|
POLYSORBATE 80 SOLUTION
|
Facility
|
OP
|
$399.50
|
|
|
Service Code
|
NDC 38779052608
|
| Hospital Charge Code |
6395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.81 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna American Axle |
$259.68
|
| Rate for Payer: Aetna Commercial |
$339.57
|
| Rate for Payer: Aetna Medicare |
$199.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
| Rate for Payer: BCBS Complete |
$159.80
|
| 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 |
$147.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$299.62
|
|
|
POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE
|
Facility
|
OP
|
$3.12
|
|
|
Service Code
|
NDC 00023050650
|
| Hospital Charge Code |
112480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: BCBS Complete |
$1.25
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.34
|
|
|
POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 00023050650
|
| Hospital Charge Code |
112480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna American Axle |
$2.03
|
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.03
|
| Rate for Payer: Priority Health SBD |
$1.97
|
| Rate for Payer: UMR Bronson Commercial |
$1.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.34
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION
|
Facility
|
OP
|
$1,921.90
|
|
|
Service Code
|
NDC 10122051001
|
| Hospital Charge Code |
27047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$711.10 |
| Max. Negotiated Rate |
$1,729.71 |
| Rate for Payer: Aetna American Axle |
$1,249.23
|
| Rate for Payer: Aetna Commercial |
$1,633.62
|
| Rate for Payer: Aetna Medicare |
$960.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,249.23
|
| Rate for Payer: BCBS Complete |
$768.76
|
| Rate for Payer: Cash Price |
$1,537.52
|
| Rate for Payer: Cofinity Commercial |
$1,345.33
|
| Rate for Payer: Cofinity Commercial |
$1,652.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,345.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,537.52
|
| Rate for Payer: Healthscope Commercial |
$1,729.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,345.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,441.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,633.62
|
| Rate for Payer: PHP Commercial |
$1,633.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,249.23
|
| Rate for Payer: Priority Health SBD |
$1,210.80
|
| Rate for Payer: UMR Bronson Commercial |
$711.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,441.42
|
|
|
PORACTANT ALFA 120 MG/1.5 ML INTRATRACHEAL SUSPENSION
|
Facility
|
IP
|
$1,921.90
|
|
|
Service Code
|
NDC 10122051001
|
| Hospital Charge Code |
27047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$845.64 |
| Max. Negotiated Rate |
$1,729.71 |
| Rate for Payer: Aetna American Axle |
$1,249.23
|
| Rate for Payer: Aetna Commercial |
$1,633.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,249.23
|
| Rate for Payer: Cash Price |
$1,537.52
|
| Rate for Payer: Cofinity Commercial |
$1,345.33
|
| Rate for Payer: Cofinity Commercial |
$1,652.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,345.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,537.52
|
| Rate for Payer: Healthscope Commercial |
$1,729.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,345.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,441.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,633.62
|
| Rate for Payer: PHP Commercial |
$1,633.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,249.23
|
| Rate for Payer: Priority Health SBD |
$1,210.80
|
| Rate for Payer: UMR Bronson Commercial |
$845.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,441.42
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4,100.79
|
|
|
Service Code
|
NDC 60687052321
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,804.35 |
| Max. Negotiated Rate |
$3,690.71 |
| Rate for Payer: Aetna American Axle |
$2,665.51
|
| Rate for Payer: Aetna Commercial |
$3,485.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,665.51
|
| Rate for Payer: Cash Price |
$3,280.63
|
| Rate for Payer: Cofinity Commercial |
$2,870.55
|
| Rate for Payer: Cofinity Commercial |
$3,526.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,870.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,280.63
|
| Rate for Payer: Healthscope Commercial |
$3,690.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,870.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,075.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,485.67
|
| Rate for Payer: PHP Commercial |
$3,485.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,665.51
|
| Rate for Payer: Priority Health SBD |
$2,583.50
|
| Rate for Payer: UMR Bronson Commercial |
$1,804.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,075.59
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$14,148.73
|
|
|
Service Code
|
NDC 00085432402
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,235.03 |
| Max. Negotiated Rate |
$12,733.86 |
| Rate for Payer: Aetna American Axle |
$9,196.67
|
| Rate for Payer: Aetna Commercial |
