|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$7,763.19
|
|
|
Service Code
|
NDC 42023015789
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,872.38 |
| Max. Negotiated Rate |
$6,986.87 |
| Rate for Payer: Aetna American Axle |
$5,046.07
|
| Rate for Payer: Aetna Commercial |
$6,598.71
|
| Rate for Payer: Aetna Medicare |
$3,881.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,046.07
|
| Rate for Payer: BCBS Complete |
$3,105.28
|
| Rate for Payer: Cash Price |
$6,210.55
|
| Rate for Payer: Cofinity Commercial |
$5,434.23
|
| Rate for Payer: Cofinity Commercial |
$6,676.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,434.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,210.55
|
| Rate for Payer: Healthscope Commercial |
$6,986.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,434.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,822.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,598.71
|
| Rate for Payer: PHP Commercial |
$6,598.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,046.07
|
| Rate for Payer: Priority Health SBD |
$4,890.81
|
| Rate for Payer: UMR Bronson Commercial |
$2,872.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,822.39
|
|
|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,657.64
|
|
|
Service Code
|
NDC 42023015701
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$729.36 |
| Max. Negotiated Rate |
$1,491.88 |
| Rate for Payer: Aetna American Axle |
$1,077.47
|
| Rate for Payer: Aetna Commercial |
$1,408.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.47
|
| Rate for Payer: Cash Price |
$1,326.11
|
| Rate for Payer: Cofinity Commercial |
$1,160.35
|
| Rate for Payer: Cofinity Commercial |
$1,425.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,326.11
|
| Rate for Payer: Healthscope Commercial |
$1,491.88
|
| 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: Multiplan/Beech St/PHCS Commercial |
$1,408.99
|
| Rate for Payer: PHP Commercial |
$1,408.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.47
|
| Rate for Payer: Priority Health SBD |
$1,044.31
|
| Rate for Payer: UMR Bronson Commercial |
$729.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,243.23
|
|
|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12,195.85
|
|
|
Service Code
|
NDC 25010021027
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
250
|
| 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 Commercial |
$10,366.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,927.30
|
| Rate for Payer: Cash Price |
$9,756.68
|
| Rate for Payer: Cofinity Commercial |
$10,488.43
|
| Rate for Payer: Cofinity Commercial |
$8,537.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,537.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,756.68
|
| Rate for Payer: Healthscope Commercial |
$10,976.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,537.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,146.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,366.47
|
| Rate for Payer: PHP Commercial |
$10,366.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,927.30
|
| Rate for Payer: Priority Health SBD |
$7,683.39
|
| Rate for Payer: UMR Bronson Commercial |
$5,366.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,146.89
|
|
|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,657.64
|
|
|
Service Code
|
NDC 42023015701
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$613.33 |
| Max. Negotiated Rate |
$1,491.88 |
| Rate for Payer: Aetna American Axle |
$1,077.47
|
| Rate for Payer: Aetna Commercial |
$1,408.99
|
| Rate for Payer: Aetna Medicare |
$828.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.47
|
| Rate for Payer: BCBS Complete |
$663.06
|
| Rate for Payer: Cash Price |
$1,326.11
|
| Rate for Payer: Cofinity Commercial |
$1,160.35
|
| Rate for Payer: Cofinity Commercial |
$1,425.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,326.11
|
| Rate for Payer: Healthscope Commercial |
$1,491.88
|
| 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: Multiplan/Beech St/PHCS Commercial |
$1,408.99
|
| Rate for Payer: PHP Commercial |
$1,408.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.47
|
| Rate for Payer: Priority Health SBD |
$1,044.31
|
| Rate for Payer: UMR Bronson Commercial |
$613.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,243.23
|
|
|
ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12,195.85
|
|
|
Service Code
|
NDC 25010021027
|
| Hospital Charge Code |
9979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,512.46 |
| Max. Negotiated Rate |
$10,976.26 |
| Rate for Payer: Aetna American Axle |
$7,927.30
|
| Rate for Payer: Aetna Commercial |
$10,366.47
|
| Rate for Payer: Aetna Medicare |
$6,097.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,927.30
|
| Rate for Payer: BCBS Complete |
$4,878.34
|
| Rate for Payer: Cash Price |
$9,756.68
|
| Rate for Payer: Cofinity Commercial |
$10,488.43
|
| Rate for Payer: Cofinity Commercial |
$8,537.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,537.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,756.68
|
| Rate for Payer: Healthscope Commercial |
