|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
IP
|
$3,429.53
|
|
|
Service Code
|
NDC 49884-276-01
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,508.99 |
| Max. Negotiated Rate |
$3,086.58 |
| Rate for Payer: Aetna American Axle |
$2,229.19
|
| Rate for Payer: Aetna Commercial |
$2,915.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,229.19
|
| Rate for Payer: Cash Price |
$2,743.62
|
| Rate for Payer: Cofinity Commercial |
$2,400.67
|
| Rate for Payer: Cofinity Commercial |
$2,949.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,743.62
|
| Rate for Payer: Healthscope Commercial |
$3,086.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,400.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,572.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,915.10
|
| Rate for Payer: PHP Commercial |
$2,915.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,400.67
|
| Rate for Payer: Priority Health SBD |
$2,160.60
|
| Rate for Payer: UMR Bronson Commercial |
$1,508.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,572.15
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
IP
|
$8,410.84
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,700.77 |
| Max. Negotiated Rate |
$7,569.76 |
| Rate for Payer: Aetna American Axle |
$5,467.05
|
| Rate for Payer: Aetna Commercial |
$7,149.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,467.05
|
| Rate for Payer: Cash Price |
$6,728.67
|
| Rate for Payer: Cofinity Commercial |
$5,887.59
|
| Rate for Payer: Cofinity Commercial |
$7,233.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,728.67
|
| Rate for Payer: Healthscope Commercial |
$7,569.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,887.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,308.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,149.21
|
| Rate for Payer: PHP Commercial |
$7,149.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,887.59
|
| Rate for Payer: Priority Health SBD |
$5,298.83
|
| Rate for Payer: UMR Bronson Commercial |
$3,700.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,308.13
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
IP
|
$426.55
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.68 |
| Max. Negotiated Rate |
$383.90 |
| Rate for Payer: Aetna American Axle |
$277.26
|
| Rate for Payer: Aetna Commercial |
$362.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.26
|
| Rate for Payer: Cash Price |
$341.24
|
| Rate for Payer: Cofinity Commercial |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$362.57
|
| Rate for Payer: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.58
|
| Rate for Payer: Priority Health SBD |
$268.73
|
| Rate for Payer: UMR Bronson Commercial |
$187.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.91
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
IP
|
$234.65
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.25 |
| Max. Negotiated Rate |
$211.18 |
| Rate for Payer: Aetna American Axle |
$152.52
|
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$152.52
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$164.26
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$199.45
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.26
|
| Rate for Payer: Priority Health SBD |
$147.83
|
| Rate for Payer: UMR Bronson Commercial |
$103.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.99
|
|
|
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 |
$174.66 |
| Max. Negotiated Rate |
$357.26 |
| Rate for Payer: Aetna American Axle |
$258.02
|
| 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: Encore Health Key Benefits Commercial |
$317.57
|
| Rate for Payer: Healthscope Commercial |
$357.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.72
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$174.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.72
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$418.56
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.17 |
| Max. Negotiated Rate |
$376.70 |
| Rate for Payer: Aetna American Axle |
$272.06
|
| Rate for Payer: Aetna Commercial |
$355.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$272.06
|
| Rate for Payer: Cash Price |
$334.85
|
| Rate for Payer: Cofinity Commercial |
$292.99
|
| Rate for Payer: Cofinity Commercial |
$359.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.85
|
| Rate for Payer: Healthscope Commercial |
$376.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$355.78
|
| Rate for Payer: PHP Commercial |
$355.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.99
|
| Rate for Payer: Priority Health SBD |
$263.69
|
| Rate for Payer: UMR Bronson Commercial |
$184.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.92
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$396.96
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.66 |
| Max. Negotiated Rate |
$357.26 |
| Rate for Payer: Aetna American Axle |
$258.02
|
| 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: Encore Health Key Benefits Commercial |
$317.57
|
| Rate for Payer: Healthscope Commercial |
$357.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.72
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$174.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.72
|
|
|
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 |
$153.12 |
| Max. Negotiated Rate |
$313.20 |
| Rate for Payer: Aetna American Axle |
$226.20
|
| 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: Encore Health Key Benefits Commercial |
$278.40
|
| Rate for Payer: Healthscope Commercial |
$313.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$243.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.00
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$153.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.00
|
|
|
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 |
$629.06 |
| Max. Negotiated Rate |
$1,286.71 |
| Rate for Payer: Aetna American Axle |
$929.29
|
| 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: Encore Health Key Benefits Commercial |
$1,143.74
|
| Rate for Payer: Healthscope Commercial |
$1,286.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,000.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.26
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$629.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.26
|
|
|
ETHMOIDECTOMY; INTRANASAL, ANTERIOR
|
Facility
|
OP
|
$16,386.90
|
|
|
Service Code
|
CPT 31200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$618.87 |
| Max. Negotiated Rate |
$16,386.90 |
| Rate for Payer: Aetna Medicare |
$5,413.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,506.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,506.78
|
| Rate for Payer: BCBS Complete |
$2,989.99
|
| Rate for Payer: BCBS MAPPO |
$5,205.42
|
| Rate for Payer: BCBS Trust/PPO |
$3,027.02
|
| Rate for Payer: BCN Medicare Advantage |