$12,026.42
|
| Rate for Payer: Aetna Medicare |
$7,074.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,196.67
|
| Rate for Payer: BCBS Complete |
$5,659.49
|
| Rate for Payer: Cash Price |
$11,318.98
|
| Rate for Payer: Cofinity Commercial |
$12,167.91
|
| Rate for Payer: Cofinity Commercial |
$9,904.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$9,904.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,318.98
|
| Rate for Payer: Healthscope Commercial |
$12,733.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,904.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,611.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,026.42
|
| Rate for Payer: PHP Commercial |
$12,026.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,196.67
|
| Rate for Payer: Priority Health SBD |
$8,913.70
|
| Rate for Payer: UMR Bronson Commercial |
$5,235.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,611.55
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$14,148.73
|
|
|
Service Code
|
NDC 00085432402
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,225.44 |
| Max. Negotiated Rate |
$12,733.86 |
| Rate for Payer: Aetna American Axle |
$9,196.67
|
| Rate for Payer: Aetna Commercial |
$12,026.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,196.67
|
| Rate for Payer: Cash Price |
$11,318.98
|
| Rate for Payer: Cofinity Commercial |
$12,167.91
|
| Rate for Payer: Cofinity Commercial |
$9,904.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$9,904.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,318.98
|
| Rate for Payer: Healthscope Commercial |
$12,733.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,904.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,611.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,026.42
|
| Rate for Payer: PHP Commercial |
$12,026.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,196.67
|
| Rate for Payer: Priority Health SBD |
$8,913.70
|
| Rate for Payer: UMR Bronson Commercial |
$6,225.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,611.55
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$4,100.79
|
|
|
Service Code
|
NDC 60687052321
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,517.29 |
| Max. Negotiated Rate |
$3,690.71 |
| Rate for Payer: Aetna American Axle |
$2,665.51
|
| Rate for Payer: Aetna Commercial |
$3,485.67
|
| Rate for Payer: Aetna Medicare |
$2,050.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,665.51
|
| Rate for Payer: BCBS Complete |
$1,640.32
|
| Rate for Payer: Cash Price |
$3,280.63
|
| Rate for Payer: Cofinity Commercial |
$2,870.55
|
| Rate for Payer: Cofinity Commercial |
$3,526.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,870.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,280.63
|
| Rate for Payer: Healthscope Commercial |
$3,690.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,870.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,075.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,485.67
|
| Rate for Payer: PHP Commercial |
$3,485.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,665.51
|
| Rate for Payer: Priority Health SBD |
$2,583.50
|
| Rate for Payer: UMR Bronson Commercial |
$1,517.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,075.59
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3,337.77
|
|
|
Service Code
|
NDC 00254204502
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,468.62 |
| Max. Negotiated Rate |
$3,003.99 |
| Rate for Payer: Aetna American Axle |
$2,169.55
|
| Rate for Payer: Aetna Commercial |
$2,837.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,169.55
|
| Rate for Payer: Cash Price |
$2,670.22
|
| Rate for Payer: Cofinity Commercial |
$2,336.44
|
| Rate for Payer: Cofinity Commercial |
$2,870.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,336.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,670.22
|
| Rate for Payer: Healthscope Commercial |
$3,003.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,336.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,503.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,837.10
|
| Rate for Payer: PHP Commercial |
$2,837.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,169.55
|
| Rate for Payer: Priority Health SBD |
$2,102.80
|
| Rate for Payer: UMR Bronson Commercial |
$1,468.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,503.33
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$1,530.25
|
|
|
Service Code
|
NDC 70748025807
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$566.19 |
| Max. Negotiated Rate |
$1,377.22 |
| Rate for Payer: Aetna American Axle |
$994.66
|
| Rate for Payer: Aetna Commercial |
$1,300.71
|
| Rate for Payer: Aetna Medicare |
$765.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$994.66
|
| Rate for Payer: BCBS Complete |
$612.10
|
| Rate for Payer: Cash Price |
$1,224.20
|
| Rate for Payer: Cofinity Commercial |
$1,071.17
|
| Rate for Payer: Cofinity Commercial |
$1,316.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,071.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,224.20
|
