|
ESTRADIOL 1 MG TABLET
|
Facility
|
IP
|
$271.70
|
|
|
Service Code
|
NDC 00555088602
|
| Hospital Charge Code |
9967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.55 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna American Axle |
$176.60
|
| 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 Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UMR Bronson Commercial |
$119.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.78
|
|
|
ESTRADIOL 1 MG TABLET
|
Facility
|
OP
|
$271.70
|
|
|
Service Code
|
NDC 00555088602
|
| Hospital Charge Code |
9967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna American Axle |
$176.60
|
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna Medicare |
$135.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: BCBS Complete |
$108.68
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$217.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.60
|
| Rate for Payer: UHC Core |
$141.56
|
| Rate for Payer: UHC Exchange |
$106.78
|
| Rate for Payer: UMR Bronson Commercial |
$100.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.78
|
|
|
ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$834.57
|
|
|
Service Code
|
HCPCS J1000
|
| Hospital Charge Code |
2929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$751.11 |
| Rate for Payer: Aetna American Axle |
$542.47
|
| Rate for Payer: Aetna Commercial |
$709.38
|
| Rate for Payer: Aetna Medicare |
$417.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$542.47
|
| Rate for Payer: BCBS Complete |
$333.83
|
| Rate for Payer: BCBS Trust/PPO |
$168.01
|
| Rate for Payer: BCN Commercial |
$168.01
|
| Rate for Payer: Cash Price |
$667.66
|
| Rate for Payer: Cash Price |
$667.66
|
| Rate for Payer: Cofinity Advantage |
$584.20
|
| Rate for Payer: Cofinity Commercial |
$717.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$667.66
|
| Rate for Payer: Healthscope Commercial |
$751.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$584.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$625.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$667.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$709.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$625.93
|
| Rate for Payer: PHP Commercial |
$709.38
|
| Rate for Payer: Priority Health SBD |
$525.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.50
|
| Rate for Payer: UHC Core |
$85.50
|
| Rate for Payer: UHC Exchange |
$85.50
|
| Rate for Payer: UMR Bronson Commercial |
$308.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$625.93
|
|
|
ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$834.57
|
|
|
Service Code
|
HCPCS J1000
|
| Hospital Charge Code |
2929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.21 |
| Max. Negotiated Rate |
$751.11 |
| Rate for Payer: Aetna American Axle |
$542.47
|
| Rate for Payer: Aetna Commercial |
$709.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$542.47
|
| Rate for Payer: Cash Price |
$667.66
|
| Rate for Payer: Cofinity Advantage |
$584.20
|
| Rate for Payer: Cofinity Commercial |
$717.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$667.66
|
| Rate for Payer: Healthscope Commercial |
$751.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$584.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$625.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$709.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$625.93
|
| Rate for Payer: PHP Commercial |
$709.38
|
| Rate for Payer: Priority Health SBD |
$525.78
|
| Rate for Payer: UMR Bronson Commercial |
$367.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$625.93
|
|
|
ESTRADIOL VALERATE 10 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$493.82
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$444.44 |
| Rate for Payer: Aetna American Axle |
$320.98
|
| Rate for Payer: Aetna American Axle |
$374.32
|
| Rate for Payer: Aetna Commercial |
$419.75
|
| Rate for Payer: Aetna Commercial |
$489.50
|
| Rate for Payer: Aetna Medicare |
$246.91
|
| Rate for Payer: Aetna Medicare |
$287.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$320.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$374.32
|
| Rate for Payer: BCBS Complete |
$230.35
|
| Rate for Payer: BCBS Complete |
$197.53
|
| Rate for Payer: BCBS Trust/PPO |
$24.12
|
| Rate for Payer: BCBS Trust/PPO |
$24.12
|
| Rate for Payer: BCN Commercial |
$24.12
|
| Rate for Payer: BCN Commercial |
$24.12
|
| Rate for Payer: Cash Price |
$395.06
|
| Rate for Payer: Cash Price |
$460.70
|
| Rate for Payer: Cash Price |
$395.06
|
| Rate for Payer: Cash Price |
$460.70
|
| Rate for Payer: Cofinity Advantage |
$345.67
|
| Rate for Payer: Cofinity Advantage |
$403.12
|
| Rate for Payer: Cofinity Commercial |
