|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43245
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$169.94 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$1,134.03
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$186.93
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$169.94
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43246
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$193.85 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$875.18
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.24
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$193.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE
|
Facility
|
OP
|
$3,138.00
|
|
|
Service Code
|
CPT 43248
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$160.77 |
| Max. Negotiated Rate |
$3,138.00 |
| Rate for Payer: Aetna Medicare |
$838.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,008.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,008.22
|
| Rate for Payer: BCBS Complete |
$463.30
|
| Rate for Payer: BCBS MAPPO |
$806.58
|
| Rate for Payer: BCBS Trust/PPO |
$382.97
|
| Rate for Payer: BCN Medicare Advantage |
$806.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$806.58
|
| Rate for Payer: Mclaren Medicaid |
$441.20
|
| Rate for Payer: Mclaren Medicare |
$806.58
|
| Rate for Payer: Meridian Medicaid |
$463.30
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$846.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$927.57
|
| Rate for Payer: PACE Medicare |
$766.25
|
| Rate for Payer: PACE SWMI |
$806.58
|
| Rate for Payer: PHP Medicare Advantage |
$806.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$441.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,519.41
|
| Rate for Payer: Priority Health Medicare |
$806.58
|
| Rate for Payer: Priority Health Narrow Network |
$2,015.53
|
| Rate for Payer: Railroad Medicare Medicare |
$806.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.85
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$806.58
|
| Rate for Payer: UHC Exchange |
$160.77
|
| Rate for Payer: UHC Medicare Advantage |
$830.78
|
| Rate for Payer: VA VA |
$806.58
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF INTRALUMINAL TUBE OR CATHETER
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43241
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$137.85 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$527.94
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$151.64
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$137.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)
|
Facility
|
OP
|
$3,138.00
|
|
|
Service Code
|
CPT 43247
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$170.92 |
| Max. Negotiated Rate |
$3,138.00 |
| Rate for Payer: Aetna Medicare |
$838.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,008.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,008.22
|
| Rate for Payer: BCBS Complete |
$463.30
|
| Rate for Payer: BCBS MAPPO |
$806.58
|
| Rate for Payer: BCBS Trust/PPO |
$897.99
|
| Rate for Payer: BCN Medicare Advantage |
$806.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$806.58
|
| Rate for Payer: Mclaren Medicaid |
$441.20
|
| Rate for Payer: Mclaren Medicare |
$806.58
|
| Rate for Payer: Meridian Medicaid |
$463.30
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$846.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$927.57
|
| Rate for Payer: PACE Medicare |
$766.25
|
| Rate for Payer: PACE SWMI |
$806.58
|
| Rate for Payer: PHP Medicare Advantage |
$806.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$441.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,519.41
|
| Rate for Payer: Priority Health Medicare |
$806.58
|
| Rate for Payer: Priority Health Narrow Network |
$2,015.53
|
| Rate for Payer: Railroad Medicare Medicare |
$806.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.01
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$806.58
|
| Rate for Payer: UHC Exchange |
$170.92
|
| Rate for Payer: UHC Medicare Advantage |
$830.78
|
| Rate for Payer: VA VA |
$806.58
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$164.70 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$527.94
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.17
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$164.70
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43251
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$189.26 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$812.07
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$208.19
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$189.26
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43249
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.66 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$615.94
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.53
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$148.66
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$3,138.00
|
|
|
Service Code
|
CPT 43200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$85.79 |
| Max. Negotiated Rate |
$3,138.00 |
| Rate for Payer: Aetna Medicare |
$838.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,008.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,008.22
|
| Rate for Payer: BCBS Complete |
$463.30
|
| Rate for Payer: BCBS MAPPO |
$806.58
|
| Rate for Payer: BCBS Trust/PPO |
$410.33
|
| Rate for Payer: BCN Medicare Advantage |
$806.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$806.58
|
| Rate for Payer: Mclaren Medicaid |
$441.20
|
| Rate for Payer: Mclaren Medicare |
$806.58
|
| Rate for Payer: Meridian Medicaid |
$463.30
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$846.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$927.57
|
| Rate for Payer: PACE Medicare |
$766.25
|
| Rate for Payer: PACE SWMI |
$806.58
|
| Rate for Payer: PHP Medicare Advantage |
$806.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$441.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,519.41
|
| Rate for Payer: Priority Health Medicare |
$806.58
|
| Rate for Payer: Priority Health Narrow Network |
$2,015.53
|
| Rate for Payer: Railroad Medicare Medicare |
$806.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94.37
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$806.58
|
| Rate for Payer: UHC Exchange |
$85.79
|
| Rate for Payer: UHC Medicare Advantage |
$830.78
|
| Rate for Payer: VA VA |
$806.58
|
|
|
ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 43202
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$100.20 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$527.94
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$110.22
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$100.20
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
ESTRADIOL 1 MG TABLET
|
Facility
|
IP
|
$271.70
|
|
|
Service Code
|
NDC 0555-0886-02
|
| Hospital Charge Code |
9967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.17 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Commercial |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.94
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.19
|
| Rate for Payer: Priority Health SBD |
$171.17
|
|
|
ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$611.67
|
|
|
Service Code
|
HCPCS J1000
|
| Hospital Charge Code |
2929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$385.35 |
| Max. Negotiated Rate |
$550.50 |
| Rate for Payer: Aetna Commercial |
$519.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$397.59
|
| Rate for Payer: Cash Price |
$489.34
|
| Rate for Payer: Cofinity Commercial |
$428.17
|
| Rate for Payer: Cofinity Commercial |
$526.04
|
| Rate for Payer: Healthscope Commercial |