| Rate for Payer: Healthscope Commercial |
$1,377.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,071.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,147.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,300.71
|
| Rate for Payer: PHP Commercial |
$1,300.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$994.66
|
| Rate for Payer: Priority Health SBD |
$964.06
|
| Rate for Payer: UMR Bronson Commercial |
$566.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,147.69
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$1,530.25
|
|
|
Service Code
|
NDC 70748025807
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$673.31 |
| Max. Negotiated Rate |
$1,377.22 |
| Rate for Payer: Aetna American Axle |
$994.66
|
| Rate for Payer: Aetna Commercial |
$1,300.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$994.66
|
| Rate for Payer: Cash Price |
$1,224.20
|
| Rate for Payer: Cofinity Commercial |
$1,071.17
|
| Rate for Payer: Cofinity Commercial |
$1,316.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,071.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,224.20
|
| Rate for Payer: Healthscope Commercial |
$1,377.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,071.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,147.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,300.71
|
| Rate for Payer: PHP Commercial |
$1,300.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$994.66
|
| Rate for Payer: Priority Health SBD |
$964.06
|
| Rate for Payer: UMR Bronson Commercial |
$673.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,147.69
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$136.70
|
|
|
Service Code
|
NDC 60687052311
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.15 |
| Max. Negotiated Rate |
$123.03 |
| Rate for Payer: Aetna American Axle |
$88.86
|
| Rate for Payer: Aetna Commercial |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.86
|
| Rate for Payer: Cash Price |
$109.36
|
| Rate for Payer: Cofinity Commercial |
$117.56
|
| Rate for Payer: Cofinity Commercial |
$95.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.36
|
| Rate for Payer: Healthscope Commercial |
$123.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.19
|
| Rate for Payer: PHP Commercial |
$116.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.86
|
| Rate for Payer: Priority Health SBD |
$86.12
|
| Rate for Payer: UMR Bronson Commercial |
$60.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.53
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$3,337.77
|
|
|
Service Code
|
NDC 00254204502
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,234.97 |
| Max. Negotiated Rate |
$3,003.99 |
| Rate for Payer: Aetna American Axle |
$2,169.55
|
| Rate for Payer: Aetna Commercial |
$2,837.10
|
| Rate for Payer: Aetna Medicare |
$1,668.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,169.55
|
| Rate for Payer: BCBS Complete |
$1,335.11
|
| Rate for Payer: Cash Price |
$2,670.22
|
| Rate for Payer: Cofinity Commercial |
$2,336.44
|
| Rate for Payer: Cofinity Commercial |
$2,870.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,336.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,670.22
|
| Rate for Payer: Healthscope Commercial |
$3,003.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,336.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,503.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,837.10
|
| Rate for Payer: PHP Commercial |
$2,837.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,169.55
|
| Rate for Payer: Priority Health SBD |
$2,102.80
|
| Rate for Payer: UMR Bronson Commercial |
$1,234.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,503.33
|
|
|
POSACONAZOLE 100 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$136.70
|
|
|
Service Code
|
NDC 60687052311
|
| Hospital Charge Code |
169019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.58 |
| Max. Negotiated Rate |
$123.03 |
| Rate for Payer: Aetna American Axle |
$88.86
|
| Rate for Payer: Aetna Commercial |
$116.19
|
| Rate for Payer: Aetna Medicare |
$68.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.86
|
| Rate for Payer: BCBS Complete |
$54.68
|
| Rate for Payer: Cash Price |
$109.36
|
| Rate for Payer: Cofinity Commercial |
$117.56
|
| Rate for Payer: Cofinity Commercial |
$95.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.36
|
| Rate for Payer: Healthscope Commercial |
$123.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.19
|
| Rate for Payer: PHP Commercial |
$116.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.86
|
| Rate for Payer: Priority Health SBD |
$86.12
|
| Rate for Payer: UMR Bronson Commercial |
$50.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.53
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$2,714.07
|
|
|
Service Code
|
NDC 00254101636
|
| Hospital Charge Code |
77371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,194.19 |
| Max. Negotiated Rate |
$2,442.66 |
| Rate for Payer: Aetna American Axle |
$1,764.15
|
| Rate for Payer: Aetna Commercial |
$2,306.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,764.15
