| Rate for Payer: PHP Commercial |
$13.63
|
| Rate for Payer: Priority Health SBD |
$10.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.42
|
| Rate for Payer: UHC Core |
$8.35
|
| Rate for Payer: UHC Exchange |
$6.30
|
| Rate for Payer: UMR Bronson Commercial |
$5.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$14.87
|
|
|
Service Code
|
NDC 00904110309
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$13.38 |
| Rate for Payer: Aetna American Axle |
$9.67
|
| Rate for Payer: Aetna Commercial |
$12.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.67
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: Cofinity Advantage |
$10.41
|
| Rate for Payer: Cofinity Commercial |
$12.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.90
|
| Rate for Payer: Healthscope Commercial |
$13.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.15
|
| Rate for Payer: PHP Commercial |
$12.64
|
| Rate for Payer: Priority Health SBD |
$9.37
|
| Rate for Payer: UMR Bronson Commercial |
$6.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.15
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$21.29
|
|
|
Service Code
|
NDC 00395232516
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna American Axle |
$13.84
|
| Rate for Payer: Aetna Commercial |
$18.10
|
| Rate for Payer: Aetna Medicare |
$10.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.84
|
| Rate for Payer: BCBS Complete |
$8.52
|
| Rate for Payer: Cash Price |
$17.03
|
| Rate for Payer: Cofinity Advantage |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$18.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.03
|
| Rate for Payer: Healthscope Commercial |
$19.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.97
|
| Rate for Payer: PHP Commercial |
$18.10
|
| Rate for Payer: Priority Health SBD |
$13.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.84
|
| Rate for Payer: UHC Core |
$11.09
|
| Rate for Payer: UHC Exchange |
$8.37
|
| Rate for Payer: UMR Bronson Commercial |
$7.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.97
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$14.94
|
|
|
Service Code
|
NDC 52380190508
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna American Axle |
$9.71
|
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.71
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: Cofinity Advantage |
$10.46
|
| Rate for Payer: Cofinity Commercial |
$12.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.95
|
| Rate for Payer: Healthscope Commercial |
$13.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.21
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: Priority Health SBD |
$9.41
|
| Rate for Payer: UMR Bronson Commercial |
$6.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.21
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$21.29
|
|
|
Service Code
|
NDC 00395232516
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna American Axle |
$13.84
|
| Rate for Payer: Aetna Commercial |
$18.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.84
|
| Rate for Payer: Cash Price |
$17.03
|
| Rate for Payer: Cofinity Advantage |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$18.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.03
|
| Rate for Payer: Healthscope Commercial |
$19.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.97
|
| Rate for Payer: PHP Commercial |
$18.10
|
| Rate for Payer: Priority Health SBD |
$13.41
|
| Rate for Payer: UMR Bronson Commercial |
$9.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.97
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$13.87
|
|
|
Service Code
|
NDC 67618015009
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Aetna American Axle |
$9.02
|
| Rate for Payer: Aetna Commercial |
$11.79
|
| Rate for Payer: Aetna Medicare |
$6.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.02
|
| Rate for Payer: BCBS Complete |
$5.55
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cofinity Advantage |
$9.71
|
| Rate for Payer: Cofinity Commercial |
$11.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.10
|
| Rate for Payer: Healthscope Commercial |
$12.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.40
|
| Rate for Payer: PHP Commercial |
$11.79
|
| Rate for Payer: Priority Health SBD |
$8.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.02
|
| Rate for Payer: UHC Core |
$7.23
|
| Rate for Payer: UHC Exchange |
$5.45
|
| Rate for Payer: UMR Bronson Commercial |
$5.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.40
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$13.87
|
|
|
Service Code
|
