|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV
|
Facility
|
IP
|
$366.56
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
29805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$238.26 |
| Max. Negotiated Rate |
$329.90 |
| Rate for Payer: Aetna Commercial |
$311.58
|
| Rate for Payer: BCBS Trust/PPO |
$299.22
|
| Rate for Payer: BCN Commercial |
$283.28
|
| Rate for Payer: Cash Price |
$293.25
|
| Rate for Payer: Cofinity Commercial |
$315.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.25
|
| Rate for Payer: Healthscope Commercial |
$329.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.58
|
| Rate for Payer: Nomi Health Commercial |
$300.58
|
| Rate for Payer: PHP Commercial |
$311.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.26
|
| Rate for Payer: Priority Health HMO/PPO |
$318.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$245.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.57
|
| Rate for Payer: UHC Core |
$306.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.92
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV
|
Facility
|
OP
|
$366.56
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
29805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$329.90 |
| Rate for Payer: Aetna Commercial |
$311.58
|
| Rate for Payer: Aetna Medicare |
$95.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.55
|
| Rate for Payer: BCBS Complete |
$146.62
|
| Rate for Payer: BCBS MAPPO |
$91.64
|
| Rate for Payer: BCBS Trust/PPO |
$301.35
|
| Rate for Payer: BCN Commercial |
$285.00
|
| Rate for Payer: BCN Medicare Advantage |
$91.64
|
| Rate for Payer: Cash Price |
$293.25
|
| Rate for Payer: Cofinity Commercial |
$315.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.64
|
| Rate for Payer: Healthscope Commercial |
$329.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.58
|
| Rate for Payer: Nomi Health Commercial |
$300.58
|
| Rate for Payer: PACE Senior Care Partners |
$87.06
|
| Rate for Payer: PACE SWMI |
$91.64
|
| Rate for Payer: PHP Commercial |
$311.58
|
| Rate for Payer: PHP Medicare Advantage |
$91.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.26
|
| Rate for Payer: Priority Health HMO/PPO |
$318.91
|
| Rate for Payer: Priority Health Medicare |
$92.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$245.60
|
| Rate for Payer: Railroad Medicare Medicare |
$91.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.57
|
| Rate for Payer: UHC Core |
$306.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.64
|
| Rate for Payer: UHC Exchange |
$91.64
|
| Rate for Payer: UHC Medicare Advantage |
$91.64
|
| Rate for Payer: VA VA |
$91.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.92
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$697.40
|
|
|
Service Code
|
CPT 43235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$664.15 |
| Max. Negotiated Rate |
$697.40 |
| Rate for Payer: BCBS Complete |
$697.40
|
| Rate for Payer: Mclaren Medicaid |
$664.15
|
| Rate for Payer: Meridian Medicaid |
$697.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$664.15
|
| Rate for Payer: UHCCP Medicaid |
$664.15
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE
|
Facility
|
OP
|
$697.40
|
|
|
Service Code
|
CPT 43239
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$664.15 |
| Max. Negotiated Rate |
$697.40 |
| Rate for Payer: BCBS Complete |
$697.40
|
| Rate for Payer: Mclaren Medicaid |
$664.15
|
| Rate for Payer: Meridian Medicaid |
$697.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$664.15
|
| Rate for Payer: UHCCP Medicaid |
$664.15
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE
|
Facility
|
OP
|
$697.40
|
|
|
Service Code
|
CPT 43248
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$664.15 |
| Max. Negotiated Rate |
$697.40 |
| Rate for Payer: BCBS Complete |
$697.40
|
| Rate for Payer: Mclaren Medicaid |
$664.15
|
| Rate for Payer: Meridian Medicaid |
$697.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$664.15
|
| Rate for Payer: UHCCP Medicaid |
$664.15
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS
|
Facility
|
OP
|
$1,411.07
|
|
|
Service Code
|
CPT 43250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,343.79 |
| Max. Negotiated Rate |
$1,411.07 |
| Rate for Payer: BCBS Complete |
$1,411.07
|
| Rate for Payer: Mclaren Medicaid |
$1,343.79
|
| Rate for Payer: Meridian Medicaid |
$1,411.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,343.79
|
| Rate for Payer: UHCCP Medicaid |
$1,343.79
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