$424.69
|
| Rate for Payer: Cofinity Commercial |
$495.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$395.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$460.70
|
| Rate for Payer: Healthscope Commercial |
$444.44
|
| Rate for Payer: Healthscope Commercial |
$518.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$345.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$403.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$370.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$431.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$395.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$460.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$419.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$489.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$431.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$370.37
|
| Rate for Payer: PHP Commercial |
$419.75
|
| Rate for Payer: PHP Commercial |
$489.50
|
| Rate for Payer: Priority Health SBD |
$311.11
|
| Rate for Payer: Priority Health SBD |
$362.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.29
|
| Rate for Payer: UHC Core |
$12.29
|
| Rate for Payer: UHC Core |
$12.29
|
| Rate for Payer: UHC Exchange |
$12.29
|
| Rate for Payer: UHC Exchange |
$12.29
|
| Rate for Payer: UMR Bronson Commercial |
$182.71
|
| Rate for Payer: UMR Bronson Commercial |
$213.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$370.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$431.91
|
|
|
ESTRADIOL VALERATE 10 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$493.82
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.28 |
| Max. Negotiated Rate |
$444.44 |
| Rate for Payer: Aetna American Axle |
$320.98
|
| Rate for Payer: Aetna American Axle |
$374.32
|
| Rate for Payer: Aetna Commercial |
$419.75
|
| Rate for Payer: Aetna Commercial |
$489.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$320.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$374.32
|
| Rate for Payer: Cash Price |
$395.06
|
| Rate for Payer: Cash Price |
$460.70
|
| Rate for Payer: Cofinity Advantage |
$403.12
|
| Rate for Payer: Cofinity Advantage |
$345.67
|
| Rate for Payer: Cofinity Commercial |
$495.26
|
| Rate for Payer: Cofinity Commercial |
$424.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$395.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$460.70
|
| Rate for Payer: Healthscope Commercial |
$444.44
|
| Rate for Payer: Healthscope Commercial |
$518.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$403.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$345.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$370.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$431.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$419.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$489.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$370.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$431.91
|
| Rate for Payer: PHP Commercial |
$419.75
|
| Rate for Payer: PHP Commercial |
$489.50
|
| Rate for Payer: Priority Health SBD |
$362.80
|
| Rate for Payer: Priority Health SBD |
$311.11
|
| Rate for Payer: UMR Bronson Commercial |
$217.28
|
| Rate for Payer: UMR Bronson Commercial |
$253.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$370.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$431.91
|
|
|
ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$811.64
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$357.12 |
| Max. Negotiated Rate |
$730.48 |
| Rate for Payer: Aetna American Axle |
$527.57
|
| Rate for Payer: Aetna Commercial |
$689.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$527.57
|
| Rate for Payer: Cash Price |
$649.31
|
| Rate for Payer: Cofinity Advantage |
$568.15
|
| Rate for Payer: Cofinity Commercial |
$698.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$649.31
|
| Rate for Payer: Healthscope Commercial |
$730.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$568.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$608.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$689.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$608.73
|
| Rate for Payer: PHP Commercial |
$689.89
|
| Rate for Payer: Priority Health SBD |
$511.33
|
| Rate for Payer: UMR Bronson Commercial |
$357.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$608.73
|
|
|
ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$811.64
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
2931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$730.48 |
| Rate for Payer: Aetna American Axle |
$527.57
|
| Rate for Payer: Aetna American Axle |
$246.59
|
| Rate for Payer: Aetna Commercial |
$322.46
|
| Rate for Payer: Aetna Commercial |