NDC 67618015009
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.10 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Aetna American Axle |
$9.02
|
| Rate for Payer: Aetna Commercial |
$11.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.02
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cofinity Advantage |
$9.71
|
| Rate for Payer: Cofinity Commercial |
$11.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.10
|
| Rate for Payer: Healthscope Commercial |
$12.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.40
|
| Rate for Payer: PHP Commercial |
$11.79
|
| Rate for Payer: Priority Health SBD |
$8.74
|
| Rate for Payer: UMR Bronson Commercial |
$6.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.40
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$14.94
|
|
|
Service Code
|
NDC 52380190508
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna American Axle |
$9.71
|
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Aetna Medicare |
$7.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.71
|
| Rate for Payer: BCBS Complete |
$5.98
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: Cofinity Advantage |
$10.46
|
| Rate for Payer: Cofinity Commercial |
$12.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.95
|
| Rate for Payer: Healthscope Commercial |
$13.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.21
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: Priority Health SBD |
$9.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.71
|
| Rate for Payer: UHC Core |
$7.78
|
| Rate for Payer: UHC Exchange |
$5.87
|
| Rate for Payer: UMR Bronson Commercial |
$5.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.21
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$14.87
|
|
|
Service Code
|
NDC 00904110309
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$13.38 |
| Rate for Payer: Aetna American Axle |
$9.67
|
| Rate for Payer: Aetna Commercial |
$12.64
|
| Rate for Payer: Aetna Medicare |
$7.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.67
|
| Rate for Payer: BCBS Complete |
$5.95
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: Cofinity Advantage |
$10.41
|
| Rate for Payer: Cofinity Commercial |
$12.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.90
|
| Rate for Payer: Healthscope Commercial |
$13.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.15
|
| Rate for Payer: PHP Commercial |
$12.64
|
| Rate for Payer: Priority Health SBD |
$9.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.67
|
| Rate for Payer: UHC Core |
$7.75
|
| Rate for Payer: UHC Exchange |
$5.84
|
| Rate for Payer: UMR Bronson Commercial |
$5.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.15
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
IP
|
$31.50
|
|
|
Service Code
|
NDC 00065041130
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$28.35 |
| Rate for Payer: Aetna American Axle |
$20.48
|
| Rate for Payer: Aetna Commercial |
$26.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.48
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Advantage |
$22.05
|
| Rate for Payer: Cofinity Commercial |
$27.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$28.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.62
|
| Rate for Payer: PHP Commercial |
$26.77
|
| Rate for Payer: Priority Health SBD |
$19.84
|
| Rate for Payer: UMR Bronson Commercial |
$13.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.62
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
IP
|
$3.54
|
|
|
Service Code
|
NDC 09900000395
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna American Axle |
$2.30
|
| Rate for Payer: Aetna Commercial |
$3.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.30
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cofinity Advantage |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$3.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.83
|
| Rate for Payer: Healthscope Commercial |
$3.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.65
|
| Rate for Payer: PHP Commercial |
$3.01
|
| Rate for Payer: Priority Health SBD |
$2.23
|
| Rate for Payer: UMR Bronson Commercial |
$1.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.65
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
OP
|
$3.54
|
|
|
Service Code
|
NDC 09900000395
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna American Axle |
$2.30
|
| Rate for Payer: Aetna Commercial |
$3.01
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.30
|
| Rate for Payer: BCBS Complete |
$1.42
