|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
OP
|
$389.50
|
|
|
Service Code
|
NDC 68180028101
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.12 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna American Axle |
$253.18
|
| Rate for Payer: Aetna Commercial |
$331.07
|
| Rate for Payer: Aetna Medicare |
$194.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.18
|
| Rate for Payer: BCBS Complete |
$155.80
|
| 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: MI Amish Medical Board Commercial |
$311.60
|
| 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: UHC All Payor (Choice/PPO) |
$253.18
|
| Rate for Payer: UHC Core |
$202.93
|
| Rate for Payer: UHC Exchange |
$153.07
|
| Rate for Payer: UMR Bronson Commercial |
$144.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.12
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
OP
|
$350.40
|
|
|
Service Code
|
NDC 68850001201
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.65 |
| Max. Negotiated Rate |
$315.36 |
| Rate for Payer: Aetna American Axle |
$227.76
|
| Rate for Payer: Aetna Commercial |
$297.84
|
| Rate for Payer: Aetna Medicare |
$175.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.76
|
| Rate for Payer: BCBS Complete |
$140.16
|
| 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: MI Amish Medical Board Commercial |
$280.32
|
| 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: UHC All Payor (Choice/PPO) |
$227.76
|
| Rate for Payer: UHC Core |
$182.56
|
| Rate for Payer: UHC Exchange |
$137.71
|
| Rate for Payer: UMR Bronson Commercial |
$129.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.80
|
|
|
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
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,573.12
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
9984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.24 |
| Max. Negotiated Rate |
$1,676.69 |
| Rate for Payer: Aetna American Axle |
$1,022.53
|
| Rate for Payer: Aetna Commercial |
$1,337.15
|
| Rate for Payer: Aetna Medicare |
$539.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$648.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$648.29
|
| Rate for Payer: BCBS Complete |
$284.83
|
| Rate for Payer: BCBS MAPPO |
$518.63
|
| Rate for Payer: BCBS Trust/PPO |
$1,676.69
|
| Rate for Payer: BCN Commercial |
$1,676.69
|
| Rate for Payer: BCN Medicare Advantage |
$518.63
|
| Rate for Payer: Cash Price |
$1,258.50
|
| Rate for Payer: Cash Price |
$1,258.50
|
| Rate for Payer: Cofinity Advantage |
$1,101.18
|
| Rate for Payer: Cofinity Commercial |
$1,352.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$518.63
|
| Rate for Payer: Healthscope Commercial |
$1,415.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,101.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,179.84
|
| Rate for Payer: Mclaren Medicaid |
$518.63
|
| Rate for Payer: Mclaren Medicare |
$518.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$544.56
|
| Rate for Payer: Meridian Medicaid |
$544.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$596.42
|
| Rate for Payer: Molina Medicare/Medicaid |
$570.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,337.15
|
| Rate for Payer: Nomi Health Commercial |
$1,555.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,179.84
|
| Rate for Payer: PACE Medicare |
$492.70
|
| Rate for Payer: PACE SWMI |
$518.63
|
| Rate for Payer: PHP Commercial |
$1,337.15
|
| Rate for Payer: PHP Medicare Advantage |
$518.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$271.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,605.25
|
| Rate for Payer: Priority Health Medicare |
$518.63
|
| Rate for Payer: Priority Health SBD |
$991.07
|
| Rate for Payer: Priority Health Tiered Network |
$1,284.20
|
| Rate for Payer: Railroad Medicare Medicare |
$518.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$853.18
|
| Rate for Payer: UHC Core |
$853.18
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$518.63
|
| Rate for Payer: UHC Exchange |
$853.18
|
| Rate for Payer: UHC Medicaid |
$271.24
|
| Rate for Payer: UHCCP Medicaid |
$271.24
|
| Rate for Payer: UMR Bronson Commercial |
$582.05
|
| Rate for Payer: VA VA |
$518.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,179.84
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,573.12
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
9984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$692.17 |
| Max. Negotiated Rate |
$1,415.81 |
| Rate for Payer: Aetna American Axle |
$1,022.53
|
| Rate for Payer: Aetna Commercial |
$1,337.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.53
|
| Rate for Payer: Cash Price |
$1,258.50
|
| Rate for Payer: Cofinity Advantage |
$1,101.18
|
| Rate for Payer: Cofinity Commercial |
$1,352.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.50
|
| Rate for Payer: Healthscope Commercial |
