|
ETHMOIDECTOMY; INTRANASAL, ANTERIOR
|
Facility
|
OP
|
$16,240.34
|
|
|
Service Code
|
CPT 31200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,092.41 |
| Max. Negotiated Rate |
$16,240.34 |
| Rate for Payer: Aetna Medicare |
$6,000.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,211.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,211.77
|
| Rate for Payer: BCBS Complete |
$3,247.03
|
| Rate for Payer: BCBS MAPPO |
$5,769.42
|
| Rate for Payer: BCN Medicare Advantage |
$5,769.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,769.42
|
| Rate for Payer: Mclaren Medicaid |
$3,092.41
|
| Rate for Payer: Mclaren Medicare |
$5,769.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,057.89
|
| Rate for Payer: Meridian Medicaid |
$3,247.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,634.83
|
| Rate for Payer: PACE Medicare |
$5,480.95
|
| Rate for Payer: PACE SWMI |
$5,769.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,769.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,092.41
|
| Rate for Payer: Priority Health Medicare |
$5,769.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,769.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,240.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,769.42
|
| Rate for Payer: UHC Exchange |
$11,025.94
|
| Rate for Payer: UHC Medicare Advantage |
$5,769.42
|
| Rate for Payer: UHCCP Medicaid |
$3,092.41
|
| Rate for Payer: VA VA |
$5,769.42
|
|
|
ETHMOIDECTOMY; INTRANASAL, TOTAL
|
Facility
|
OP
|
$4,066.57
|
|
|
Service Code
|
CPT 31201
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$774.34 |
| Max. Negotiated Rate |
$4,066.57 |
| Rate for Payer: Aetna Medicare |
$1,502.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,805.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,805.83
|
| Rate for Payer: BCBS Complete |
$813.05
|
| Rate for Payer: BCBS MAPPO |
$1,444.66
|
| Rate for Payer: BCN Medicare Advantage |
$1,444.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,444.66
|
| Rate for Payer: Mclaren Medicaid |
$774.34
|
| Rate for Payer: Mclaren Medicare |
$1,444.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,516.89
|
| Rate for Payer: Meridian Medicaid |
$813.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,661.36
|
| Rate for Payer: PACE Medicare |
$1,372.43
|
| Rate for Payer: PACE SWMI |
$1,444.66
|
| Rate for Payer: PHP Medicare Advantage |
$1,444.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$774.34
|
| Rate for Payer: Priority Health Medicare |
$1,444.66
|
| Rate for Payer: Railroad Medicare Medicare |
$1,444.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,066.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,444.66
|
| Rate for Payer: UHC Exchange |
$2,760.89
|
| Rate for Payer: UHC Medicare Advantage |
$1,444.66
|
| Rate for Payer: UHCCP Medicaid |
$774.34
|
| Rate for Payer: VA VA |
$1,444.66
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,280.99
|
|
|
Service Code
|
NDC 59762235007
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$473.97 |
| Max. Negotiated Rate |
$1,152.89 |
| Rate for Payer: Aetna American Axle |
$832.64
|
| Rate for Payer: Aetna Commercial |
$1,088.84
|
| Rate for Payer: Aetna Medicare |
$640.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$832.64
|
| Rate for Payer: BCBS Complete |
$512.40
|
| Rate for Payer: Cash Price |
$1,024.79
|
| Rate for Payer: Cofinity Commercial |
$1,101.65
|
| Rate for Payer: Cofinity Commercial |
$896.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$896.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,024.79
|
| Rate for Payer: Healthscope Commercial |
$1,152.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$896.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$960.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,088.84
|
| Rate for Payer: PHP Commercial |
$1,088.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$832.64
|
| Rate for Payer: Priority Health SBD |
$807.02
|
| Rate for Payer: UMR Bronson Commercial |
$473.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$960.74
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,233.83
|
|
|
Service Code
|
NDC 00071241819
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$542.89 |
| Max. Negotiated Rate |
$1,110.45 |
| Rate for Payer: Aetna American Axle |
$801.99
|
| Rate for Payer: Aetna Commercial |
$1,048.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$801.99
|
| Rate for Payer: Cash Price |
$987.06
|
| Rate for Payer: Cofinity Commercial |
$1,061.09
|
| Rate for Payer: Cofinity Commercial |
$863.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$863.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$987.06
|
| Rate for Payer: Healthscope Commercial |
$1,110.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$863.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$925.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,048.76
|
| Rate for Payer: PHP Commercial |
$1,048.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$801.99
|
| Rate for Payer: Priority Health SBD |
$777.31
|
| Rate for Payer: UMR Bronson Commercial |
$542.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$925.37
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,280.99
|
|
|
Service Code
|
NDC 59762235007
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$563.64 |