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cofinity Advantage |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$3.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.83
|
| Rate for Payer: Healthscope Commercial |
$3.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.65
|
| Rate for Payer: PHP Commercial |
$3.01
|
| Rate for Payer: Priority Health SBD |
$2.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.30
|
| Rate for Payer: UHC Core |
$1.84
|
| Rate for Payer: UHC Exchange |
$1.39
|
| Rate for Payer: UMR Bronson Commercial |
$1.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.65
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
OP
|
$31.50
|
|
|
Service Code
|
NDC 00065041130
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$28.35 |
| Rate for Payer: Aetna American Axle |
$20.48
|
| Rate for Payer: Aetna Commercial |
$26.77
|
| Rate for Payer: Aetna Medicare |
$15.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.48
|
| Rate for Payer: BCBS Complete |
$12.60
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Advantage |
$22.05
|
| Rate for Payer: Cofinity Commercial |
$27.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$28.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.62
|
| Rate for Payer: PHP Commercial |
$26.77
|
| Rate for Payer: Priority Health SBD |
$19.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.48
|
| Rate for Payer: UHC Core |
$16.41
|
| Rate for Payer: UHC Exchange |
$12.38
|
| Rate for Payer: UMR Bronson Commercial |
$11.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.62
|
|
|
PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR
|
Professional
|
Both
|
$2,161.00
|
|
|
Service Code
|
HCPCS 54332
|
| Min. Negotiated Rate |
$578.30 |
| Max. Negotiated Rate |
$1,789.21 |
| Rate for Payer: Aetna Commercial |
$1,201.51
|
| Rate for Payer: Aetna Medicare |
$932.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,201.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,291.18
|
| Rate for Payer: BCBS Complete |
$607.22
|
| Rate for Payer: BCBS MAPPO |
$896.65
|
| Rate for Payer: BCN Commercial |
$1,508.88
|
| Rate for Payer: BCN Medicare Advantage |
$896.65
|
| Rate for Payer: Cash Price |
$1,728.80
|
| Rate for Payer: Cash Price |
$1,728.80
|
| Rate for Payer: Cofinity Commercial |
$1,201.51
|
| Rate for Payer: Cofinity Commercial |
$1,291.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$896.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$941.48
|
| Rate for Payer: Meridian Medicaid |
$607.22
|
| Rate for Payer: Molina Medicare/Medicaid |
$986.32
|
| Rate for Payer: Nomi Health Commercial |
$1,075.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,620.75
|
| Rate for Payer: PACE SWMI |
$896.65
|
| Rate for Payer: PHP Commercial |
$1,255.31
|
| Rate for Payer: PHP Medicare Advantage |
$896.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$578.30
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,643.67
|
| Rate for Payer: Priority Health Medicare |
$896.65
|
| Rate for Payer: Priority Health SBD |
$1,643.67
|
| Rate for Payer: Priority Health Tiered Network |
$1,643.67
|
| Rate for Payer: Railroad Medicare Medicare |
$896.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,789.21
|
| Rate for Payer: UHC Core |
$1,789.21
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$896.65
|
| Rate for Payer: UHC Exchange |
$1,789.21
|
| Rate for Payer: UHC Medicaid |
$578.30
|
| Rate for Payer: UHCCP Medicaid |
$578.30
|
| Rate for Payer: UMR Bronson Commercial |
$994.06
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS
|
Professional
|
Both
|
$1,827.00
|
|
|
Service Code
|
HCPCS 54326
|
| Min. Negotiated Rate |
$540.59 |
| Max. Negotiated Rate |
$1,668.02 |
| Rate for Payer: Aetna Commercial |
$1,122.30
|
| Rate for Payer: Aetna Medicare |
$871.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,122.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,206.06
|
| Rate for Payer: BCBS Complete |
$567.62
|
| Rate for Payer: BCBS MAPPO |
$837.54
|
| Rate for Payer: BCN Commercial |
$1,408.29
|
| Rate for Payer: BCN Medicare Advantage |
$837.54
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cofinity Commercial |
$1,122.30
|
| Rate for Payer: Cofinity Commercial |
$1,206.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$837.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$879.42
|
| Rate for Payer: Meridian Medicaid |
$567.62
|
| Rate for Payer: Molina Medicare/Medicaid |
$921.29
|
| Rate for Payer: Nomi Health Commercial |
$1,005.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,370.25
|
| Rate for Payer: PACE SWMI |
$837.54
|
| Rate for Payer: PHP Commercial |
$1,172.56
|