$1,415.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,101.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,179.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,337.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,179.84
|
| Rate for Payer: PHP Commercial |
$1,337.15
|
| Rate for Payer: Priority Health SBD |
$991.07
|
| Rate for Payer: UMR Bronson Commercial |
$692.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,179.84
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,203.02
|
|
|
Service Code
|
NDC 00121067016
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$529.33 |
| Max. Negotiated Rate |
$1,082.72 |
| Rate for Payer: Aetna American Axle |
$781.96
|
| Rate for Payer: Aetna Commercial |
$1,022.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.96
|
| Rate for Payer: Cash Price |
$962.42
|
| Rate for Payer: Cofinity Advantage |
$842.11
|
| Rate for Payer: Cofinity Commercial |
$1,034.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$962.42
|
| Rate for Payer: Healthscope Commercial |
$1,082.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$842.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$902.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,022.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$902.26
|
| Rate for Payer: PHP Commercial |
$1,022.57
|
| Rate for Payer: Priority Health SBD |
$757.90
|
| Rate for Payer: UMR Bronson Commercial |
$529.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$902.26
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,265.35
|
|
|
Service Code
|
NDC 00071241819
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$468.18 |
| Max. Negotiated Rate |
$1,138.82 |
| Rate for Payer: Aetna American Axle |
$822.48
|
| Rate for Payer: Aetna Commercial |
$1,075.55
|
| Rate for Payer: Aetna Medicare |
$632.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$822.48
|
| Rate for Payer: BCBS Complete |
$506.14
|
| Rate for Payer: Cash Price |
$1,012.28
|
| Rate for Payer: Cofinity Advantage |
$885.75
|
| Rate for Payer: Cofinity Commercial |
$1,088.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,012.28
|
| Rate for Payer: Healthscope Commercial |
$1,138.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$885.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$949.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,012.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,075.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$949.01
|
| Rate for Payer: PHP Commercial |
$1,075.55
|
| Rate for Payer: Priority Health SBD |
$797.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$822.48
|
| Rate for Payer: UHC Core |
$659.25
|
| Rate for Payer: UHC Exchange |
$497.28
|
| Rate for Payer: UMR Bronson Commercial |
$468.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$949.01
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,236.43
|
|
|
Service Code
|
NDC 59762235007
|
| 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 Advantage |
$865.50
|
| Rate for Payer: Cofinity Commercial |
$1,063.33
|
| 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 Commercial |
$1,050.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$927.32
|
| Rate for Payer: PHP Commercial |
$1,050.97
|
| 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
|
OP
|
$1,203.02
|
|
|
Service Code
|
NDC 00121067016
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$445.12 |
| Max. Negotiated Rate |
$1,082.72 |
| Rate for Payer: Aetna American Axle |
$781.96
|
| Rate for Payer: Aetna Commercial |
$1,022.57
|
| Rate for Payer: Aetna Medicare |
$601.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.96
|
| Rate for Payer: BCBS Complete |
$481.21
|
| Rate for Payer: Cash Price |
$962.42
|
| Rate for Payer: Cofinity Advantage |
$842.11
|
| Rate for Payer: Cofinity Commercial |
$1,034.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$962.42
|
| Rate for Payer: Healthscope Commercial |
$1,082.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$842.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$902.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$962.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,022.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$902.26
|
| Rate for Payer: PHP Commercial |
$1,022.57
|
| Rate for Payer: Priority Health SBD |
$757.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$781.96
|
| Rate for Payer: UHC Core |
$626.77
|
| Rate for Payer: UHC Exchange |
$472.79
|
| Rate for Payer: UMR Bronson Commercial |
$445.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$902.26
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,236.43
|
|
|
Service Code
|
NDC 59762235007
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$457.48 |
| 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 Medicare |
$618.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$803.68
|
| Rate for Payer: BCBS Complete |
$494.57
|
| Rate for Payer: Cash Price |
$989.14