|
Facility
|
OP
|
$1,411.07
|
|
|
Service Code
|
CPT 43251
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,343.79 |
| Max. Negotiated Rate |
$1,411.07 |
| Rate for Payer: BCBS Complete |
$1,411.07
|
| Rate for Payer: Mclaren Medicaid |
$1,343.79
|
| Rate for Payer: Meridian Medicaid |
$1,411.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,343.79
|
| Rate for Payer: UHCCP Medicaid |
$1,343.79
|
|
|
ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)
|
Facility
|
OP
|
$1,411.07
|
|
|
Service Code
|
CPT 43249
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,343.79 |
| Max. Negotiated Rate |
$1,411.07 |
| Rate for Payer: BCBS Complete |
$1,411.07
|
| Rate for Payer: Mclaren Medicaid |
$1,343.79
|
| Rate for Payer: Meridian Medicaid |
$1,411.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,343.79
|
| Rate for Payer: UHCCP Medicaid |
$1,343.79
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
OP
|
$143.35
|
|
|
Service Code
|
NDC 70954056410
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.05 |
| Max. Negotiated Rate |
$129.02 |
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: Aetna Medicare |
$37.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$44.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$44.80
|
| Rate for Payer: BCBS Complete |
$57.34
|
| Rate for Payer: BCBS MAPPO |
$35.84
|
| Rate for Payer: BCBS Trust/PPO |
$117.85
|
| Rate for Payer: BCN Commercial |
$111.45
|
| Rate for Payer: BCN Medicare Advantage |
$35.84
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$123.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35.84
|
| Rate for Payer: Healthscope Commercial |
$129.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$37.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: PACE Senior Care Partners |
$34.05
|
| Rate for Payer: PACE SWMI |
$35.84
|
| Rate for Payer: PHP Commercial |
$121.85
|
| Rate for Payer: PHP Medicare Advantage |
$35.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.18
|
| Rate for Payer: Priority Health HMO/PPO |
$124.71
|
| Rate for Payer: Priority Health Medicare |
$36.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$96.04
|
| Rate for Payer: Railroad Medicare Medicare |
$35.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.15
|
| Rate for Payer: UHC Core |
$119.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$35.84
|
| Rate for Payer: UHC Exchange |
$35.84
|
| Rate for Payer: UHC Medicare Advantage |
$35.84
|
| Rate for Payer: VA VA |
$35.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.51
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
IP
|
$143.35
|
|
|
Service Code
|
NDC 70954056410
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.18 |
| Max. Negotiated Rate |
$129.02 |
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: BCBS Trust/PPO |
$117.02
|
| Rate for Payer: BCN Commercial |
$110.78
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$123.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$129.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: PHP Commercial |
$121.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.18
|
| Rate for Payer: Priority Health HMO/PPO |
$124.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$96.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.15
|
| Rate for Payer: UHC Core |
$119.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.51
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 00555089902
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.63 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$62.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$74.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$74.52
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: BCBS MAPPO |
$59.61
|
| Rate for Payer: BCBS Trust/PPO |
$196.03
|
| Rate for Payer: BCN Commercial |
$185.39
|
| Rate for Payer: BCN Medicare Advantage |
$59.61
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.61
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: PACE Senior Care Partners |
$56.63
|
| Rate for Payer: PACE SWMI |
$59.61
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: PHP Medicare Advantage |
$59.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.99
|
| Rate for Payer: Priority Health HMO/PPO |
$207.45
|
| Rate for Payer: Priority Health Medicare |
$60.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$159.76
|
| Rate for Payer: Railroad Medicare Medicare |
$59.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.84
|
| Rate for Payer: UHC Core |