$689.89
|
| Rate for Payer: Aetna Medicare |
$405.82
|
| Rate for Payer: Aetna Medicare |
$189.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$527.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.59
|
| Rate for Payer: BCBS Complete |
$151.75
|
| Rate for Payer: BCBS Complete |
$324.66
|
| Rate for Payer: BCBS Trust/PPO |
$24.12
|
| Rate for Payer: BCBS Trust/PPO |
$24.12
|
| Rate for Payer: BCN Commercial |
$24.12
|
| Rate for Payer: BCN Commercial |
$24.12
|
| Rate for Payer: Cash Price |
$649.31
|
| Rate for Payer: Cash Price |
$303.50
|
| Rate for Payer: Cash Price |
$303.50
|
| Rate for Payer: Cash Price |
$649.31
|
| Rate for Payer: Cofinity Advantage |
$568.15
|
| Rate for Payer: Cofinity Advantage |
$265.56
|
| Rate for Payer: Cofinity Commercial |
$326.26
|
| Rate for Payer: Cofinity Commercial |
$698.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$649.31
|
| Rate for Payer: Healthscope Commercial |
$730.48
|
| Rate for Payer: Healthscope Commercial |
$341.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$568.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$608.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$303.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$649.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$689.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$608.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.53
|
| Rate for Payer: PHP Commercial |
$322.46
|
| Rate for Payer: PHP Commercial |
$689.89
|
| Rate for Payer: Priority Health SBD |
$511.33
|
| Rate for Payer: Priority Health SBD |
$239.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.29
|
| Rate for Payer: UHC Core |
$12.29
|
| Rate for Payer: UHC Core |
$12.29
|
| Rate for Payer: UHC Exchange |
$12.29
|
| Rate for Payer: UHC Exchange |
$12.29
|
| Rate for Payer: UMR Bronson Commercial |
$300.31
|
| Rate for Payer: UMR Bronson Commercial |
$140.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$608.73
|
|
|
ETEPLIRSEN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,120.00
|
|
|
Service Code
|
HCPCS J1428
|
| Hospital Charge Code |
180827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.61 |
| Max. Negotiated Rate |
$4,608.00 |
| Rate for Payer: Aetna American Axle |
$3,328.00
|
| Rate for Payer: Aetna American Axle |
$13,520.00
|
| Rate for Payer: Aetna Commercial |
$17,680.00
|
| Rate for Payer: Aetna Commercial |
$4,352.00
|
| Rate for Payer: Aetna Medicare |
$174.21
|
| Rate for Payer: Aetna Medicare |
$174.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,328.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,520.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$209.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$209.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$209.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$209.39
|
| Rate for Payer: BCBS Complete |
$92.00
|
| Rate for Payer: BCBS Complete |
$92.00
|
| Rate for Payer: BCBS MAPPO |
$167.51
|
| Rate for Payer: BCBS MAPPO |
$167.51
|
| Rate for Payer: BCN Medicare Advantage |
$167.51
|
| Rate for Payer: BCN Medicare Advantage |
$167.51
|
| Rate for Payer: Cash Price |
$16,640.00
|
| Rate for Payer: Cash Price |
$16,640.00
|
| Rate for Payer: Cash Price |
$4,096.00
|
| Rate for Payer: Cash Price |
$4,096.00
|
| Rate for Payer: Cofinity Advantage |
$3,584.00
|
| Rate for Payer: Cofinity Advantage |
$14,560.00
|
| Rate for Payer: Cofinity Commercial |
$17,888.00
|
| Rate for Payer: Cofinity Commercial |
$4,403.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,096.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,640.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$167.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$167.51
|
| Rate for Payer: Healthscope Commercial |
$18,720.00
|
| Rate for Payer: Healthscope Commercial |
$4,608.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,584.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,560.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,840.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,600.00
|
| Rate for Payer: Mclaren Medicaid |
$167.51
|
| Rate for Payer: Mclaren Medicaid |
$167.51
|
| Rate for Payer: Mclaren Medicare |
$167.51
|
| Rate for Payer: Mclaren Medicare |
$167.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$175.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$175.89
|
| Rate for Payer: Meridian Medicaid |
$175.89
|
| Rate for Payer: Meridian Medicaid |
$175.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$192.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$192.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$184.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$184.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,680.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,352.00