|
| Rate for Payer: Cofinity Advantage |
$865.50
|
| Rate for Payer: Cofinity Commercial |
$1,063.33
|
| 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: MI Amish Medical Board Commercial |
$989.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,050.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$927.32
|
| Rate for Payer: PHP Commercial |
$1,050.97
|
| Rate for Payer: Priority Health SBD |
$778.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$803.68
|
| Rate for Payer: UHC Core |
$644.18
|
| Rate for Payer: UHC Exchange |
$485.92
|
| Rate for Payer: UMR Bronson Commercial |
$457.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$927.32
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,265.35
|
|
|
Service Code
|
NDC 00071241819
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$556.75 |
| Max. Negotiated Rate |
$1,138.82 |
| Rate for Payer: Aetna American Axle |
$822.48
|
| Rate for Payer: Aetna Commercial |
$1,075.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$822.48
|
| Rate for Payer: Cash Price |
$1,012.28
|
| Rate for Payer: Cofinity Advantage |
$885.75
|
| Rate for Payer: Cofinity Commercial |
$1,088.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,012.28
|
| Rate for Payer: Healthscope Commercial |
$1,138.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$885.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$949.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,075.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$949.01
|
| Rate for Payer: PHP Commercial |
$1,075.55
|
| Rate for Payer: Priority Health SBD |
$797.17
|
| Rate for Payer: UMR Bronson Commercial |
$556.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$949.01
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
IP
|
$264.10
|
|
|
Service Code
|
NDC 64380087806
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna American Axle |
$171.66
|
| Rate for Payer: Aetna Commercial |
$224.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Advantage |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.07
|
| Rate for Payer: PHP Commercial |
$224.49
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UMR Bronson Commercial |
$116.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.07
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
OP
|
$535.68
|
|
|
Service Code
|
NDC 23155053201
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.20 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna American Axle |
$348.19
|
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna Medicare |
$267.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: BCBS Complete |
$214.27
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Advantage |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$428.54
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$374.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$401.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$428.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$401.76
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health SBD |
$337.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$348.19
|
| Rate for Payer: UHC Core |
$279.09
|
| Rate for Payer: UHC Exchange |
$210.52
|
| Rate for Payer: UMR Bronson Commercial |
$198.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$401.76
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
IP
|
$535.68
|
|
|
Service Code
|
NDC 23155053201
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.70 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna American Axle |
$348.19
|
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Advantage |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$428.54
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$374.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$401.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$401.76
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health SBD |
$337.48
|
| Rate for Payer: UMR Bronson Commercial |
$235.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$401.76
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE
|
Facility
|
OP
|
$264.10
|
|
|
Service Code
|
NDC 64380087806
|
| Hospital Charge Code |
9989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.72 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna American Axle |
$171.66
|
| Rate for Payer: Aetna Commercial |
$224.49
|
| Rate for Payer: Aetna Medicare |
$132.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: BCBS Complete |
$105.64
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Advantage |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.07
|
| Rate for Payer: PHP Commercial |
$224.49
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.66
|
| Rate for Payer: UHC Core |
$137.60
|
| Rate for Payer: UHC Exchange |
$103.79
|
| Rate for Payer: UMR Bronson Commercial |
$97.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.07
|
|