$199.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$59.61
|
| Rate for Payer: UHC Exchange |
$59.61
|
| Rate for Payer: UHC Medicare Advantage |
$59.61
|
| Rate for Payer: VA VA |
$59.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 00555089902
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.99 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: BCBS Trust/PPO |
$194.65
|
| Rate for Payer: BCN Commercial |
$184.27
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.99
|
| Rate for Payer: Priority Health HMO/PPO |
$207.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$159.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.84
|
| Rate for Payer: UHC Core |
$199.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$117.34
|
|
|
Service Code
|
NDC 00386000103
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.27 |
| Max. Negotiated Rate |
$105.61 |
| Rate for Payer: Aetna Commercial |
$99.74
|
| Rate for Payer: BCBS Trust/PPO |
$95.78
|
| Rate for Payer: BCN Commercial |
$90.68
|
| Rate for Payer: Cash Price |
$93.87
|
| Rate for Payer: Cofinity Commercial |
$100.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.87
|
| Rate for Payer: Healthscope Commercial |
$105.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.74
|
| Rate for Payer: Nomi Health Commercial |
$96.22
|
| Rate for Payer: PHP Commercial |
$99.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.27
|
| Rate for Payer: Priority Health HMO/PPO |
$102.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$78.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$103.26
|
| Rate for Payer: UHC Core |
$97.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.00
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
OP
|
$210.11
|
|
|
Service Code
|
NDC 00386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.90 |
| Max. Negotiated Rate |
$189.10 |
| Rate for Payer: Aetna Commercial |
$178.59
|
| Rate for Payer: Aetna Medicare |
$54.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$65.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$65.66
|
| Rate for Payer: BCBS Complete |
$84.04
|
| Rate for Payer: BCBS MAPPO |
$52.53
|
| Rate for Payer: BCBS Trust/PPO |
$172.73
|
| Rate for Payer: BCN Commercial |
$163.36
|
| Rate for Payer: BCN Medicare Advantage |
$52.53
|
| Rate for Payer: Cash Price |
$168.09
|
| Rate for Payer: Cofinity Commercial |
$180.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$52.53
|
| Rate for Payer: Healthscope Commercial |
$189.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.58
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$55.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$60.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.59
|
| Rate for Payer: Nomi Health Commercial |
$172.29
|
| Rate for Payer: PACE Senior Care Partners |
$49.90
|
| Rate for Payer: PACE SWMI |
$52.53
|
| Rate for Payer: PHP Commercial |
$178.59
|
| Rate for Payer: PHP Medicare Advantage |
$52.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.57
|
| Rate for Payer: Priority Health HMO/PPO |
$182.80
|
| Rate for Payer: Priority Health Medicare |
$53.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$140.77
|
| Rate for Payer: Railroad Medicare Medicare |
$52.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$184.90
|
| Rate for Payer: UHC Core |
$175.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$52.53
|
| Rate for Payer: UHC Exchange |
$52.53
|
| Rate for Payer: UHC Medicare Advantage |
$52.53
|
| Rate for Payer: VA VA |
$52.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.58
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$210.11
|
|
|
Service Code
|
NDC 00386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.57 |
| Max. Negotiated Rate |
$189.10 |
| Rate for Payer: Aetna Commercial |
$178.59
|
| Rate for Payer: BCBS Trust/PPO |
$171.51
|
| Rate for Payer: BCN Commercial |
$162.37
|
| Rate for Payer: Cash Price |
$168.09
|
| Rate for Payer: Cofinity Commercial |
$180.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.09
|
| Rate for Payer: Healthscope Commercial |
$189.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.59
|
| Rate for Payer: Nomi Health Commercial |
$172.29
|
| Rate for Payer: PHP Commercial |
$178.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.57
|
| Rate for Payer: Priority Health HMO/PPO |
$182.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$140.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$184.90
|
| Rate for Payer: UHC Core |
$175.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.58