|
| Rate for Payer: Nomi Health Commercial |
$502.53
|
| Rate for Payer: Nomi Health Commercial |
$502.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,840.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,600.00
|
| Rate for Payer: PACE Medicare |
$159.13
|
| Rate for Payer: PACE Medicare |
$159.13
|
| Rate for Payer: PACE SWMI |
$167.51
|
| Rate for Payer: PACE SWMI |
$167.51
|
| Rate for Payer: PHP Commercial |
$17,680.00
|
| Rate for Payer: PHP Commercial |
$4,352.00
|
| Rate for Payer: PHP Medicare Advantage |
$167.51
|
| Rate for Payer: PHP Medicare Advantage |
$167.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$87.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$87.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$527.80
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$527.80
|
| Rate for Payer: Priority Health Medicare |
$167.51
|
| Rate for Payer: Priority Health Medicare |
$167.51
|
| Rate for Payer: Priority Health SBD |
$13,104.00
|
| Rate for Payer: Priority Health SBD |
$3,225.60
|
| Rate for Payer: Priority Health Tiered Network |
$422.24
|
| Rate for Payer: Priority Health Tiered Network |
$422.24
|
| Rate for Payer: Railroad Medicare Medicare |
$167.51
|
| Rate for Payer: Railroad Medicare Medicare |
$167.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.14
|
| Rate for Payer: UHC Core |
$276.14
|
| Rate for Payer: UHC Core |
$276.14
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$167.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$167.51
|
| Rate for Payer: UHC Exchange |
$276.14
|
| Rate for Payer: UHC Exchange |
$276.14
|
| Rate for Payer: UHC Medicaid |
$87.61
|
| Rate for Payer: UHC Medicaid |
$87.61
|
| Rate for Payer: UHCCP Medicaid |
$87.61
|
| Rate for Payer: UHCCP Medicaid |
$87.61
|
| Rate for Payer: UMR Bronson Commercial |
$7,696.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,894.40
|
| Rate for Payer: VA VA |
$167.51
|
| Rate for Payer: VA VA |
$167.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,840.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,600.00
|
|
|
ETEPLIRSEN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20,800.00
|
|
|
Service Code
|
HCPCS J1428
|
| Hospital Charge Code |
180827
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,152.00 |
| Max. Negotiated Rate |
$18,720.00 |
| Rate for Payer: Aetna American Axle |
$13,520.00
|
| Rate for Payer: Aetna American Axle |
$3,328.00
|
| Rate for Payer: Aetna Commercial |
$17,680.00
|
| Rate for Payer: Aetna Commercial |
$4,352.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,520.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,328.00
|
| Rate for Payer: Cash Price |
$16,640.00
|
| Rate for Payer: Cash Price |
$4,096.00
|
| Rate for Payer: Cofinity Advantage |
$3,584.00
|
| Rate for Payer: Cofinity Advantage |
$14,560.00
|
| Rate for Payer: Cofinity Commercial |
$4,403.20
|
| Rate for Payer: Cofinity Commercial |
$17,888.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,640.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,096.00
|
| Rate for Payer: Healthscope Commercial |
$18,720.00
|
| Rate for Payer: Healthscope Commercial |
$4,608.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,584.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14,560.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,600.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,840.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,680.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,352.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15,600.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,840.00
|
| Rate for Payer: PHP Commercial |
$17,680.00
|
| Rate for Payer: PHP Commercial |
$4,352.00
|
| Rate for Payer: Priority Health SBD |
$3,225.60
|
| Rate for Payer: Priority Health SBD |
$13,104.00
|
| Rate for Payer: UMR Bronson Commercial |
$9,152.00
|
| Rate for Payer: UMR Bronson Commercial |
$2,252.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,600.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,840.00
|
|
|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,657.64
|
|
|
Service Code
|
HCPCS J1807
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,491.88 |
| Rate for Payer: Aetna American Axle |
$1,077.47
|
| Rate for Payer: Aetna American Axle |
$7,927.30
|
| Rate for Payer: Aetna American Axle |
$957.53
|
| Rate for Payer: Aetna Commercial |
$1,408.99
|
| Rate for Payer: Aetna Commercial |
$1,252.15
|
| Rate for Payer: Aetna Commercial |
$10,366.47
|
| Rate for Payer: Aetna Medicare |
$19.00
|
| Rate for Payer: Aetna Medicare |
$19.00
|