$10,976.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,537.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,146.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,366.47
|
| Rate for Payer: PHP Commercial |
$10,366.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,927.30
|
| Rate for Payer: Priority Health SBD |
$7,683.39
|
| Rate for Payer: UMR Bronson Commercial |
$4,512.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,146.89
|
|
|
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 Commercial |
$5,887.59
|
| Rate for Payer: Cofinity Commercial |
$7,233.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,887.59
|
| 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: PHP Commercial |
$7,149.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,467.05
|
| 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
|
$870.24
|
|
|
Service Code
|
NDC 68180015901
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$382.91 |
| Max. Negotiated Rate |
$783.22 |
| Rate for Payer: Aetna American Axle |
$565.66
|
| Rate for Payer: Aetna Commercial |
$739.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$565.66
|
| Rate for Payer: Cash Price |
$696.19
|
| Rate for Payer: Cofinity Commercial |
$609.17
|
| Rate for Payer: Cofinity Commercial |
$748.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$609.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$696.19
|
| Rate for Payer: Healthscope Commercial |
$783.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$609.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$652.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$739.70
|
| Rate for Payer: PHP Commercial |
$739.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$565.66
|
| Rate for Payer: Priority Health SBD |
$548.25
|
| Rate for Payer: UMR Bronson Commercial |
$382.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$652.68
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
OP
|
$870.24
|
|
|
Service Code
|
NDC 68180015901
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.99 |
| Max. Negotiated Rate |
$783.22 |
| Rate for Payer: Aetna American Axle |
$565.66
|
| Rate for Payer: Aetna Commercial |
$739.70
|
| Rate for Payer: Aetna Medicare |
$435.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$565.66
|
| Rate for Payer: BCBS Complete |
$348.10
|
| Rate for Payer: Cash Price |
$696.19
|
| Rate for Payer: Cofinity Commercial |
$609.17
|
| Rate for Payer: Cofinity Commercial |
$748.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$609.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$696.19
|
| Rate for Payer: Healthscope Commercial |
$783.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$609.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$652.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$739.70
|
| Rate for Payer: PHP Commercial |
$739.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$565.66
|
| Rate for Payer: Priority Health SBD |
$548.25
|
| Rate for Payer: UMR Bronson Commercial |
$321.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$652.68
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
OP
|
$3,429.53
|
|
|
Service Code
|
NDC 49884027601
|
| Hospital Charge Code |
9980
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,268.93 |
| 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 Medicare |
$1,714.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,229.19
|
| Rate for Payer: BCBS Complete |
$1,371.81
|
| 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: Cofinity Medicare Advantage |
$2,400.67
|
| 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 Commercial |
$2,915.10
|
| Rate for Payer: PHP Commercial |
$2,915.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,229.19
|
| Rate for Payer: Priority Health SBD |
$2,160.60
|
| Rate for Payer: UMR Bronson Commercial |
$1,268.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,572.15
|
|
|
ETHACRYNIC ACID 25 MG TABLET
|
Facility
|
IP
|
$3,429.53
|
|
|
Service Code
|
NDC 49884027601
|
| 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: Cofinity Medicare Advantage |
$2,400.67
|
| 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 Commercial |
$2,915.10
|
| Rate for Payer: PHP Commercial |
$2,915.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,229.19
|
| 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
|
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 Commercial |
$5,887.59
|
| Rate for Payer: Cofinity Commercial |
$7,233.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,887.59
|
| 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: PHP Commercial |
$7,149.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,467.05
|
| Rate for Payer: Priority Health SBD |
$5,298.83
|
| 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
|
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 Commercial |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.58
|
| 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: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.26
|
| Rate for Payer: Priority Health SBD |
$268.73
|
| Rate for Payer: UMR Bronson Commercial |