|
| Rate for Payer: Cash Price |
$2,171.26
|
| Rate for Payer: Cofinity Commercial |
$1,899.85
|
| Rate for Payer: Cofinity Commercial |
$2,334.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,899.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,171.26
|
| Rate for Payer: Healthscope Commercial |
$2,442.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,899.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,035.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,306.96
|
| Rate for Payer: PHP Commercial |
$2,306.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,764.15
|
| Rate for Payer: Priority Health SBD |
$1,709.86
|
| Rate for Payer: UMR Bronson Commercial |
$1,194.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,035.55
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$2,714.07
|
|
|
Service Code
|
NDC 00254101636
|
| Hospital Charge Code |
77371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,004.21 |
| Max. Negotiated Rate |
$2,442.66 |
| Rate for Payer: Aetna American Axle |
$1,764.15
|
| Rate for Payer: Aetna Commercial |
$2,306.96
|
| Rate for Payer: Aetna Medicare |
$1,357.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,764.15
|
| Rate for Payer: BCBS Complete |
$1,085.63
|
| Rate for Payer: Cash Price |
$2,171.26
|
| Rate for Payer: Cofinity Commercial |
$1,899.85
|
| Rate for Payer: Cofinity Commercial |
$2,334.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,899.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,171.26
|
| Rate for Payer: Healthscope Commercial |
$2,442.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,899.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,035.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,306.96
|
| Rate for Payer: PHP Commercial |
$2,306.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,764.15
|
| Rate for Payer: Priority Health SBD |
$1,709.86
|
| Rate for Payer: UMR Bronson Commercial |
$1,004.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,035.55
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$4,953.38
|
|
|
Service Code
|
NDC 00085132801
|
| Hospital Charge Code |
77371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,179.49 |
| Max. Negotiated Rate |
$4,458.04 |
| Rate for Payer: Aetna American Axle |
$3,219.70
|
| Rate for Payer: Aetna Commercial |
$4,210.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,219.70
|
| Rate for Payer: Cash Price |
$3,962.70
|
| Rate for Payer: Cofinity Commercial |
$3,467.37
|
| Rate for Payer: Cofinity Commercial |
$4,259.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,467.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,962.70
|
| Rate for Payer: Healthscope Commercial |
$4,458.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,467.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,715.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,210.37
|
| Rate for Payer: PHP Commercial |
$4,210.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,219.70
|
| Rate for Payer: Priority Health SBD |
$3,120.63
|
| Rate for Payer: UMR Bronson Commercial |
$2,179.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,715.03
|
|
|
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$4,953.38
|
|
|
Service Code
|
NDC 00085132801
|
| Hospital Charge Code |
77371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,832.75 |
| Max. Negotiated Rate |
$4,458.04 |
| Rate for Payer: Aetna American Axle |
$3,219.70
|
| Rate for Payer: Aetna Commercial |
$4,210.37
|
| Rate for Payer: Aetna Medicare |
$2,476.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,219.70
|
| Rate for Payer: BCBS Complete |
$1,981.35
|
| Rate for Payer: Cash Price |
$3,962.70
|
| Rate for Payer: Cofinity Commercial |
$3,467.37
|
| Rate for Payer: Cofinity Commercial |
$4,259.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,467.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,962.70
|
| Rate for Payer: Healthscope Commercial |
$4,458.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,467.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,715.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,210.37
|
| Rate for Payer: PHP Commercial |
$4,210.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,219.70
|
| Rate for Payer: Priority Health SBD |
$3,120.63
|
| Rate for Payer: UMR Bronson Commercial |
$1,832.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,715.03
|
|
|
POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 57250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN
|
Facility
|
OP
|
$1,322.75
|
|
|
Service Code
|
NDC 58657031116
|
| Hospital Charge Code |
11057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$489.42 |
| Max. Negotiated Rate |
$1,190.47 |
| Rate for Payer: Aetna American Axle |
$859.79
|
| Rate for Payer: Aetna Commercial |
$1,124.34
|
| Rate for Payer: Aetna Medicare |
$661.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$859.79
|
| Rate for Payer: BCBS Complete |
$529.10
|
| Rate for Payer: Cash Price |
$1,058.20
|
| Rate for Payer: Cofinity Commercial |
$1,137.57
|