| Rate for Payer: Aetna Medicare |
$19.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,927.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$957.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.84
|
| Rate for Payer: BCBS Complete |
$10.03
|
| Rate for Payer: BCBS Complete |
$10.03
|
| Rate for Payer: BCBS Complete |
$10.03
|
| Rate for Payer: BCBS MAPPO |
$18.27
|
| Rate for Payer: BCBS MAPPO |
$18.27
|
| Rate for Payer: BCBS MAPPO |
$18.27
|
| Rate for Payer: BCBS Trust/PPO |
$237.99
|
| Rate for Payer: BCBS Trust/PPO |
$237.99
|
| Rate for Payer: BCBS Trust/PPO |
$237.99
|
| Rate for Payer: BCN Commercial |
$237.99
|
| Rate for Payer: BCN Commercial |
$237.99
|
| Rate for Payer: BCN Commercial |
$237.99
|
| Rate for Payer: BCN Medicare Advantage |
$18.27
|
| Rate for Payer: BCN Medicare Advantage |
$18.27
|
| Rate for Payer: BCN Medicare Advantage |
$18.27
|
| Rate for Payer: Cash Price |
$1,178.50
|
| Rate for Payer: Cash Price |
$1,326.11
|
| Rate for Payer: Cash Price |
$9,756.68
|
| Rate for Payer: Cash Price |
$1,326.11
|
| Rate for Payer: Cash Price |
$1,178.50
|
| Rate for Payer: Cash Price |
$9,756.68
|
| Rate for Payer: Cofinity Advantage |
$8,537.09
|
| Rate for Payer: Cofinity Advantage |
$1,031.18
|
| Rate for Payer: Cofinity Advantage |
$1,160.35
|
| Rate for Payer: Cofinity Commercial |
$1,266.88
|
| Rate for Payer: Cofinity Commercial |
$1,425.57
|
| Rate for Payer: Cofinity Commercial |
$10,488.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,756.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,178.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,326.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$10,976.26
|
| Rate for Payer: Healthscope Commercial |
$1,325.81
|
| Rate for Payer: Healthscope Commercial |
$1,491.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,031.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,537.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,160.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,104.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,243.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,146.89
|
| Rate for Payer: Mclaren Medicaid |
$18.27
|
| Rate for Payer: Mclaren Medicaid |
$18.27
|
| Rate for Payer: Mclaren Medicaid |
$18.27
|
| Rate for Payer: Mclaren Medicare |
$18.27
|
| Rate for Payer: Mclaren Medicare |
$18.27
|
| Rate for Payer: Mclaren Medicare |
$18.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.18
|
| Rate for Payer: Meridian Medicaid |
$19.18
|
| Rate for Payer: Meridian Medicaid |
$19.18
|
| Rate for Payer: Meridian Medicaid |
$19.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.01
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,366.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,252.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.99
|
| Rate for Payer: Nomi Health Commercial |
$54.81
|
| Rate for Payer: Nomi Health Commercial |
$54.81
|
| Rate for Payer: Nomi Health Commercial |
$54.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9,146.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,104.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,243.23
|
| Rate for Payer: PACE Medicare |
$17.36
|
| Rate for Payer: PACE Medicare |
$17.36
|
| Rate for Payer: PACE Medicare |
$17.36
|
| Rate for Payer: PACE SWMI |
$18.27
|
| Rate for Payer: PACE SWMI |
$18.27
|
| Rate for Payer: PACE SWMI |
$18.27
|
| Rate for Payer: PHP Commercial |
$1,408.99
|
| Rate for Payer: PHP Commercial |
$10,366.47
|
| Rate for Payer: PHP Commercial |
$1,252.15
|
| Rate for Payer: PHP Medicare Advantage |
$18.27
|
| Rate for Payer: PHP Medicare Advantage |
$18.27
|
| Rate for Payer: PHP Medicare Advantage |
$18.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$66.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$66.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$66.14
|
| Rate for Payer: Priority Health Medicare |
$18.27
|
| Rate for Payer: Priority Health Medicare |
$18.27
|
| Rate for Payer: Priority Health Medicare |
$18.27
|
| Rate for Payer: Priority Health SBD |
$1,044.31
|
| Rate for Payer: Priority Health SBD |
$928.07
|
| Rate for Payer: Priority Health SBD |
$7,683.39
|
| Rate for Payer: Priority Health Tiered Network |
$52.91
|
| Rate for Payer: Priority Health Tiered Network |
$52.91
|
| Rate for Payer: Priority Health Tiered Network |
$52.91
|
| Rate for Payer: Railroad Medicare Medicare |
$18.27
|
| Rate for Payer: Railroad Medicare Medicare |
$18.27
|
| Rate for Payer: Railroad Medicare Medicare |
$18.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.25
|
| Rate for Payer: UHC Core |
$21.25
|
| Rate for Payer: UHC Core |
$21.25
|
| Rate for Payer: UHC Core |
$21.25
