|
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 Commercial |
$48.92
|
| Rate for Payer: Cofinity Commercial |
$60.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.92
|
| 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: PHP Commercial |
$59.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.43
|
| Rate for Payer: Priority Health SBD |
$44.03
|
| Rate for Payer: UMR Bronson Commercial |
$25.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.42
|
|
|
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 Commercial |
$364.56
|
| Rate for Payer: Cofinity Commercial |
$447.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$364.56
|
| 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: PHP Commercial |
$442.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$338.52
|
| Rate for Payer: Priority Health SBD |
$328.10
|
| Rate for Payer: UMR Bronson Commercial |
$192.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$390.60
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
OP
|
$261.45
|
|
|
Service Code
|
NDC 00023782410
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.74 |
| Max. Negotiated Rate |
$235.31 |
| Rate for Payer: Aetna American Axle |
$169.94
|
| Rate for Payer: Aetna Commercial |
$222.23
|
| Rate for Payer: Aetna Medicare |
$130.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.94
|
| Rate for Payer: BCBS Complete |
$104.58
|
| Rate for Payer: Cash Price |
$209.16
|
| Rate for Payer: Cofinity Commercial |
$183.01
|
| Rate for Payer: Cofinity Commercial |
$224.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.16
|
| Rate for Payer: Healthscope Commercial |
$235.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.23
|
| Rate for Payer: PHP Commercial |
$222.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.94
|
| Rate for Payer: Priority Health SBD |
$164.71
|
| Rate for Payer: UMR Bronson Commercial |
$96.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.09
|
|
|
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 Commercial |
$12.45
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.45
|
| 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: PHP Commercial |
$15.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.56
|
| 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
|
$261.45
|
|
|
Service Code
|
NDC 00023782410
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.04 |
| Max. Negotiated Rate |
$235.31 |
| Rate for Payer: Aetna American Axle |
$169.94
|
| Rate for Payer: Aetna Commercial |
$222.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.94
|
| Rate for Payer: Cash Price |
$209.16
|
| Rate for Payer: Cofinity Commercial |
$183.01
|
| Rate for Payer: Cofinity Commercial |
$224.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.16
|
| Rate for Payer: Healthscope Commercial |
$235.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.23
|
| Rate for Payer: PHP Commercial |
$222.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.94
|
| Rate for Payer: Priority Health SBD |
$164.71
|
| Rate for Payer: UMR Bronson Commercial |
$115.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.09
|
|
|
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 Commercial |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$30.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.82
|
| 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: PHP Commercial |
$30.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.05
|
| 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
|
$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 Commercial |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.50
|
| 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: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| 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
|
$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 Commercial |
$12.45
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.45
|
| 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: PHP Commercial |
$15.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.56
|
| Rate for Payer: Priority Health SBD |
$11.20
|
| Rate for Payer: UMR Bronson Commercial |
$6.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.34
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
OP
|
$21.88
|
|
|
Service Code
|
NDC 61314062810
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna American Axle |
$14.22
|
| Rate for Payer: Aetna Commercial |
$18.60
|
| Rate for Payer: Aetna Medicare |
$10.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.22
|
| Rate for Payer: BCBS Complete |
$8.75
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Cofinity Commercial |
$18.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.50
|
| Rate for Payer: Healthscope Commercial |
$19.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.60
|
| Rate for Payer: PHP Commercial |
$18.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.22
|
| Rate for Payer: Priority Health SBD |
$13.78
|
| Rate for Payer: UMR Bronson Commercial |
$8.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.41
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS
|
Facility
|
IP
|
$21.88
|
|
|
Service Code
|
NDC 61314062810
|
| Hospital Charge Code |
109275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna American Axle |
$14.22
|
| Rate for Payer: Aetna Commercial |
$18.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.22
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Cofinity Commercial |
$18.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.50
|
| Rate for Payer: Healthscope Commercial |
$19.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.60
|
| Rate for Payer: PHP Commercial |
$18.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.22
|
| Rate for Payer: Priority Health SBD |
$13.78
|
| Rate for Payer: UMR Bronson Commercial |
$9.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.41
|
|
|
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 Commercial |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.50
|
| 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: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: Priority Health SBD |
$22.05
|
| 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
|
$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 Commercial |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$30.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.82
|
| 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: PHP Commercial |
$30.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.05
|
| Rate for Payer: Priority Health SBD |
$22.34
|
| Rate for Payer: UMR Bronson Commercial |
$13.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.59
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$45.44
|
|
|
Service Code
|
NDC 63323036701
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$40.90 |
| Rate for Payer: Aetna American Axle |
$29.54
|
| Rate for Payer: Aetna Commercial |
$38.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.54
|
| Rate for Payer: Cash Price |
$36.35
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.35
|
| Rate for Payer: Healthscope Commercial |
$40.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.62
|
| Rate for Payer: PHP Commercial |
$38.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.54