| Rate for Payer: Cofinity Commercial |
$925.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$925.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,058.20
|
| Rate for Payer: Healthscope Commercial |
$1,190.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$925.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$992.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,124.34
|
| Rate for Payer: PHP Commercial |
$1,124.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$859.79
|
| Rate for Payer: Priority Health SBD |
$833.33
|
| Rate for Payer: UMR Bronson Commercial |
$489.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$992.06
|
|
|
POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN
|
Facility
|
IP
|
$289.01
|
|
|
Service Code
|
NDC 00121067716
|
| Hospital Charge Code |
11057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.16 |
| Max. Negotiated Rate |
$260.11 |
| Rate for Payer: Aetna American Axle |
$187.86
|
| Rate for Payer: Aetna Commercial |
$245.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.86
|
| Rate for Payer: Cash Price |
$231.21
|
| Rate for Payer: Cofinity Commercial |
$202.31
|
| Rate for Payer: Cofinity Commercial |
$248.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.21
|
| Rate for Payer: Healthscope Commercial |
$260.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.66
|
| Rate for Payer: PHP Commercial |
$245.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.86
|
| Rate for Payer: Priority Health SBD |
$182.08
|
| Rate for Payer: UMR Bronson Commercial |
$127.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.76
|
|
|
POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN
|
Facility
|
OP
|
$1,289.40
|
|
|
Service Code
|
NDC 60258000216
|
| Hospital Charge Code |
11057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$477.08 |
| Max. Negotiated Rate |
$1,160.46 |
| Rate for Payer: Aetna American Axle |
$838.11
|
| Rate for Payer: Aetna Commercial |
$1,095.99
|
| Rate for Payer: Aetna Medicare |
$644.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$838.11
|
| Rate for Payer: BCBS Complete |
$515.76
|
| Rate for Payer: Cash Price |
$1,031.52
|
| Rate for Payer: Cofinity Commercial |
$1,108.88
|
| Rate for Payer: Cofinity Commercial |
$902.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$902.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,031.52
|
| Rate for Payer: Healthscope Commercial |
$1,160.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$902.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$967.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,095.99
|
| Rate for Payer: PHP Commercial |
$1,095.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$838.11
|
| Rate for Payer: Priority Health SBD |
$812.32
|
| Rate for Payer: UMR Bronson Commercial |
$477.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$967.05
|
|
|
POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN
|
Facility
|
IP
|
$1,289.40
|
|
|
Service Code
|
NDC 60258000216
|
| Hospital Charge Code |
11057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$567.34 |
| Max. Negotiated Rate |
$1,160.46 |
| Rate for Payer: Aetna American Axle |
$838.11
|
| Rate for Payer: Aetna Commercial |
$1,095.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$838.11
|
| Rate for Payer: Cash Price |
$1,031.52
|
| Rate for Payer: Cofinity Commercial |
$1,108.88
|
| Rate for Payer: Cofinity Commercial |
$902.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$902.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,031.52
|
| Rate for Payer: Healthscope Commercial |
$1,160.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$902.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$967.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,095.99
|
| Rate for Payer: PHP Commercial |
$1,095.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$838.11
|
| Rate for Payer: Priority Health SBD |
$812.32
|
| Rate for Payer: UMR Bronson Commercial |
$567.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$967.05
|
|
|
POTAS AND SOD CITRATE-CITRIC ACID 550 MG-500 MG-334 MG/5 ML ORAL SOLN
|
Facility
|
OP
|
$289.01
|
|
|
Service Code
|
NDC 00121067716
|
| Hospital Charge Code |
11057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.93 |
| Max. Negotiated Rate |
$260.11 |
| Rate for Payer: Aetna American Axle |
$187.86
|
| Rate for Payer: Aetna Commercial |
$245.66
|
| Rate for Payer: Aetna Medicare |
$144.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.86
|
| Rate for Payer: BCBS Complete |
$115.60
|
| Rate for Payer: Cash Price |
$231.21
|
| Rate for Payer: Cofinity Commercial |
$202.31
|
| Rate for Payer: Cofinity Commercial |
$248.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.21
|
| Rate for Payer: Healthscope Commercial |
$260.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.66
|
| Rate for Payer: PHP Commercial |
$245.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.86
|
| Rate for Payer: Priority Health SBD |
$182.08
|
| Rate for Payer: UMR Bronson Commercial |
$106.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.76
|
|