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$18.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$18.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$18.27
|
| Rate for Payer: UHC Exchange |
$21.25
|
| Rate for Payer: UHC Exchange |
$21.25
|
| Rate for Payer: UHC Exchange |
$21.25
|
| Rate for Payer: UHC Medicaid |
$9.56
|
| Rate for Payer: UHC Medicaid |
$9.56
|
| Rate for Payer: UHC Medicaid |
$9.56
|
| Rate for Payer: UHCCP Medicaid |
$9.56
|
| Rate for Payer: UHCCP Medicaid |
$9.56
|
| Rate for Payer: UHCCP Medicaid |
$9.56
|
| Rate for Payer: UMR Bronson Commercial |
$545.05
|
| Rate for Payer: UMR Bronson Commercial |
$4,512.46
|
| Rate for Payer: UMR Bronson Commercial |
$613.33
|
| Rate for Payer: VA VA |
$18.27
|
| Rate for Payer: VA VA |
$18.27
|
| Rate for Payer: VA VA |
$18.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,146.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,243.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,104.84
|
|
|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12,195.85
|
|
|
Service Code
|
HCPCS J1807
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,366.17 |
| Max. Negotiated Rate |
$10,976.26 |
| Rate for Payer: Aetna American Axle |
$7,927.30
|
| Rate for Payer: Aetna American Axle |
$1,077.47
|
| Rate for Payer: Aetna American Axle |
$957.53
|
| Rate for Payer: Aetna Commercial |
$1,252.15
|
| Rate for Payer: Aetna Commercial |
$10,366.47
|
| Rate for Payer: Aetna Commercial |
$1,408.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,927.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$957.53
|
| Rate for Payer: Cash Price |
$1,178.50
|
| Rate for Payer: Cash Price |
$9,756.68
|
| Rate for Payer: Cash Price |
$1,326.11
|
| Rate for Payer: Cofinity Advantage |
$1,160.35
|
| Rate for Payer: Cofinity Advantage |
$8,537.09
|
| Rate for Payer: Cofinity Advantage |
$1,031.18
|
| Rate for Payer: Cofinity Commercial |
$1,425.57
|
| Rate for Payer: Cofinity Commercial |
$10,488.43
|
| Rate for Payer: Cofinity Commercial |
$1,266.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,756.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,178.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,326.11
|
| Rate for Payer: Healthscope Commercial |
$1,325.81
|
| Rate for Payer: Healthscope Commercial |
$1,491.88
|
| Rate for Payer: Healthscope Commercial |
$10,976.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,031.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,537.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,160.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,243.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,146.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,104.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,366.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,252.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9,146.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,104.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,243.23
|
| Rate for Payer: PHP Commercial |
$1,252.15
|
| Rate for Payer: PHP Commercial |
$10,366.47
|
| Rate for Payer: PHP Commercial |
$1,408.99
|
| Rate for Payer: Priority Health SBD |
$7,683.39
|
| Rate for Payer: Priority Health SBD |
$928.07
|
| Rate for Payer: Priority Health SBD |
$1,044.31
|
| Rate for Payer: UMR Bronson Commercial |
$5,366.17
|
| Rate for Payer: UMR Bronson Commercial |
$729.36
|
| Rate for Payer: UMR Bronson Commercial |
$648.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,104.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,146.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,243.23
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
OP
|
$870.72
|
|
|
Service Code
|
NDC 68180015901
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$322.17 |
| Max. Negotiated Rate |
$783.65 |
| Rate for Payer: Aetna American Axle |
$565.97
|
| Rate for Payer: Aetna Commercial |
$740.11
|
| Rate for Payer: Aetna Medicare |
$435.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$565.97
|
| Rate for Payer: BCBS Complete |
$348.29
|
| Rate for Payer: Cash Price |
$696.58
|
| Rate for Payer: Cofinity Advantage |
$609.50
|
| Rate for Payer: Cofinity Commercial |
$748.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$696.58
|
| Rate for Payer: Healthscope Commercial |
$783.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$609.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$653.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$696.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$740.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$653.04
|
| Rate for Payer: PHP Commercial |
$740.11
|
| Rate for Payer: Priority Health SBD |
$548.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$565.97