| Max. Negotiated Rate |
$1,152.89 |
| Rate for Payer: Aetna American Axle |
$832.64
|
| Rate for Payer: Aetna Commercial |
$1,088.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$832.64
|
| Rate for Payer: Cash Price |
$1,024.79
|
| Rate for Payer: Cofinity Commercial |
$1,101.65
|
| Rate for Payer: Cofinity Commercial |
$896.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$896.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,024.79
|
| Rate for Payer: Healthscope Commercial |
$1,152.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$896.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$960.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,088.84
|
| Rate for Payer: PHP Commercial |
$1,088.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$832.64
|
| Rate for Payer: Priority Health SBD |
$807.02
|
| Rate for Payer: UMR Bronson Commercial |
$563.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$960.74
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,180.74
|
|
|
Service Code
|
NDC 00121067016
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$436.87 |
| Max. Negotiated Rate |
$1,062.67 |
| Rate for Payer: Aetna American Axle |
$767.48
|
| Rate for Payer: Aetna Commercial |
$1,003.63
|
| Rate for Payer: Aetna Medicare |
$590.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$767.48
|
| Rate for Payer: BCBS Complete |
$472.30
|
| Rate for Payer: Cash Price |
$944.59
|
| Rate for Payer: Cofinity Commercial |
$1,015.44
|
| Rate for Payer: Cofinity Commercial |
$826.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$826.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$944.59
|
| Rate for Payer: Healthscope Commercial |
$1,062.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$826.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$885.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,003.63
|
| Rate for Payer: PHP Commercial |
$1,003.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$767.48
|
| Rate for Payer: Priority Health SBD |
$743.87
|
| Rate for Payer: UMR Bronson Commercial |
$436.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$885.55
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,180.74
|
|
|
Service Code
|
NDC 00121067016
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$519.53 |
| Max. Negotiated Rate |
$1,062.67 |
| Rate for Payer: Aetna American Axle |
$767.48
|
| Rate for Payer: Aetna Commercial |
$1,003.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$767.48
|
| Rate for Payer: Cash Price |
$944.59
|
| Rate for Payer: Cofinity Commercial |
$1,015.44
|
| Rate for Payer: Cofinity Commercial |
$826.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$826.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$944.59
|
| Rate for Payer: Healthscope Commercial |
$1,062.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$826.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$885.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,003.63
|
| Rate for Payer: PHP Commercial |
$1,003.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$767.48
|
| Rate for Payer: Priority Health SBD |
$743.87
|
| Rate for Payer: UMR Bronson Commercial |
$519.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$885.55
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,233.83
|
|
|
Service Code
|
NDC 00071241819
|
| Hospital Charge Code |
38489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$456.52 |
| Max. Negotiated Rate |
$1,110.45 |
| Rate for Payer: Aetna American Axle |
$801.99
|
| Rate for Payer: Aetna Commercial |
$1,048.76
|
| Rate for Payer: Aetna Medicare |
$616.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$801.99
|
| Rate for Payer: BCBS Complete |
$493.53
|
| Rate for Payer: Cash Price |
$987.06
|
| Rate for Payer: Cofinity Commercial |
$1,061.09
|
| Rate for Payer: Cofinity Commercial |
$863.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$863.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$987.06
|
| Rate for Payer: Healthscope Commercial |
$1,110.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$863.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$925.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,048.76
|
| Rate for Payer: PHP Commercial |
$1,048.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$801.99
|
| Rate for Payer: Priority Health SBD |
$777.31
|
| Rate for Payer: UMR Bronson Commercial |
$456.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$925.37
|
|
|
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 Commercial |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$374.98
|
| 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: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.19
|
| Rate for Payer: Priority Health SBD |
$337.48
|
| 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 Commercial |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$374.98
|
| 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: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.19
|
| 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
|
|
|
ETHOXYDIGLYCOL (BULK) 100 % LIQUID
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
NDC 38779190305
|
| Hospital Charge Code |
42293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.28 |
