|
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 |
$383.90 |
| 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 |
$383.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: Multiplan/Beech St/PHCS 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
|
OP
|
$240.35
|
|
|
Service Code
|
NDC 68180028001
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.93 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Medicare |
$120.18
|
| 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 |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$168.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.24
|
| 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
|
$426.55
|
|
|
Service Code
|
NDC 54879000100
|
| Hospital Charge Code |
9982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.68 |
| Max. Negotiated Rate |
$383.90 |
| Rate for Payer: Aetna American Axle |
$277.26
|
| Rate for Payer: Aetna Commercial |
$362.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.26
|
| Rate for Payer: Cash Price |
$341.24
|
| Rate for Payer: Cofinity Commercial |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: Multiplan/Beech St/PHCS 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 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
|
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 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
|
$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 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
|
|
|
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
|
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
|
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
|
|
|
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
|
|
|
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 |
$263.52 |
| Max. Negotiated Rate |
$1,474.95 |
| Rate for Payer: Aetna American Axle |
$929.29
|
| Rate for Payer: Aetna Commercial |
$1,215.23
|
| Rate for Payer: Aetna Medicare |
$511.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$614.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$614.56
|
| Rate for Payer: BCBS Complete |
$276.70
|
| Rate for Payer: BCBS MAPPO |
$491.65
|
| Rate for Payer: BCBS Trust/PPO |
$1,325.74
|
| Rate for Payer: BCN Commercial |
$1,325.74
|
| Rate for Payer: BCN Medicare Advantage |
$491.65
|
| 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 |
$491.65
|
| 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 |
$263.52
|
| Rate for Payer: Mclaren Medicare |
$491.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$516.23
|
| Rate for Payer: Meridian Medicaid |
$276.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$565.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.23
|
| Rate for Payer: Nomi Health Commercial |
$1,474.95
|
| Rate for Payer: PACE Medicare |
$467.07
|
| Rate for Payer: PACE SWMI |
$491.65
|
| Rate for Payer: PHP Commercial |
$1,215.23
|
| Rate for Payer: PHP Medicare Advantage |
$491.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$263.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,415.08
|
| Rate for Payer: Priority Health Medicare |
$491.65
|
| Rate for Payer: Priority Health Narrow Network |
$1,132.06
|
| Rate for Payer: Priority Health SBD |
$900.70
|
| Rate for Payer: Railroad Medicare Medicare |
$491.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,383.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$491.65
|
| Rate for Payer: UHC Exchange |
$939.59
|
| Rate for Payer: UHC Medicare Advantage |
$491.65
|
| Rate for Payer: UHCCP Medicaid |
$263.52
|
| Rate for Payer: UMR Bronson Commercial |
$528.98
|
| Rate for Payer: VA VA |
$491.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.26
|
|
|
ETHMOIDECTOMY; INTRANASAL, ANTERIOR
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 31200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$582.63 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$3,174.78
|
| Rate for Payer: BCN Commercial |
$3,174.78
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$640.89
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$582.63
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,106.68
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
ETHMOIDECTOMY; INTRANASAL, TOTAL
|
Facility
|
OP
|
$4,561.52
|
|
|
Service Code
|
CPT 31201
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$738.28 |
| Max. Negotiated Rate |
$4,561.52 |
| Rate for Payer: Aetna Medicare |
$1,509.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,814.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,814.16
|
| Rate for Payer: BCBS Complete |
$816.81
|
| Rate for Payer: BCBS MAPPO |
$1,451.33
|
| Rate for Payer: BCBS Trust/PPO |
$2,005.60
|
| Rate for Payer: BCN Commercial |
$2,005.60
|
| Rate for Payer: BCN Medicare Advantage |
$1,451.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,451.33
|
| Rate for Payer: Mclaren Medicaid |
$777.91
|
| Rate for Payer: Mclaren Medicare |
$1,451.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,523.90
|
| Rate for Payer: Meridian Medicaid |
$816.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,669.03
|
| Rate for Payer: Nomi Health Commercial |
$3,047.79
|
| Rate for Payer: PACE Medicare |
$1,378.76
|
| Rate for Payer: PACE SWMI |
$1,451.33
|
| Rate for Payer: PHP Medicare Advantage |
$1,451.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$777.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,561.52
|
| Rate for Payer: Priority Health Medicare |
$1,451.33
|
| Rate for Payer: Priority Health Narrow Network |
$3,649.22
|
| Rate for Payer: Railroad Medicare Medicare |
$1,451.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$812.11
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,451.33
|
| Rate for Payer: UHC Exchange |
$738.28
|
| Rate for Payer: UHC Medicare Advantage |
$1,451.33
|
| Rate for Payer: UHCCP Medicaid |
$777.91
|
| Rate for Payer: VA VA |
$1,451.33
|
|
|
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 |
$885.56
|
| 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 |
$885.56
|
|
|
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
|
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 |
$616.92
|
| 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/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
|
$1,180.74
|
|
|
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 |
$885.56
|
| 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 |
$885.56
|
|
|
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
|
|
|
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
|
|
|
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
|
|
|
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
|
|