|
| Rate for Payer: UHC Core |
$453.65
|
| Rate for Payer: UHC Exchange |
$342.19
|
| Rate for Payer: UMR Bronson Commercial |
$322.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$653.04
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
IP
|
$8,410.84
|
|
|
Service Code
|
NDC 25010021515
|
| 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 Advantage |
$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 Commercial |
$7,149.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,308.13
|
| Rate for Payer: PHP Commercial |
$7,149.21
|
| 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
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
IP
|
$870.72
|
|
|
Service Code
|
NDC 68180015901
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$383.12 |
| Max. Negotiated Rate |
$783.65 |
| Rate for Payer: Aetna American Axle |
$565.97
|
| Rate for Payer: Aetna Commercial |
$740.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$565.97
|
| Rate for Payer: Cash Price |
$696.58
|
| Rate for Payer: Cofinity Advantage |
$609.50
|
| Rate for Payer: Cofinity Commercial |
$748.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$696.58
|
| Rate for Payer: Healthscope Commercial |
$783.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$609.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$653.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$740.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$653.04
|
| Rate for Payer: PHP Commercial |
$740.11
|
| Rate for Payer: Priority Health SBD |
$548.55
|
| Rate for Payer: UMR Bronson Commercial |
$383.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$653.04
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
OP
|
$8,410.84
|
|
|
Service Code
|
NDC 25010021515
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,112.01 |
| 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 Medicare |
$4,205.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,467.05
|
| Rate for Payer: BCBS Complete |
$3,364.34
|
| Rate for Payer: Cash Price |
$6,728.67
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$6,728.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,149.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,308.13
|
| Rate for Payer: PHP Commercial |
$7,149.21
|
| Rate for Payer: Priority Health SBD |
$5,298.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,467.05
|
| Rate for Payer: UHC Core |
$4,382.05
|
| Rate for Payer: UHC Exchange |
$3,305.46
|
| Rate for Payer: UMR Bronson Commercial |
$3,112.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,308.13
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
IP
|
$277.40
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.06 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna American Axle |
$180.31
|
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Advantage |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.05
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UMR Bronson Commercial |
$122.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
OP
|
$426.55
|
|
|
Service Code
|
NDC 54879000100
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.82 |
| Max. Negotiated Rate |
$383.89 |
| Rate for Payer: Aetna American Axle |
$277.26
|
| Rate for Payer: Aetna Commercial |
$362.57
|
| Rate for Payer: Aetna Medicare |
$213.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.26
|
| Rate for Payer: BCBS Complete |
$170.62
|
| Rate for Payer: Cash Price |
$341.24
|
| Rate for Payer: Cofinity Advantage |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$341.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.91
|
| Rate for Payer: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health SBD |
$268.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$277.26
|
| Rate for Payer: UHC Core |
$222.23
|
| Rate for Payer: UHC Exchange |
$167.63
|
| Rate for Payer: UMR Bronson Commercial |
$157.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.91
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.64 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna American Axle |
$180.31
|
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Advantage |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$221.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.05
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$180.31
|
| Rate for Payer: UHC Core |
$144.53
|
| Rate for Payer: UHC Exchange |
$109.02
|
| Rate for Payer: UMR Bronson Commercial |
$102.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
IP
|
$426.55
|
|
|
Service Code
|
NDC 54879000100
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.68 |
| Max. Negotiated Rate |
$383.89 |