$5,205.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,205.42
|
| Rate for Payer: Mclaren Medicaid |
$2,847.36
|
| Rate for Payer: Mclaren Medicare |
$5,205.42
|
| Rate for Payer: Meridian Medicaid |
$2,989.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,465.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,986.23
|
| Rate for Payer: PACE Medicare |
$4,945.15
|
| Rate for Payer: PACE SWMI |
$5,205.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,205.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,847.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,386.90
|
| Rate for Payer: Priority Health Medicare |
$5,205.42
|
| Rate for Payer: Priority Health Narrow Network |
$13,109.52
|
| Rate for Payer: Railroad Medicare Medicare |
$5,205.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$680.76
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,205.42
|
| Rate for Payer: UHC Exchange |
$618.87
|
| Rate for Payer: UHC Medicare Advantage |
$5,361.58
|
| Rate for Payer: VA VA |
$5,205.42
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,130.26
|
|
|
Service Code
|
NDC 61748-024-16
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$497.31 |
| Max. Negotiated Rate |
$1,017.23 |
| Rate for Payer: Aetna American Axle |
$734.67
|
| Rate for Payer: Aetna Commercial |
$960.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$734.67
|
| Rate for Payer: Cash Price |
$904.21
|
| Rate for Payer: Cofinity Commercial |
$791.18
|
| Rate for Payer: Cofinity Commercial |
$972.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$904.21
|
| Rate for Payer: Healthscope Commercial |
$1,017.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$791.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$847.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$960.72
|
| Rate for Payer: PHP Commercial |
$960.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$791.18
|
| Rate for Payer: Priority Health SBD |
$712.06
|
| Rate for Payer: UMR Bronson Commercial |
$497.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$847.70
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,233.83
|
|
|
Service Code
|
NDC 0071-2418-19
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$542.89 |
| Max. Negotiated Rate |
$1,110.45 |
| Rate for Payer: Aetna American Axle |
$801.99
|
| Rate for Payer: Aetna Commercial |
$1,048.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$801.99
|
| Rate for Payer: Cash Price |
$987.06
|
| Rate for Payer: Cofinity Commercial |
$1,061.09
|
| Rate for Payer: Cofinity Commercial |
$863.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$987.06
|
| Rate for Payer: Healthscope Commercial |
$1,110.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$863.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$925.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,048.76
|
| Rate for Payer: PHP Commercial |
$1,048.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$863.68
|
| Rate for Payer: Priority Health SBD |
$777.31
|
| Rate for Payer: UMR Bronson Commercial |
$542.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$925.37
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,236.43
|
|
|
Service Code
|
NDC 59762-2350-7
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$544.03 |
| Max. Negotiated Rate |
$1,112.79 |
| Rate for Payer: Aetna American Axle |
$803.68
|
| Rate for Payer: Aetna Commercial |
$1,050.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$803.68
|
| Rate for Payer: Cash Price |
$989.14
|
| Rate for Payer: Cofinity Commercial |
$1,063.33
|
| Rate for Payer: Cofinity Commercial |
$865.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$989.14
|
| Rate for Payer: Healthscope Commercial |
$1,112.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$865.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$927.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,050.97
|
| Rate for Payer: PHP Commercial |
$1,050.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$865.50
|
| Rate for Payer: Priority Health SBD |
$778.95
|
| Rate for Payer: UMR Bronson Commercial |
$544.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$927.32
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,169.60
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$514.62 |
| Max. Negotiated Rate |
$1,052.64 |
| Rate for Payer: Aetna American Axle |
$760.24
|
| Rate for Payer: Aetna Commercial |
$994.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$760.24
|
| Rate for Payer: Cash Price |
$935.68
|
| Rate for Payer: Cofinity Commercial |
$1,005.86
|
| Rate for Payer: Cofinity Commercial |
$818.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$935.68
|
| Rate for Payer: Healthscope Commercial |
$1,052.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$818.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$877.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$994.16
|
| Rate for Payer: PHP Commercial |
$994.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$818.72
|
| Rate for Payer: Priority Health SBD |
$736.85
|
| Rate for Payer: UMR Bronson Commercial |
$514.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$877.20
|
|
|
ETHOXYDIGLYCOL (BULK) 100 % LIQUID
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
NDC 3877919035
|
| Hospital Charge Code |
42293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.28 |
| Max. Negotiated Rate |
$145.80 |
| Rate for Payer: Aetna American Axle |
$105.30
|
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.30
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cofinity Commercial |
$113.40
|
| Rate for Payer: Cofinity Commercial |
$139.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.60
|
| Rate for Payer: Healthscope Commercial |
$145.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.70
|
| Rate for Payer: PHP Commercial |
$137.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.40
|
| Rate for Payer: Priority Health SBD |
$102.06
|
| Rate for Payer: UMR Bronson Commercial |
$71.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.50
|
|
|
ETHYL ALCOHOL (BULK) LIQUID
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
NDC 5155202566
|
| Hospital Charge Code |
16626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$211.20 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna American Axle |
$312.00
|
| Rate for Payer: Aetna Commercial |
$408.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cofinity Commercial |
$336.00
|
| Rate for Payer: Cofinity Commercial |
$412.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$384.00
|
| Rate for Payer: Healthscope Commercial |
$432.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$336.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$360.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$408.00
|
| Rate for Payer: PHP Commercial |