$157.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.91
|
|
|
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 Commercial |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.58
|
| 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: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.26
|
| 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
|
OP
|
$240.35
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.93 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Medicare |
$120.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: BCBS Complete |
$96.14
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.25
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.23
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$88.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
ETHAMBUTOL 100 MG TABLET
|
Facility
|
IP
|
$240.35
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.75 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.25
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.23
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$105.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
OP
|
$426.24
|
|
|
Service Code
|
NDC 68180028101
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.71 |
| Max. Negotiated Rate |
$383.62 |
| Rate for Payer: Aetna American Axle |
$277.06
|
| Rate for Payer: Aetna Commercial |
$362.30
|
| Rate for Payer: Aetna Medicare |
$213.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.06
|
| Rate for Payer: BCBS Complete |
$170.50
|
| Rate for Payer: Cash Price |
$340.99
|
| Rate for Payer: Cofinity Commercial |
$298.37
|
| Rate for Payer: Cofinity Commercial |
$366.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.99
|
| Rate for Payer: Healthscope Commercial |
$383.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.30
|
| Rate for Payer: PHP Commercial |
$362.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.06
|
| Rate for Payer: Priority Health SBD |
$268.53
|
| Rate for Payer: UMR Bronson Commercial |
$157.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.68
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
OP
|
$404.64
|
|
|
Service Code
|
NDC 68084028011
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.72 |
| Max. Negotiated Rate |
$364.18 |
| Rate for Payer: Aetna American Axle |
$263.02
|
| Rate for Payer: Aetna Commercial |
$343.94
|
| Rate for Payer: Aetna Medicare |
$202.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.02
|
| Rate for Payer: BCBS Complete |
$161.86
|
| Rate for Payer: Cash Price |
$323.71
|
| Rate for Payer: Cofinity Commercial |
$283.25
|
| Rate for Payer: Cofinity Commercial |
$347.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$283.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.71
|
| Rate for Payer: Healthscope Commercial |
$364.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.94
|
| Rate for Payer: PHP Commercial |
$343.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.02
|
| Rate for Payer: Priority Health SBD |
$254.92
|
| Rate for Payer: UMR Bronson Commercial |
$149.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.48
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$426.24
|
|
|
Service Code
|
NDC 68180028101
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.55 |
| Max. Negotiated Rate |
$383.62 |
| Rate for Payer: Aetna American Axle |
$277.06
|
| Rate for Payer: Aetna Commercial |
$362.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.06
|
| Rate for Payer: Cash Price |
$340.99
|
| Rate for Payer: Cofinity Commercial |
$298.37
|
| Rate for Payer: Cofinity Commercial |
$366.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.99
|
| Rate for Payer: Healthscope Commercial |
$383.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.30
|
| Rate for Payer: PHP Commercial |
$362.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.06
|
| Rate for Payer: Priority Health SBD |
$268.53
|
| Rate for Payer: UMR Bronson Commercial |
$187.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.68
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$404.64
|
|
|
Service Code
|
NDC 68084028001
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.04 |
| Max. Negotiated Rate |
$364.18 |
| Rate for Payer: Aetna American Axle |
$263.02
|
| Rate for Payer: Aetna Commercial |
$343.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.02
|
| Rate for Payer: Cash Price |
$323.71
|
| Rate for Payer: Cofinity Commercial |
$283.25
|
| Rate for Payer: Cofinity Commercial |
$347.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$283.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.71
|
| Rate for Payer: Healthscope Commercial |
$364.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.94
|
| Rate for Payer: PHP Commercial |
$343.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.02
|
| Rate for Payer: Priority Health SBD |
$254.92
|
| Rate for Payer: UMR Bronson Commercial |
$178.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.48
|
|
|
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 Commercial |
$245.28
|
| Rate for Payer: Cofinity Commercial |
$301.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$245.28