| 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 Advantage |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.89
|
| 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 Commercial |
$362.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.91
|
| Rate for Payer: PHP Commercial |
$362.57
|
| 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 400 MG TABLET
|
Facility
|
IP
|
$389.50
|
|
|
Service Code
|
NDC 68180028101
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.38 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna American Axle |
$253.18
|
| Rate for Payer: Aetna Commercial |
$331.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.18
|
| Rate for Payer: Cash Price |
$311.60
|
| Rate for Payer: Cofinity Advantage |
$272.65
|
| Rate for Payer: Cofinity Commercial |
$334.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.60
|
| Rate for Payer: Healthscope Commercial |
$350.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$272.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.12
|
| Rate for Payer: PHP Commercial |
$331.07
|
| Rate for Payer: Priority Health SBD |
$245.38
|
| Rate for Payer: UMR Bronson Commercial |
$171.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.12
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$603.84
|
|
|
Service Code
|
NDC 68084028001
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.69 |
| Max. Negotiated Rate |
$543.46 |
| Rate for Payer: Aetna American Axle |
$392.50
|
| Rate for Payer: Aetna Commercial |
$513.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$392.50
|
| Rate for Payer: Cash Price |
$483.07
|
| Rate for Payer: Cofinity Advantage |
$422.69
|
| Rate for Payer: Cofinity Commercial |
$519.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$483.07
|
| Rate for Payer: Healthscope Commercial |
$543.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$422.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$452.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$513.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$452.88
|
| Rate for Payer: PHP Commercial |
$513.26
|
| Rate for Payer: Priority Health SBD |
$380.42
|
| Rate for Payer: UMR Bronson Commercial |
$265.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$452.88
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 68084028011
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Aetna American Axle |
$3.93
|
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.93
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Cofinity Advantage |
$4.23
|
| Rate for Payer: Cofinity Commercial |
$5.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.83
|
| Rate for Payer: Healthscope Commercial |
$5.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.53
|
| Rate for Payer: PHP Commercial |
$5.13
|
| Rate for Payer: Priority Health SBD |
$3.81
|
| Rate for Payer: UMR Bronson Commercial |
$2.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.53
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 68084028011
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Aetna American Axle |
$3.93
|
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: Aetna Medicare |
$3.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.93
|
| Rate for Payer: BCBS Complete |
$2.42
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Cofinity Advantage |
$4.23
|
| Rate for Payer: Cofinity Commercial |
$5.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.83
|
| Rate for Payer: Healthscope Commercial |
$5.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.53
|
| Rate for Payer: PHP Commercial |
$5.13
|
| Rate for Payer: Priority Health SBD |
$3.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.93
|
| Rate for Payer: UHC Core |
$3.15
|
| Rate for Payer: UHC Exchange |
$2.37
|
| Rate for Payer: UMR Bronson Commercial |
$2.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.53
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$350.40
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.18 |
| Max. Negotiated Rate |
$315.36 |
| Rate for Payer: Aetna American Axle |
$227.76
|
| Rate for Payer: Aetna Commercial |
$297.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.76
|
| Rate for Payer: Cash Price |
$280.32
|
| Rate for Payer: Cofinity Advantage |
$245.28
|
| Rate for Payer: Cofinity Commercial |
$301.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.32
|
| Rate for Payer: Healthscope Commercial |
$315.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$245.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.80
|
| Rate for Payer: PHP Commercial |
$297.84
|
| Rate for Payer: Priority Health SBD |
$220.75
|
| Rate for Payer: UMR Bronson Commercial |
$154.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.80
|
|