|
| Rate for Payer: Priority Health SBD |
$28.63
|
| Rate for Payer: UMR Bronson Commercial |
$19.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.08
|
|
|
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 Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| 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: PHP Commercial |
$17.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| 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
|
$45.44
|
|
|
Service Code
|
NDC 63323036711
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.81 |
| Max. Negotiated Rate |
$40.90 |
| Rate for Payer: Aetna American Axle |
$29.54
|
| Rate for Payer: Aetna Commercial |
$38.62
|
| Rate for Payer: Aetna Medicare |
$22.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.54
|
| Rate for Payer: BCBS Complete |
$18.18
|
| Rate for Payer: Cash Price |
$36.35
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.35
|
| Rate for Payer: Healthscope Commercial |
$40.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.62
|
| Rate for Payer: PHP Commercial |
$38.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.54
|
| Rate for Payer: Priority Health SBD |
$28.63
|
| Rate for Payer: UMR Bronson Commercial |
$16.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.08
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$45.44
|
|
|
Service Code
|
NDC 63323036711
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$40.90 |
| Rate for Payer: Aetna American Axle |
$29.54
|
| Rate for Payer: Aetna Commercial |
$38.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.54
|
| Rate for Payer: Cash Price |
$36.35
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.35
|
| Rate for Payer: Healthscope Commercial |
$40.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.62
|
| Rate for Payer: PHP Commercial |
$38.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.54
|
| Rate for Payer: Priority Health SBD |
$28.63
|
| Rate for Payer: UMR Bronson Commercial |
$19.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.08
|
|
|
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 Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| 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: PHP Commercial |
$17.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.53
|
|
|
POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$45.44
|
|
|
Service Code
|
NDC 63323036701
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.81 |
| Max. Negotiated Rate |
$40.90 |
| Rate for Payer: Aetna American Axle |
$29.54
|
| Rate for Payer: Aetna Commercial |
$38.62
|
| Rate for Payer: Aetna Medicare |
$22.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.54
|
| Rate for Payer: BCBS Complete |
$18.18
|
| Rate for Payer: Cash Price |
$36.35
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.35
|
| Rate for Payer: Healthscope Commercial |
$40.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.62
|
| Rate for Payer: PHP Commercial |
$38.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.54
|
| Rate for Payer: Priority Health SBD |
$28.63
|
| Rate for Payer: UMR Bronson Commercial |
$16.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.08
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
OP
|
$418.30
|
|
|
Service Code
|
NDC 51991020311
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.77 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.89
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna Medicare |
$209.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.89
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| 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: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.89
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$154.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.73
|
|
|
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 Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| 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: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.89
|
| 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
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
IP
|
$4.19
|
|
|
Service Code
|
NDC 51991020399
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Aetna American Axle |
$2.72
|
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.72
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cofinity Commercial |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.35
|
| Rate for Payer: Healthscope Commercial |
$3.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.56
|
| Rate for Payer: PHP Commercial |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.14
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
OP
|
$4.19
|
|
|
Service Code
|
NDC 51991020399
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Aetna American Axle |
$2.72
|
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Aetna Medicare |
$2.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.72
|
| Rate for Payer: BCBS Complete |
$1.68
|
| Rate for Payer: Cash Price |
$3.35
|
| Rate for Payer: Cofinity Commercial |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.35
|
| Rate for Payer: Healthscope Commercial |
$3.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.56
|
| Rate for Payer: PHP Commercial |
$3.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.14
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 00904539561
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.33 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.69
|
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.69
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$101.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE
|
Facility
|
OP
|
$230.30
|
|
|
Service Code
|
NDC 00904539561
|
| Hospital Charge Code |
11050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.21 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.69
|
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna Medicare |
$115.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.69
|
| Rate for Payer: BCBS Complete |
$92.12
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$85.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
POLYSORBATE 80 SOLUTION
|
Facility
|
IP
|
$399.50
|
|
|
Service Code
|
NDC 38779052608
|
| Hospital Charge Code |
6395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.78 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna American Axle |
$259.68
|
| Rate for Payer: Aetna Commercial |
$339.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
| Rate for Payer: Cash Price |
$319.60
|
| Rate for Payer: Cofinity Commercial |
$279.65
|
| Rate for Payer: Cofinity Commercial |
$343.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$279.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.60
|
| Rate for Payer: Healthscope Commercial |
$359.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$279.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$299.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$339.57
|
| Rate for Payer: PHP Commercial |
$339.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$259.68
|
| Rate for Payer: Priority Health SBD |
$251.69
|
| Rate for Payer: UMR Bronson Commercial |
$175.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$299.62
|
|