| Max. Negotiated Rate |
$145.80 |
| Rate for Payer: Aetna American Axle |
$105.30
|
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.30
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cofinity Commercial |
$113.40
|
| Rate for Payer: Cofinity Commercial |
$139.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.60
|
| Rate for Payer: Healthscope Commercial |
$145.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.70
|
| Rate for Payer: PHP Commercial |
$137.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.30
|
| Rate for Payer: Priority Health SBD |
$102.06
|
| Rate for Payer: UMR Bronson Commercial |
$71.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.50
|
|
|
ETHOXYDIGLYCOL (BULK) 100 % LIQUID
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
NDC 38779190305
|
| Hospital Charge Code |
42293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.94 |
| Max. Negotiated Rate |
$145.80 |
| Rate for Payer: Aetna American Axle |
$105.30
|
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.30
|
| Rate for Payer: BCBS Complete |
$64.80
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cofinity Commercial |
$113.40
|
| Rate for Payer: Cofinity Commercial |
$139.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.60
|
| Rate for Payer: Healthscope Commercial |
$145.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.70
|
| Rate for Payer: PHP Commercial |
$137.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.30
|
| Rate for Payer: Priority Health SBD |
$102.06
|
| Rate for Payer: UMR Bronson Commercial |
$59.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.50
|
|
|
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 Commercial |
$336.00
|
| Rate for Payer: Cofinity Commercial |
$412.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$336.00
|
| 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: PHP Commercial |
$408.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.00
|
| Rate for Payer: Priority Health SBD |
$302.40
|
| 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 Commercial |
$336.00
|
| Rate for Payer: Cofinity Commercial |
$412.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$336.00
|
| 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: PHP Commercial |
$408.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.00
|
| 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 Commercial |
$151.64
|
| Rate for Payer: Cofinity Commercial |
$186.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$151.64
|
| 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: PHP Commercial |
$184.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.81
|
| 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 Commercial |
$151.64
|
| Rate for Payer: Cofinity Commercial |
$186.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$151.64
|
| 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: PHP Commercial |
$184.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.81
|
| Rate for Payer: Priority Health SBD |
$136.48
|
| Rate for Payer: UMR Bronson Commercial |
$80.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.47
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18.06
|
|
|
Service Code
|
NDC 55150022110
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Aetna American Axle |
$11.74
|
| Rate for Payer: Aetna Commercial |
$15.35
|
| Rate for Payer: Aetna Medicare |
$9.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.74
|
| Rate for Payer: BCBS Complete |
$7.22
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cofinity Commercial |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$15.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.45
|
| Rate for Payer: Healthscope Commercial |
$16.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.35
|
| Rate for Payer: PHP Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.74
|
| Rate for Payer: Priority Health SBD |
$11.38
|
| Rate for Payer: UMR Bronson Commercial |
$6.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.54
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.65
|
|
|
Service Code
|
NDC 00143950601
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: Cash Price |
$19.72
|
| Rate for Payer: Cofinity Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.72
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.95
|
| Rate for Payer: PHP Commercial |
$20.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health SBD |
$15.53
|
| Rate for Payer: UMR Bronson Commercial |
$10.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.49
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18.43
|
|
|
Service Code
|
NDC 65219044501
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna American Axle |
$11.98
|
| Rate for Payer: Aetna Commercial |
$15.67
|
| Rate for Payer: Aetna Medicare |
$9.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.98
|
| Rate for Payer: BCBS Complete |
$7.37
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Commercial |
$15.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.74
|
| Rate for Payer: Healthscope Commercial |
$16.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.67
|
| Rate for Payer: PHP Commercial |
$15.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.98
|
| Rate for Payer: Priority Health SBD |
$11.61
|
| Rate for Payer: UMR Bronson Commercial |