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
OP
|
$117.34
|
|
|
Service Code
|
NDC 00386000103
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.87 |
| Max. Negotiated Rate |
$105.61 |
| Rate for Payer: Aetna Commercial |
$99.74
|
| Rate for Payer: Aetna Medicare |
$30.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36.67
|
| Rate for Payer: BCBS Complete |
$46.94
|
| Rate for Payer: BCBS MAPPO |
$29.34
|
| Rate for Payer: BCBS Trust/PPO |
$96.47
|
| Rate for Payer: BCN Commercial |
$91.23
|
| Rate for Payer: BCN Medicare Advantage |
$29.34
|
| Rate for Payer: Cash Price |
$93.87
|
| Rate for Payer: Cofinity Commercial |
$100.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29.34
|
| Rate for Payer: Healthscope Commercial |
$105.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$30.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.74
|
| Rate for Payer: Nomi Health Commercial |
$96.22
|
| Rate for Payer: PACE Senior Care Partners |
$27.87
|
| Rate for Payer: PACE SWMI |
$29.34
|
| Rate for Payer: PHP Commercial |
$99.74
|
| Rate for Payer: PHP Medicare Advantage |
$29.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.27
|
| Rate for Payer: Priority Health HMO/PPO |
$102.09
|
| Rate for Payer: Priority Health Medicare |
$29.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$78.62
|
| Rate for Payer: Railroad Medicare Medicare |
$29.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$103.26
|
| Rate for Payer: UHC Core |
$97.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$29.34
|
| Rate for Payer: UHC Exchange |
$29.34
|
| Rate for Payer: UHC Medicare Advantage |
$29.34
|
| Rate for Payer: VA VA |
$29.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.00
|
|
|
ETODOLAC 400 MG TABLET
|
Facility
|
OP
|
$284.55
|
|
|
Service Code
|
NDC 63629137705
|
| Hospital Charge Code |
9999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.58 |
| Max. Negotiated Rate |
$256.10 |
| Rate for Payer: Aetna Commercial |
$241.87
|
| Rate for Payer: Aetna Medicare |
$73.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$88.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$88.92
|
| Rate for Payer: BCBS Complete |
$113.82
|
| Rate for Payer: BCBS MAPPO |
$71.14
|
| Rate for Payer: BCBS Trust/PPO |
$233.93
|
| Rate for Payer: BCN Commercial |
$221.24
|
| Rate for Payer: BCN Medicare Advantage |
$71.14
|
| Rate for Payer: Cash Price |
$227.64
|
| Rate for Payer: Cofinity Commercial |
$244.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$71.14
|
| Rate for Payer: Healthscope Commercial |
$256.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$74.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$81.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.87
|
| Rate for Payer: Nomi Health Commercial |
$233.33
|
| Rate for Payer: PACE Senior Care Partners |
$67.58
|
| Rate for Payer: PACE SWMI |
$71.14
|
| Rate for Payer: PHP Commercial |
$241.87
|
| Rate for Payer: PHP Medicare Advantage |
$71.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.96
|
| Rate for Payer: Priority Health HMO/PPO |
$247.56
|
| Rate for Payer: Priority Health Medicare |
$71.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$190.65
|
| Rate for Payer: Railroad Medicare Medicare |
$71.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.40
|
| Rate for Payer: UHC Core |
$237.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$71.14
|
| Rate for Payer: UHC Exchange |
$71.14
|
| Rate for Payer: UHC Medicare Advantage |
$71.14
|
| Rate for Payer: VA VA |
$71.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.41
|
|
|
ETODOLAC 400 MG TABLET
|
Facility
|
IP
|
$284.55
|
|
|
Service Code
|
NDC 63629137705
|
| Hospital Charge Code |
9999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.96 |
| Max. Negotiated Rate |
$256.10 |
| Rate for Payer: Aetna Commercial |
$241.87
|
| Rate for Payer: BCBS Trust/PPO |
$232.28
|
| Rate for Payer: BCN Commercial |
$219.90
|
| Rate for Payer: Cash Price |
$227.64
|
| Rate for Payer: Cofinity Commercial |
$244.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.64
|
| Rate for Payer: Healthscope Commercial |
$256.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.87
|
| Rate for Payer: Nomi Health Commercial |
$233.33
|
| Rate for Payer: PHP Commercial |
$241.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.96
|
| Rate for Payer: Priority Health HMO/PPO |
$247.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$190.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.40
|
