|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$17,906.89
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,879.03 |
| Max. Negotiated Rate |
$16,116.20 |
| Rate for Payer: Aetna American Axle |
$11,639.48
|
| Rate for Payer: Aetna Commercial |
$15,220.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,639.48
|
| Rate for Payer: Cash Price |
$14,325.51
|
| Rate for Payer: Cofinity Commercial |
$12,534.82
|
| Rate for Payer: Cofinity Commercial |
$15,399.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,534.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,325.51
|
| Rate for Payer: Healthscope Commercial |
$16,116.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,534.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,430.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,220.86
|
| Rate for Payer: PHP Commercial |
$15,220.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,639.48
|
| Rate for Payer: Priority Health SBD |
$11,281.34
|
| Rate for Payer: UMR Bronson Commercial |
$7,879.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,430.17
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$81.54
|
|
|
Service Code
|
NDC 67850014005
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$35.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$81.54
|
|
|
Service Code
|
NDC 67850014000
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: BCBS Complete |
$32.62
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$30.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$81.54
|
|
|
Service Code
|
NDC 67850014000
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$35.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$81.54
|
|
|
Service Code
|
NDC 67850014005
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: BCBS Complete |
$32.62
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$30.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$93.54
|
|
|
Service Code
|
NDC 67850014105
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$46.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: BCBS Complete |
$37.42
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Commercial |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.80
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$34.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$46.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: BCBS Complete |
$37.42
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Commercial |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.80
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$34.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Commercial |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.80
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$41.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014105
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Commercial |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.80
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$41.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION
|
Facility
|
IP
|
$944.30
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
108802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$415.49 |
| Max. Negotiated Rate |
$849.87 |
| Rate for Payer: Aetna American Axle |
$613.80
|
| Rate for Payer: Aetna Commercial |
$802.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.80
|
| Rate for Payer: Cash Price |
$755.44
|
| Rate for Payer: Cofinity Commercial |
$661.01
|
| Rate for Payer: Cofinity Commercial |
$812.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$661.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.44
|
| Rate for Payer: Healthscope Commercial |
$849.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$661.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$802.66
|
| Rate for Payer: PHP Commercial |
$802.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$613.80
|
| Rate for Payer: Priority Health SBD |
$594.91
|
| Rate for Payer: UMR Bronson Commercial |
$415.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.22
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION
|
Facility
|
OP
|
$944.30
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
108802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$116.15 |
| Max. Negotiated Rate |
$849.87 |
| Rate for Payer: Aetna American Axle |
$613.80
|
| Rate for Payer: Aetna Commercial |
$802.66
|
| Rate for Payer: Aetna Medicare |
$472.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$613.80
|
| Rate for Payer: BCBS Complete |
$377.72
|
| Rate for Payer: BCBS Trust/PPO |
$116.15
|
| Rate for Payer: BCN Commercial |
$116.15
|
| Rate for Payer: Cash Price |
$755.44
|
| Rate for Payer: Cash Price |
$755.44
|
| Rate for Payer: Cofinity Commercial |
$661.01
|
| Rate for Payer: Cofinity Commercial |
$812.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$661.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$755.44
|
| Rate for Payer: Healthscope Commercial |
$849.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$661.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$708.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$802.66
|
| Rate for Payer: PHP Commercial |
$802.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$613.80
|
| Rate for Payer: Priority Health SBD |
$594.91
|
| Rate for Payer: UMR Bronson Commercial |
$349.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$708.22
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$18.75
|
|
|
Service Code
|
NDC 45802086801
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna American Axle |
$12.19
|
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna Medicare |
$9.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.19
|
| Rate for Payer: BCBS Complete |
$7.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.00
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.94
|
| Rate for Payer: PHP Commercial |
$15.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.19
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: UMR Bronson Commercial |
$6.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.06
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
NDC 69230032434
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$21.69 |
| Rate for Payer: Aetna American Axle |
$15.66
|
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.66
|
| Rate for Payer: Cash Price |
$19.28
|
| Rate for Payer: Cofinity Commercial |
$16.87
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.28
|
| Rate for Payer: Healthscope Commercial |
$21.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: PHP Commercial |
$20.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.66
|
| Rate for Payer: Priority Health SBD |
$15.18
|
| Rate for Payer: UMR Bronson Commercial |
$10.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.08
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$24.16
|
|
|
Service Code
|
NDC 57896048914
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Aetna American Axle |
$15.70
|
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna Medicare |
$12.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.70
|
| Rate for Payer: BCBS Complete |
$9.66
|
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cofinity Commercial |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$20.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.33
|
| Rate for Payer: Healthscope Commercial |
$21.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.54
|
| Rate for Payer: PHP Commercial |
$20.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.70
|
| Rate for Payer: Priority Health SBD |