|
ETHOXYDIGLYCOL (BULK) 100 % LIQUID
|
Facility
|
OP
|
$205.20
|
|
|
Service Code
|
NDC 38779190305
|
| Hospital Charge Code |
42293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.92 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna American Axle |
$133.38
|
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.38
|
| Rate for Payer: BCBS Complete |
$82.08
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Advantage |
$143.64
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$164.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$153.90
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health SBD |
$129.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$133.38
|
| Rate for Payer: UHC Core |
$106.91
|
| Rate for Payer: UHC Exchange |
$80.64
|
| Rate for Payer: UMR Bronson Commercial |
$75.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
|
ETHOXYDIGLYCOL (BULK) 100 % LIQUID
|
Facility
|
IP
|
$205.20
|
|
|
Service Code
|
NDC 38779190305
|
| Hospital Charge Code |
42293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.29 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna American Axle |
$133.38
|
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.38
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Advantage |
$143.64
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$153.90
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health SBD |
$129.28
|
| Rate for Payer: UMR Bronson Commercial |
$90.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION
|
Facility
|
IP
|
$1,078.31
|
|
|
Service Code
|
NDC 16729071045
|
| Hospital Charge Code |
189453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$474.46 |
| Max. Negotiated Rate |
$970.48 |
| Rate for Payer: Aetna American Axle |
$700.90
|
| Rate for Payer: Aetna Commercial |
$916.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$700.90
|
| Rate for Payer: Cash Price |
$862.65
|
| Rate for Payer: Cofinity Advantage |
$754.82
|
| Rate for Payer: Cofinity Commercial |
$927.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$862.65
|
| Rate for Payer: Healthscope Commercial |
$970.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$754.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$808.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$916.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$808.73
|
| Rate for Payer: PHP Commercial |
$916.56
|
| Rate for Payer: Priority Health SBD |
$679.34
|
| Rate for Payer: UMR Bronson Commercial |
$474.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$808.73
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION
|
Facility
|
OP
|
$1,078.31
|
|
|
Service Code
|
NDC 16729071045
|
| Hospital Charge Code |
189453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$398.97 |
| Max. Negotiated Rate |
$970.48 |
| Rate for Payer: Aetna American Axle |
$700.90
|
| Rate for Payer: Aetna Commercial |
$916.56
|
| Rate for Payer: Aetna Medicare |
$539.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$700.90
|
| Rate for Payer: BCBS Complete |
$431.32
|
| Rate for Payer: Cash Price |
$862.65
|
| Rate for Payer: Cofinity Advantage |
$754.82
|
| Rate for Payer: Cofinity Commercial |
$927.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$862.65
|
| Rate for Payer: Healthscope Commercial |
$970.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$754.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$808.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$862.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$916.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$808.73
|
| Rate for Payer: PHP Commercial |
$916.56
|
| Rate for Payer: Priority Health SBD |
$679.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$700.90
|
| Rate for Payer: UHC Core |
$561.80
|
| Rate for Payer: UHC Exchange |
$423.78
|
| Rate for Payer: UMR Bronson Commercial |
$398.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$808.73
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION
|
Facility
|
OP
|
$1,078.31
|
|
|
Service Code
|
NDC 16729071031
|
| Hospital Charge Code |
189453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$398.97 |
| Max. Negotiated Rate |
$970.48 |
| Rate for Payer: Aetna American Axle |
$700.90
|
| Rate for Payer: Aetna Commercial |
$916.56
|
| Rate for Payer: Aetna Medicare |
$539.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$700.90
|
| Rate for Payer: BCBS Complete |
$431.32
|
| Rate for Payer: Cash Price |
$862.65
|
| Rate for Payer: Cofinity Advantage |
$754.82
|
| Rate for Payer: Cofinity Commercial |
$927.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$862.65
|
| Rate for Payer: Healthscope Commercial |
$970.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$754.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$808.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$862.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$916.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$808.73