|
| 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: PHP Commercial |
$297.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.76
|
| 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
|
|
|
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 Commercial |
$245.28
|
| Rate for Payer: Cofinity Commercial |
$301.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$245.28
|
| 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: PHP Commercial |
$297.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.76
|
| Rate for Payer: Priority Health SBD |
$220.75
|
| Rate for Payer: UMR Bronson Commercial |
$129.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.80
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
OP
|
$404.64
|
|
|
Service Code
|
NDC 68084028001
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.72 |
| Max. Negotiated Rate |
$364.18 |
| Rate for Payer: Aetna American Axle |
$263.02
|
| Rate for Payer: Aetna Commercial |
$343.94
|
| Rate for Payer: Aetna Medicare |
$202.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.02
|
| Rate for Payer: BCBS Complete |
$161.86
|
| Rate for Payer: Cash Price |
$323.71
|
| Rate for Payer: Cofinity Commercial |
$283.25
|
| Rate for Payer: Cofinity Commercial |
$347.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$283.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.71
|
| Rate for Payer: Healthscope Commercial |
$364.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.94
|
| Rate for Payer: PHP Commercial |
$343.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.02
|
| Rate for Payer: Priority Health SBD |
$254.92
|
| Rate for Payer: UMR Bronson Commercial |
$149.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.48
|
|
|
ETHAMBUTOL 400 MG TABLET
|
Facility
|
IP
|
$404.64
|
|
|
Service Code
|
NDC 68084028011
|
| Hospital Charge Code |
9983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.04 |
| Max. Negotiated Rate |
$364.18 |
| Rate for Payer: Aetna American Axle |
$263.02
|
| Rate for Payer: Aetna Commercial |
$343.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.02
|
| Rate for Payer: Cash Price |
$323.71
|
| Rate for Payer: Cofinity Commercial |
$283.25
|
| Rate for Payer: Cofinity Commercial |
$347.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$283.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.71
|
| Rate for Payer: Healthscope Commercial |
$364.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.94
|
| Rate for Payer: PHP Commercial |
$343.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.02
|
| Rate for Payer: Priority Health SBD |
$254.92
|
| Rate for Payer: UMR Bronson Commercial |
$178.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.48
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,429.68
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
9984
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$272.80 |
| Max. Negotiated Rate |
$1,432.67 |
| Rate for Payer: Aetna American Axle |
$929.29
|
| Rate for Payer: Aetna Commercial |
$1,215.23
|
| Rate for Payer: Aetna Medicare |
$529.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$636.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$636.20
|
| Rate for Payer: BCBS Complete |
$286.44
|
| Rate for Payer: BCBS MAPPO |
$508.96
|
| Rate for Payer: BCN Medicare Advantage |
$508.96
|
| Rate for Payer: Cash Price |
$1,143.74
|
| Rate for Payer: Cash Price |
$1,143.74
|
| Rate for Payer: Cofinity Commercial |
$1,229.52
|
| Rate for Payer: Cofinity Commercial |
$1,000.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$508.96
|
| 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: Mclaren Medicaid |
$272.80
|
| Rate for Payer: Mclaren Medicare |
$508.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$534.41
|
| Rate for Payer: Meridian Medicaid |
$286.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$585.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.23
|
| Rate for Payer: PACE Medicare |
$483.51
|
| Rate for Payer: PACE SWMI |
$508.96
|
| Rate for Payer: PHP Commercial |
$1,215.23
|
| Rate for Payer: PHP Medicare Advantage |
$508.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$272.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.29
|
| Rate for Payer: Priority Health Medicare |
$508.96
|
| Rate for Payer: Priority Health SBD |
$900.70
|
| Rate for Payer: Railroad Medicare Medicare |
$508.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,432.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$508.96
|
| Rate for Payer: UHC Exchange |
$972.67
|
| Rate for Payer: UHC Medicare Advantage |
$508.96
|
| Rate for Payer: UHCCP Medicaid |
$272.80
|
| Rate for Payer: UMR Bronson Commercial |
$528.98
|
| Rate for Payer: VA VA |
$508.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.26
|
|
|
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: Cofinity Medicare Advantage |
$1,000.78
|
| 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 Commercial |
$1,215.23
|
| Rate for Payer: PHP Commercial |
$1,215.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.29
|
| 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
|
|