| Rate for Payer: PHP Medicare Advantage |
$837.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$540.59
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,534.09
|
| Rate for Payer: Priority Health Medicare |
$837.54
|
| Rate for Payer: Priority Health SBD |
$1,534.09
|
| Rate for Payer: Priority Health Tiered Network |
$1,534.09
|
| Rate for Payer: Railroad Medicare Medicare |
$837.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,668.02
|
| Rate for Payer: UHC Core |
$1,668.02
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$837.54
|
| Rate for Payer: UHC Exchange |
$1,668.02
|
| Rate for Payer: UHC Medicaid |
$540.59
|
| Rate for Payer: UHCCP Medicaid |
$540.59
|
| Rate for Payer: UMR Bronson Commercial |
$840.42
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT
|
Professional
|
Both
|
$5,150.00
|
|
|
Service Code
|
HCPCS 54322
|
| Min. Negotiated Rate |
$449.43 |
| Max. Negotiated Rate |
$3,862.50 |
| Rate for Payer: Aetna Commercial |
$932.21
|
| Rate for Payer: Aetna Medicare |
$723.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,001.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$932.21
|
| Rate for Payer: BCBS Complete |
$471.90
|
| Rate for Payer: BCBS MAPPO |
$695.68
|
| Rate for Payer: BCN Commercial |
$1,169.25
|
| Rate for Payer: BCN Medicare Advantage |
$695.68
|
| Rate for Payer: Cash Price |
$4,120.00
|
| Rate for Payer: Cash Price |
$4,120.00
|
| Rate for Payer: Cofinity Commercial |
$1,001.78
|
| Rate for Payer: Cofinity Commercial |
$932.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$695.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$730.46
|
| Rate for Payer: Meridian Medicaid |
$471.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$765.25
|
| Rate for Payer: Nomi Health Commercial |
$834.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,862.50
|
| Rate for Payer: PACE SWMI |
$695.68
|
| Rate for Payer: PHP Commercial |
$973.95
|
| Rate for Payer: PHP Medicare Advantage |
$695.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$449.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,273.71
|
| Rate for Payer: Priority Health Medicare |
$695.68
|
| Rate for Payer: Priority Health SBD |
$1,273.71
|
| Rate for Payer: Priority Health Tiered Network |
$1,273.71
|
| Rate for Payer: Railroad Medicare Medicare |
$695.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,380.52
|
| Rate for Payer: UHC Core |
$1,380.52
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$695.68
|
| Rate for Payer: UHC Exchange |
$1,380.52
|
| Rate for Payer: UHC Medicaid |
$449.43
|
| Rate for Payer: UHCCP Medicaid |
$449.43
|
| Rate for Payer: UMR Bronson Commercial |
$2,369.00
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS
|
Professional
|
Both
|
$2,072.00
|
|
|
Service Code
|
HCPCS 54324
|
| Min. Negotiated Rate |
$554.65 |
| Max. Negotiated Rate |
$1,710.70 |
| Rate for Payer: Aetna Commercial |
$1,151.88
|
| Rate for Payer: Aetna Medicare |
$893.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,151.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,237.84
|
| Rate for Payer: BCBS Complete |
$582.38
|
| Rate for Payer: BCBS MAPPO |
$859.61
|
| Rate for Payer: BCN Commercial |
$1,446.63
|
| Rate for Payer: BCN Medicare Advantage |
$859.61
|
| Rate for Payer: Cash Price |
$1,657.60
|
| Rate for Payer: Cash Price |
$1,657.60
|
| Rate for Payer: Cofinity Commercial |
$1,151.88
|
| Rate for Payer: Cofinity Commercial |
$1,237.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$859.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$902.59
|
| Rate for Payer: Meridian Medicaid |
$582.38
|
| Rate for Payer: Molina Medicare/Medicaid |
$945.57
|
| Rate for Payer: Nomi Health Commercial |
$1,031.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,554.00
|
| Rate for Payer: PACE SWMI |
$859.61
|
| Rate for Payer: PHP Commercial |
$1,203.45
|
| Rate for Payer: PHP Medicare Advantage |
$859.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$554.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,575.86
|
| Rate for Payer: Priority Health Medicare |
$859.61
|
| Rate for Payer: Priority Health SBD |
$1,575.86
|
| Rate for Payer: Priority Health Tiered Network |
$1,575.86
|
| Rate for Payer: Railroad Medicare Medicare |
$859.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,710.70
|
| Rate for Payer: UHC Core |
$1,710.70
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$859.61
|
| Rate for Payer: UHC Exchange |
$1,710.70
|
| Rate for Payer: UHC Medicaid |
$554.65
|
| Rate for Payer: UHCCP Medicaid |
$554.65
|
| Rate for Payer: UMR Bronson Commercial |
$953.12
|
|