$550.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$519.92
|
| Rate for Payer: PHP Commercial |
$519.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$428.17
|
| Rate for Payer: Priority Health SBD |
$385.35
|
|
|
ESTRADIOL VALERATE 10 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$549.31
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$346.07 |
| Max. Negotiated Rate |
$494.38 |
| Rate for Payer: Aetna Commercial |
$466.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$357.05
|
| Rate for Payer: Cash Price |
$439.45
|
| Rate for Payer: Cofinity Commercial |
$384.52
|
| Rate for Payer: Cofinity Commercial |
$472.41
|
| Rate for Payer: Healthscope Commercial |
$494.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$466.91
|
| Rate for Payer: PHP Commercial |
$466.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$384.52
|
| Rate for Payer: Priority Health SBD |
$346.07
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$396.96
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$250.08 |
| Max. Negotiated Rate |
$357.26 |
| Rate for Payer: Aetna Commercial |
$337.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.02
|
| Rate for Payer: Cash Price |
$317.57
|
| Rate for Payer: Cofinity Commercial |
$277.87
|
| Rate for Payer: Cofinity Commercial |
$341.39
|
| Rate for Payer: Healthscope Commercial |
$357.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$337.42
|
| Rate for Payer: PHP Commercial |
$337.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.87
|
| Rate for Payer: Priority Health SBD |
$250.08
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$348.00
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$219.24 |
| Max. Negotiated Rate |
$313.20 |
| Rate for Payer: Aetna Commercial |
$295.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.20
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cofinity Commercial |
$243.60
|
| Rate for Payer: Cofinity Commercial |
$299.28
|
| Rate for Payer: Healthscope Commercial |
$313.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$295.80
|
| Rate for Payer: PHP Commercial |
$295.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.60
|
| Rate for Payer: Priority Health SBD |
$219.24
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$348.00
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$219.24 |
| Max. Negotiated Rate |
$313.20 |
| Rate for Payer: Aetna Commercial |
$295.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.20
|
| Rate for Payer: Cash Price |
$278.40
|
| Rate for Payer: Cofinity Commercial |
$243.60
|
| Rate for Payer: Cofinity Commercial |
$299.28
|
| Rate for Payer: Healthscope Commercial |
$313.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$295.80
|
| Rate for Payer: PHP Commercial |
$295.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.60
|
| Rate for Payer: Priority Health SBD |
$219.24
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,429.68
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
9984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$900.70 |
| Max. Negotiated Rate |
$1,286.71 |
| Rate for Payer: Aetna Commercial |
$1,215.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.29
|
| Rate for Payer: Cash Price |
$1,143.74
|
| Rate for Payer: Cofinity Commercial |
$1,000.78
|
| Rate for Payer: Cofinity Commercial |
$1,229.52
|
| Rate for Payer: Healthscope Commercial |
$1,286.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,215.23
|
| Rate for Payer: PHP Commercial |
$1,215.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,000.78
|
| Rate for Payer: Priority Health SBD |
$900.70
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
IP
|
$535.68
|
|
|
Service Code
|
NDC 61748-025-01
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.48 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Commercial |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$455.33
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.98
|
| Rate for Payer: Priority Health SBD |
$337.48
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
IP
|
$535.68
|
|
|
Service Code
|
NDC 23155-532-01
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.48 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Commercial |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$455.33
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.98
|
| Rate for Payer: Priority Health SBD |
$337.48
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
IP
|
$308.75
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.51 |
| Max. Negotiated Rate |
$277.88 |
| Rate for Payer: Aetna Commercial |
$262.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.69
|
| Rate for Payer: Cash Price |
$247.00
|
| Rate for Payer: Cofinity Commercial |
$216.12
|
| Rate for Payer: Cofinity Commercial |
$265.52
|
| Rate for Payer: Healthscope Commercial |
$277.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$262.44
|
| Rate for Payer: PHP Commercial |
$262.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.12
|
| Rate for Payer: Priority Health SBD |
$194.51
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$203.59
|
|
|
Service Code
|
NDC 386000102
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.26 |
| Max. Negotiated Rate |
$183.23 |
| Rate for Payer: Aetna Commercial |
$173.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.33
|
| Rate for Payer: Cash Price |
$162.87
|
| Rate for Payer: Cofinity Commercial |
$142.51
|
| Rate for Payer: Cofinity Commercial |
$175.09
|
| Rate for Payer: Healthscope Commercial |
$183.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$173.05
|
| Rate for Payer: PHP Commercial |
$173.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.51
|
| Rate for Payer: Priority Health SBD |
$128.26
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.61
|
|
|
Service Code
|
NDC 67457-902-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.98 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.40
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.52
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: Priority Health SBD |
$12.98
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.61
|
|
|
Service Code
|
NDC 67457-902-00
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.98 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.40
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.52
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: Priority Health SBD |
$12.98
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$66.44
|
|
|
Service Code
|
NDC 0409-8062-01
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.86 |
| Max. Negotiated Rate |
$59.80 |
| Rate for Payer: Aetna Commercial |
$56.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.19
|
| Rate for Payer: Cash Price |
$53.15
|
| Rate for Payer: Cofinity Commercial |
$46.51
|
| Rate for Payer: Cofinity Commercial |
$57.14
|
| Rate for Payer: Healthscope Commercial |
$59.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.47
|
| Rate for Payer: PHP Commercial |
$56.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.51
|
| Rate for Payer: Priority Health SBD |
$41.86
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
NDC 0143-9310-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$16.92 |
| Rate for Payer: Aetna Commercial |
$15.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.22
|
| Rate for Payer: Cash Price |
$15.04
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Cofinity Commercial |
$16.17
|
| Rate for Payer: Healthscope Commercial |
$16.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.98
|
| Rate for Payer: PHP Commercial |
$15.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health SBD |
$11.84
|
|