$6.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.82
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.43
|
|
|
Service Code
|
NDC 65219044501
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$16.59 |
| Rate for Payer: Aetna American Axle |
$11.98
|
| Rate for Payer: Aetna Commercial |
$15.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.98
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$12.90
|
| Rate for Payer: Cofinity Commercial |
$15.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.74
|
| Rate for Payer: Healthscope Commercial |
$16.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.67
|
| Rate for Payer: PHP Commercial |
$15.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.98
|
| Rate for Payer: Priority Health SBD |
$11.61
|
| Rate for Payer: UMR Bronson Commercial |
$8.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.82
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$22.92
|
|
|
Service Code
|
NDC 00409669501
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$20.63 |
| Rate for Payer: Aetna American Axle |
$14.90
|
| Rate for Payer: Aetna Commercial |
$19.48
|
| Rate for Payer: Aetna Medicare |
$11.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.90
|
| Rate for Payer: BCBS Complete |
$9.17
|
| Rate for Payer: Cash Price |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$16.04
|
| Rate for Payer: Cofinity Commercial |
$19.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.34
|
| Rate for Payer: Healthscope Commercial |
$20.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.48
|
| Rate for Payer: PHP Commercial |
$19.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.90
|
| Rate for Payer: Priority Health SBD |
$14.44
|
| Rate for Payer: UMR Bronson Commercial |
$8.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.19
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.01
|
|
|
Service Code
|
NDC 23155016041
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: Aetna American Axle |
$14.96
|
| Rate for Payer: Aetna Commercial |
$19.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.96
|
| Rate for Payer: Cash Price |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$16.11
|
| Rate for Payer: Cofinity Commercial |
$19.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.41
|
| Rate for Payer: Healthscope Commercial |
$20.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.56
|
| Rate for Payer: PHP Commercial |
$19.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.96
|
| Rate for Payer: Priority Health SBD |
$14.50
|
| Rate for Payer: UMR Bronson Commercial |
$10.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.26
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.01
|
|
|
Service Code
|
NDC 23155016031
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$20.71 |
| Rate for Payer: Aetna American Axle |
$14.96
|
| Rate for Payer: Aetna Commercial |
$19.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.96
|
| Rate for Payer: Cash Price |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$16.11
|
| Rate for Payer: Cofinity Commercial |
$19.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.41
|
| Rate for Payer: Healthscope Commercial |
$20.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.56
|
| Rate for Payer: PHP Commercial |
$19.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.96
|
| Rate for Payer: Priority Health SBD |
$14.50
|
| Rate for Payer: UMR Bronson Commercial |
$10.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.26
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$31.24
|
|
|
Service Code
|
NDC 00517078010
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.75 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Aetna American Axle |
$20.31
|
| Rate for Payer: Aetna Commercial |
$26.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.31
|
| Rate for Payer: Cash Price |
$24.99
|
| Rate for Payer: Cofinity Commercial |
$21.87
|
| Rate for Payer: Cofinity Commercial |
$26.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.99
|
| Rate for Payer: Healthscope Commercial |
$28.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.55
|
| Rate for Payer: PHP Commercial |
$26.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.31
|
| Rate for Payer: Priority Health SBD |
$19.68
|
| Rate for Payer: UMR Bronson Commercial |
$13.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.43
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$66.44
|
|
|
Service Code
|
NDC 00409806201
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.23 |
| Max. Negotiated Rate |
$59.80 |
| Rate for Payer: Aetna American Axle |
$43.19
|
| Rate for Payer: Aetna Commercial |
$56.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.19
|
| Rate for Payer: Cash Price |
$53.15
|
| Rate for Payer: Cofinity Commercial |
$46.51
|
| Rate for Payer: Cofinity Commercial |
$57.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.15
|
| Rate for Payer: Healthscope Commercial |
$59.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.47
|
| Rate for Payer: PHP Commercial |
$56.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.19
|
| Rate for Payer: Priority Health SBD |
$41.86
|
| Rate for Payer: UMR Bronson Commercial |
$29.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.83
|
|