| Rate for Payer: UHC Core |
$237.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.41
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.79
|
|
|
Service Code
|
NDC 72266014710
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$24.11 |
| Rate for Payer: Aetna Commercial |
$22.77
|
| Rate for Payer: Aetna Medicare |
$6.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.37
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.37
|
| Rate for Payer: BCBS Complete |
$10.72
|
| Rate for Payer: BCBS MAPPO |
$6.70
|
| Rate for Payer: BCBS Trust/PPO |
$22.02
|
| Rate for Payer: BCN Commercial |
$20.83
|
| Rate for Payer: BCN Medicare Advantage |
$6.70
|
| Rate for Payer: Cash Price |
$21.43
|
| Rate for Payer: Cofinity Commercial |
$23.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.70
|
| Rate for Payer: Healthscope Commercial |
$24.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.77
|
| Rate for Payer: Nomi Health Commercial |
$21.97
|
| Rate for Payer: PACE Senior Care Partners |
$6.36
|
| Rate for Payer: PACE SWMI |
$6.70
|
| Rate for Payer: PHP Commercial |
$22.77
|
| Rate for Payer: PHP Medicare Advantage |
$6.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.41
|
| Rate for Payer: Priority Health HMO/PPO |
$23.31
|
| Rate for Payer: Priority Health Medicare |
$6.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.95
|
| Rate for Payer: Railroad Medicare Medicare |
$6.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.58
|
| Rate for Payer: UHC Core |
$22.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.70
|
| Rate for Payer: UHC Exchange |
$6.70
|
| Rate for Payer: UHC Medicare Advantage |
$6.70
|
| Rate for Payer: VA VA |
$6.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.09
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.54
|
|
|
Service Code
|
NDC 00143931101
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$17.59 |
| Rate for Payer: Aetna Commercial |
$16.61
|
| Rate for Payer: Aetna Medicare |
$5.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.11
|
| Rate for Payer: BCBS Complete |
$7.82
|
| Rate for Payer: BCBS MAPPO |
$4.88
|
| Rate for Payer: BCBS Trust/PPO |
$16.06
|
| Rate for Payer: BCN Commercial |
$15.19
|
| Rate for Payer: BCN Medicare Advantage |
$4.88
|
| Rate for Payer: Cash Price |
$15.63
|
| Rate for Payer: Cofinity Commercial |
$16.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.88
|
| Rate for Payer: Healthscope Commercial |
$17.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.61
|
| Rate for Payer: Nomi Health Commercial |
$16.02
|
| Rate for Payer: PACE Senior Care Partners |
$4.64
|
| Rate for Payer: PACE SWMI |
$4.88
|
| Rate for Payer: PHP Commercial |
$16.61
|
| Rate for Payer: PHP Medicare Advantage |
$4.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.70
|
| Rate for Payer: Priority Health HMO/PPO |
$17.00
|
| Rate for Payer: Priority Health Medicare |
$4.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.09
|
| Rate for Payer: Railroad Medicare Medicare |
$4.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.20
|
| Rate for Payer: UHC Core |
$16.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.88
|
| Rate for Payer: UHC Exchange |
$4.88
|
| Rate for Payer: UHC Medicare Advantage |
$4.88
|
| Rate for Payer: VA VA |
$4.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.66
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.66
|
|
|
Service Code
|
NDC 67457090320
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.03 |
| Max. Negotiated Rate |
$22.19 |
| Rate for Payer: Aetna Commercial |
$20.96
|
| Rate for Payer: BCBS Trust/PPO |
$20.13
|
| Rate for Payer: BCN Commercial |
$19.06
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$21.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.73
|
| Rate for Payer: Healthscope Commercial |
$22.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.96
|
| Rate for Payer: Nomi Health Commercial |
$20.22
|
| Rate for Payer: PHP Commercial |
$20.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.03
|
| Rate for Payer: Priority Health HMO/PPO |
$21.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.70
|
| Rate for Payer: UHC Core |
$20.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.50
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.06
|
|
|
Service Code
|
NDC 55150022110
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Aetna Commercial |
$15.35
|
| Rate for Payer: BCBS Trust/PPO |
$14.74
|
| Rate for Payer: BCN Commercial |
$13.96
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cofinity Commercial |