$15.22
|
| Rate for Payer: UMR Bronson Commercial |
$8.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.12
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$39.99
|
|
|
Service Code
|
NDC 41100082073
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$35.99 |
| Rate for Payer: Aetna American Axle |
$25.99
|
| Rate for Payer: Aetna Commercial |
$33.99
|
| Rate for Payer: Aetna Medicare |
$20.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.99
|
| Rate for Payer: BCBS Complete |
$16.00
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Cofinity Commercial |
$34.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.99
|
| Rate for Payer: Healthscope Commercial |
$35.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.99
|
| Rate for Payer: PHP Commercial |
$33.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.99
|
| Rate for Payer: Priority Health SBD |
$25.19
|
| Rate for Payer: UMR Bronson Commercial |
$14.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.99
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
NDC 69230032434
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.92 |
| Max. Negotiated Rate |
$21.69 |
| Rate for Payer: Aetna American Axle |
$15.66
|
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: Aetna Medicare |
$12.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.66
|
| Rate for Payer: BCBS Complete |
$9.64
|
| Rate for Payer: Cash Price |
$19.28
|
| Rate for Payer: Cofinity Commercial |
$16.87
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.28
|
| Rate for Payer: Healthscope Commercial |
$21.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: PHP Commercial |
$20.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.66
|
| Rate for Payer: Priority Health SBD |
$15.18
|
| Rate for Payer: UMR Bronson Commercial |
$8.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.08
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$18.75
|
|
|
Service Code
|
NDC 45802086801
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna American Axle |
$12.19
|
| Rate for Payer: Aetna Commercial |
$15.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.19
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.00
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.94
|
| Rate for Payer: PHP Commercial |
$15.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.19
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: UMR Bronson Commercial |
$8.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.06
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$39.99
|
|
|
Service Code
|
NDC 41100082073
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$35.99 |
| Rate for Payer: Aetna American Axle |
$25.99
|
| Rate for Payer: Aetna Commercial |
$33.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.99
|
| Rate for Payer: Cash Price |
$31.99
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Cofinity Commercial |
$34.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.99
|
| Rate for Payer: Healthscope Commercial |
$35.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.99
|
| Rate for Payer: PHP Commercial |
$33.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.99
|
| Rate for Payer: Priority Health SBD |
$25.19
|
| Rate for Payer: UMR Bronson Commercial |
$17.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.99
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 70000041501
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna American Axle |
$9.75
|
| Rate for Payer: Aetna Commercial |
$12.75
|
| Rate for Payer: Aetna Medicare |
$7.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.75
|
| Rate for Payer: BCBS Complete |
$6.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.75
|
| Rate for Payer: PHP Commercial |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.75
|
| Rate for Payer: Priority Health SBD |
$9.45
|
| Rate for Payer: UMR Bronson Commercial |
$5.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.25
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$24.16
|
|
|
Service Code
|
NDC 57896048914
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$21.74 |
| Rate for Payer: Cash Price |
$19.33
|
| Rate for Payer: Cofinity Commercial |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$20.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.91
|
| Rate for Payer: Aetna American Axle |
$15.70
|
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.33
|
| Rate for Payer: Healthscope Commercial |
$21.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.54
|
| Rate for Payer: PHP Commercial |
$20.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.70
|
| Rate for Payer: Priority Health SBD |
$15.22
|
| Rate for Payer: UMR Bronson Commercial |
$10.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.12
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 70000041501
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna American Axle |
$9.75
|
| Rate for Payer: Aetna Commercial |
$12.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.75
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.75
|
| Rate for Payer: PHP Commercial |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.75
|
| Rate for Payer: Priority Health SBD |
$9.45
|
| Rate for Payer: UMR Bronson Commercial |
$6.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.25
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$205.20
|
|
|
Service Code
|
NDC 51079030630
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.92 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna American Axle |
$133.38
|
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.38
|
| Rate for Payer: BCBS Complete |
$82.08
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Commercial |
$143.64
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.38
|
| Rate for Payer: Priority Health SBD |
$129.28
|
| Rate for Payer: UMR Bronson Commercial |
$75.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
|
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
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$6.71
|
|
|
Service Code
|
NDC 00904693186
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna American Axle |
$4.36
|
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.36
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cofinity Commercial |
$4.70
|
| Rate for Payer: Cofinity Commercial |
$5.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.37
|
| Rate for Payer: Healthscope Commercial |
$6.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.70
|
| Rate for Payer: PHP Commercial |
$5.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.36
|
| Rate for Payer: Priority Health SBD |
$4.23
|
| Rate for Payer: UMR Bronson Commercial |
$2.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$6.71
|
|
|
Service Code
|
NDC 00904693186
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna American Axle |
$4.36
|
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Aetna Medicare |
$3.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.36
|
| Rate for Payer: BCBS Complete |
$2.68
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cofinity Commercial |
$4.70
|
| Rate for Payer: Cofinity Commercial |
$5.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.37
|
| Rate for Payer: Healthscope Commercial |
$6.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.70
|
| Rate for Payer: PHP Commercial |
$5.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.36
|
| Rate for Payer: Priority Health SBD |
$4.23
|
| Rate for Payer: UMR Bronson Commercial |
$2.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.03
|
|