|
| Rate for Payer: PHP Commercial |
$916.56
|
| Rate for Payer: Priority Health SBD |
$679.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$700.90
|
| Rate for Payer: UHC Core |
$561.80
|
| Rate for Payer: UHC Exchange |
$423.78
|
| Rate for Payer: UMR Bronson Commercial |
$398.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$808.73
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION
|
Facility
|
IP
|
$1,078.31
|
|
|
Service Code
|
NDC 16729071031
|
| Hospital Charge Code |
189453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$474.46 |
| Max. Negotiated Rate |
$970.48 |
| Rate for Payer: Aetna American Axle |
$700.90
|
| Rate for Payer: Aetna Commercial |
$916.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$700.90
|
| Rate for Payer: Cash Price |
$862.65
|
| Rate for Payer: Cofinity Advantage |
$754.82
|
| Rate for Payer: Cofinity Commercial |
$927.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$862.65
|
| Rate for Payer: Healthscope Commercial |
$970.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$754.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$808.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$916.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$808.73
|
| Rate for Payer: PHP Commercial |
$916.56
|
| Rate for Payer: Priority Health SBD |
$679.34
|
| Rate for Payer: UMR Bronson Commercial |
$474.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$808.73
|
|
|
ETHYL ALCOHOL (BULK) LIQUID
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
NDC 51552025606
|
| Hospital Charge Code |
16626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.60 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna American Axle |
$312.00
|
| Rate for Payer: Aetna Commercial |
$408.00
|
| Rate for Payer: Aetna Medicare |
$240.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.00
|
| Rate for Payer: BCBS Complete |
$192.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$384.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$408.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$360.00
|
| Rate for Payer: PHP Commercial |
$408.00
|
| Rate for Payer: Priority Health SBD |
$302.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$312.00
|
| Rate for Payer: UHC Core |
$250.08
|
| Rate for Payer: UHC Exchange |
$188.64
|
| Rate for Payer: UMR Bronson Commercial |
$177.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$360.00
|
|
|
ETHYL ALCOHOL (BULK) LIQUID
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
NDC 51552025606
|
| 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 Advantage |
$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 Commercial |
$408.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$360.00
|
| Rate for Payer: PHP Commercial |
$408.00
|
| 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
|
IP
|
$216.63
|
|
|
Service Code
|
NDC 00386000102
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.32 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Aetna American Axle |
$140.81
|
| Rate for Payer: Aetna Commercial |
$184.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.81
|
| Rate for Payer: Cash Price |
$173.30
|
| Rate for Payer: Cofinity Advantage |
$151.64
|
| Rate for Payer: Cofinity Commercial |
$186.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.30
|
| Rate for Payer: Healthscope Commercial |
$194.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$151.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.47
|
| Rate for Payer: PHP Commercial |
$184.14
|
| Rate for Payer: Priority Health SBD |
$136.48
|
| Rate for Payer: UMR Bronson Commercial |
$95.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.47
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
OP
|
$216.63
|
|
|
Service Code
|
NDC 00386000102
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.15 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Aetna American Axle |
$140.81
|
| Rate for Payer: Aetna Commercial |
$184.14
|
| Rate for Payer: Aetna Medicare |
$108.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.81
|
| Rate for Payer: BCBS Complete |
$86.65
|
| Rate for Payer: Cash Price |
$173.30
|
| Rate for Payer: Cofinity Advantage |
$151.64
|
| Rate for Payer: Cofinity Commercial |
$186.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.30
|
| Rate for Payer: Healthscope Commercial |
$194.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$151.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$173.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.47
|
| Rate for Payer: PHP Commercial |
$184.14
|
| Rate for Payer: Priority Health SBD |
$136.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$140.81
|
| Rate for Payer: UHC Core |
$112.86
|
| Rate for Payer: UHC Exchange |
$85.14
|
| Rate for Payer: UMR Bronson Commercial |
$80.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.47
|
|