$15.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.45
|
| Rate for Payer: Healthscope Commercial |
$16.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.35
|
| Rate for Payer: Nomi Health Commercial |
$14.81
|
| Rate for Payer: PHP Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.74
|
| Rate for Payer: Priority Health HMO/PPO |
$15.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.89
|
| Rate for Payer: UHC Core |
$15.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.54
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$24.66
|
|
|
Service Code
|
NDC 67457090300
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$22.19 |
| Rate for Payer: Aetna Commercial |
$20.96
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.71
|
| Rate for Payer: BCBS Complete |
$9.86
|
| Rate for Payer: BCBS MAPPO |
$6.16
|
| Rate for Payer: BCBS Trust/PPO |
$20.27
|
| Rate for Payer: BCN Commercial |
$19.17
|
| Rate for Payer: BCN Medicare Advantage |
$6.16
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$21.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.16
|
| Rate for Payer: Healthscope Commercial |
$22.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.96
|
| Rate for Payer: Nomi Health Commercial |
$20.22
|
| Rate for Payer: PACE Senior Care Partners |
$5.86
|
| Rate for Payer: PACE SWMI |
$6.16
|
| Rate for Payer: PHP Commercial |
$20.96
|
| Rate for Payer: PHP Medicare Advantage |
$6.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.03
|
| Rate for Payer: Priority Health HMO/PPO |
$21.45
|
| Rate for Payer: Priority Health Medicare |
$6.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.52
|
| Rate for Payer: Railroad Medicare Medicare |
$6.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.70
|
| Rate for Payer: UHC Core |
$20.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.16
|
| Rate for Payer: UHC Exchange |
$6.16
|
| Rate for Payer: UHC Medicare Advantage |
$6.16
|
| Rate for Payer: VA VA |
$6.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.50
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.54
|
|
|
Service Code
|
NDC 00143950710
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$17.59 |
| Rate for Payer: Aetna Commercial |
$16.61
|
| Rate for Payer: BCBS Trust/PPO |
$15.95
|
| Rate for Payer: BCN Commercial |
$15.10
|
| Rate for Payer: Cash Price |
$15.63
|
| Rate for Payer: Cofinity Commercial |
$16.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.63
|
| Rate for Payer: Healthscope Commercial |
$17.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.61
|
| Rate for Payer: Nomi Health Commercial |
$16.02
|
| Rate for Payer: PHP Commercial |
$16.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.70
|
| Rate for Payer: Priority Health HMO/PPO |
$17.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.20
|
| Rate for Payer: UHC Core |
$16.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.66
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$24.66
|
|
|
Service Code
|
NDC 67457090320
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$22.19 |
| Rate for Payer: Aetna Commercial |
$20.96
|
| Rate for Payer: Aetna Medicare |
$6.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.71
|
| Rate for Payer: BCBS Complete |
$9.86
|
| Rate for Payer: BCBS MAPPO |
$6.16
|
| Rate for Payer: BCBS Trust/PPO |
$20.27
|
| Rate for Payer: BCN Commercial |
$19.17
|
| Rate for Payer: BCN Medicare Advantage |
$6.16
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cofinity Commercial |
$21.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.16
|
| Rate for Payer: Healthscope Commercial |
$22.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.96
|
| Rate for Payer: Nomi Health Commercial |
$20.22
|
| Rate for Payer: PACE Senior Care Partners |
$5.86
|
| Rate for Payer: PACE SWMI |
$6.16
|
| Rate for Payer: PHP Commercial |
$20.96
|
| Rate for Payer: PHP Medicare Advantage |
$6.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.03
|
| Rate for Payer: Priority Health HMO/PPO |
$21.45
|
| Rate for Payer: Priority Health Medicare |
$6.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.52
|
| Rate for Payer: Railroad Medicare Medicare |
$6.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.70
|
| Rate for Payer: UHC Core |
$20.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.16
|
| Rate for Payer: UHC Exchange |
$6.16
|
| Rate for Payer: UHC Medicare Advantage |
$6.16
|
| Rate for Payer: VA VA |
$6.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.50
|
|