$408.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$336.00
|
| Rate for Payer: Priority Health SBD |
$302.40
|
| Rate for Payer: UMR Bronson Commercial |
$211.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$360.00
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
OP
|
$203.59
|
|
|
Service Code
|
NDC 386000102
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.33 |
| Max. Negotiated Rate |
$183.23 |
| Rate for Payer: Aetna American Axle |
$132.33
|
| Rate for Payer: Aetna Commercial |
$173.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.33
|
| Rate for Payer: BCBS Complete |
$81.44
|
| Rate for Payer: Cash Price |
$162.87
|
| Rate for Payer: Cofinity Commercial |
$142.51
|
| Rate for Payer: Cofinity Commercial |
$175.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$162.87
|
| Rate for Payer: Healthscope Commercial |
$183.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.69
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$75.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.69
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$203.59
|
|
|
Service Code
|
NDC 386000102
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.58 |
| Max. Negotiated Rate |
$183.23 |
| Rate for Payer: Aetna American Axle |
$132.33
|
| 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: Encore Health Key Benefits Commercial |
$162.87
|
| Rate for Payer: Healthscope Commercial |
$183.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.69
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$89.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.69
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.79
|
|
|
Service Code
|
NDC 70860-652-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$20.51 |
| Rate for Payer: Aetna American Axle |
$14.81
|
| Rate for Payer: Aetna Commercial |
$19.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.81
|
| Rate for Payer: Cash Price |
$18.23
|
| Rate for Payer: Cofinity Commercial |
$15.95
|
| Rate for Payer: Cofinity Commercial |
$19.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.23
|
| Rate for Payer: Healthscope Commercial |
$20.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.37
|
| Rate for Payer: PHP Commercial |
$19.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.95
|
| Rate for Payer: Priority Health SBD |
$14.36
|
| Rate for Payer: UMR Bronson Commercial |
$10.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.09
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.87
|
|
|
Service Code
|
NDC 72572-160-01
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$24.18 |
| Rate for Payer: Aetna American Axle |
$17.47
|
| Rate for Payer: Aetna Commercial |
$22.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.47
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cofinity Commercial |
$18.81
|
| Rate for Payer: Cofinity Commercial |
$23.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.50
|
| Rate for Payer: Healthscope Commercial |
$24.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.84
|
| Rate for Payer: PHP Commercial |
$22.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.81
|
| Rate for Payer: Priority Health SBD |
$16.93
|
| Rate for Payer: UMR Bronson Commercial |
$11.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.15
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.06
|
|
|
Service Code
|
NDC 55150-221-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.95 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Aetna American Axle |
$11.74
|
| Rate for Payer: Aetna Commercial |
$15.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.74
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cofinity Commercial |
$12.64
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$12.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.35
|
| Rate for Payer: PHP Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.64
|
| Rate for Payer: Priority Health SBD |
$11.38
|
| Rate for Payer: UMR Bronson Commercial |
$7.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.54
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
NDC 0143-9506-10
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$16.92 |
| Rate for Payer: Aetna American Axle |
$12.22
|
| 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: Encore Health Key Benefits Commercial |
$15.04
|
| Rate for Payer: Healthscope Commercial |
$16.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.10
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$8.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.10
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.43
|
|
|
Service Code
|
NDC 65219-445-01
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna American Axle |
$11.98
|
| Rate for Payer: Aetna Commercial |
$15.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.98
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Commercial |
$15.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.74
|
| Rate for Payer: Healthscope Commercial |
$16.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.67
|
| Rate for Payer: PHP Commercial |
$15.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.90
|
| Rate for Payer: Priority Health SBD |
$11.61
|
| Rate for Payer: UMR Bronson Commercial |
$8.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.82
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.01
|
|
|
Service Code
|
NDC 23155-160-41
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: Aetna American Axle |
$14.96
|
| Rate for Payer: Aetna Commercial |
$19.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.96
|
| Rate for Payer: Cash Price |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$16.11
|
| Rate for Payer: Cofinity Commercial |
$19.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.41
|
| Rate for Payer: Healthscope Commercial |
$20.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.56
|
| Rate for Payer: PHP Commercial |
$19.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health SBD |
$14.50
|
| Rate for Payer: UMR Bronson Commercial |
$10.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.26
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.01
|
|
|
Service Code
|
NDC 23155-160-31
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: Aetna American Axle |
$14.96
|
| Rate for Payer: Aetna Commercial |
$19.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.96
|
| Rate for Payer: Cash Price |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$16.11
|
| Rate for Payer: Cofinity Commercial |
$19.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.41
|
| Rate for Payer: Healthscope Commercial |
$20.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.56
|
| Rate for Payer: PHP Commercial |
$19.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health SBD |
$14.50
|
| Rate for Payer: UMR Bronson Commercial |
$10.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.26
|
|
