|
HC KERECIS OMEGA3 MARIGEN 3X3.5, PER SQ CM
|
Facility
|
IP
|
$182.07
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.70 |
| Max. Negotiated Rate |
$163.86 |
| Rate for Payer: Aetna Commercial |
$154.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.35
|
| Rate for Payer: Cash Price |
$145.66
|
| Rate for Payer: Cofinity Advantage |
$127.45
|
| Rate for Payer: Cofinity Commercial |
$156.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.66
|
| Rate for Payer: Healthscope Commercial |
$163.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$136.55
|
| Rate for Payer: PHP Commercial |
$154.76
|
| Rate for Payer: Priority Health SBD |
$114.70
|
|
|
HC KERECIS OMEGA3 MARIGEN CIRC 16 MM, PER SQ CM
|
Facility
|
OP
|
$687.50
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$618.75 |
| Rate for Payer: Aetna Commercial |
$584.38
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$446.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$88.86
|
| Rate for Payer: BCN Commercial |
$265.37
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cofinity Advantage |
$481.25
|
| Rate for Payer: Cofinity Commercial |
$591.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$550.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$618.75
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$584.38
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$515.62
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$584.38
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$433.12
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC KERECIS OMEGA3 MARIGEN CIRC 16 MM, PER SQ CM
|
Facility
|
IP
|
$687.50
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600275
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$433.12 |
| Max. Negotiated Rate |
$618.75 |
| Rate for Payer: Encore Health Key Benefits Commercial |
$550.00
|
| Rate for Payer: Aetna Commercial |
$584.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$446.88
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cofinity Advantage |
$481.25
|
| Rate for Payer: Cofinity Commercial |
$591.25
|
| Rate for Payer: Healthscope Commercial |
$618.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$584.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$515.62
|
| Rate for Payer: PHP Commercial |
$584.38
|
| Rate for Payer: Priority Health SBD |
$433.12
|
|
|
HC KERECIS OMEGA3 MARIGEN EXPANSE 2X2, PER SQ CM
|
Facility
|
OP
|
$626.88
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600273
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$564.19 |
| Rate for Payer: Aetna Commercial |
$532.85
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$407.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$88.86
|
| Rate for Payer: BCN Commercial |
$265.37
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cofinity Advantage |
$438.82
|
| Rate for Payer: Cofinity Commercial |
$539.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$501.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$564.19
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$532.85
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$470.16
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$532.85
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$394.93
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC KERECIS OMEGA3 MARIGEN EXPANSE 2X2, PER SQ CM
|
Facility
|
IP
|
$626.88
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600273
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$394.93 |
| Max. Negotiated Rate |
$564.19 |
| Rate for Payer: Aetna Commercial |
$532.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$407.47
|
| Rate for Payer: Cash Price |
$501.50
|
| Rate for Payer: Cofinity Advantage |
$438.82
|
| Rate for Payer: Cofinity Commercial |
$539.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$501.50
|
| Rate for Payer: Healthscope Commercial |
$564.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$532.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$470.16
|
| Rate for Payer: PHP Commercial |
$532.85
|
| Rate for Payer: Priority Health SBD |
$394.93
|
|
|
HC KERECIS OMEGA3 MARIGEN MICRO 4 SQ CM, PER SQ CM
|
Facility
|
IP
|
$365.06
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$229.99 |
| Max. Negotiated Rate |
$328.55 |
| Rate for Payer: Aetna Commercial |
$310.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.29
|
| Rate for Payer: Cash Price |
$292.05
|
| Rate for Payer: Cofinity Advantage |
$255.54
|
| Rate for Payer: Cofinity Commercial |
$313.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.05
|
| Rate for Payer: Healthscope Commercial |
$328.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.80
|
| Rate for Payer: PHP Commercial |
$310.30
|
| Rate for Payer: Priority Health SBD |
$229.99
|
|
|
HC KERECIS OMEGA3 MARIGEN MICRO 4 SQ CM, PER SQ CM
|
Facility
|
OP
|
$365.06
|
|
|
Service Code
|
HCPCS Q4158
|
| Hospital Charge Code |
63600274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$401.00 |
| Rate for Payer: Aetna Commercial |
$310.30
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$88.86
|
| Rate for Payer: BCN Commercial |
$265.37
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$292.05
|
| Rate for Payer: Cash Price |
$292.05
|
| Rate for Payer: Cash Price |
$292.05
|
| Rate for Payer: Cofinity Advantage |
$255.54
|
| Rate for Payer: Cofinity Commercial |
$313.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$328.55
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.30
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.80
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$310.30
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$229.99
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC KETONES (ACETONE)
|
Facility
|
OP
|
$37.56
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
30100067
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Aetna Medicare |
$4.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.65
|
| Rate for Payer: BCBS Complete |
$2.48
|
| Rate for Payer: BCBS MAPPO |
$4.52
|
| Rate for Payer: BCBS Trust/PPO |
$4.82
|
| Rate for Payer: BCN Commercial |
$4.82
|
| Rate for Payer: BCN Medicare Advantage |
$4.52
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cofinity Advantage |
$26.29
|
| Rate for Payer: Cofinity Commercial |
$32.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.52
|
| Rate for Payer: Healthscope Commercial |
$33.80
|
| Rate for Payer: Mclaren Medicaid |
$2.36
|
| Rate for Payer: Mclaren Medicare |
$4.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.75
|
| Rate for Payer: Meridian Medicaid |
$4.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$4.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.93
|
| Rate for Payer: Nomi Health Commercial |
$6.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.17
|
| Rate for Payer: PACE Medicare |
$4.29
|
| Rate for Payer: PACE SWMI |
$4.52
|
| Rate for Payer: PHP Commercial |
$31.93
|
| Rate for Payer: PHP Medicare Advantage |
$4.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$4.52
|
| Rate for Payer: Priority Health Medicare |
$4.52
|
| Rate for Payer: Priority Health SBD |
$23.66
|
| Rate for Payer: Priority Health Tiered Network |
$3.62
|
| Rate for Payer: Railroad Medicare Medicare |
$4.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.78
|
| Rate for Payer: UHC Core |
$6.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$4.52
|
| Rate for Payer: UHC Exchange |
$6.78
|
| Rate for Payer: UHC Medicaid |
$2.36
|
| Rate for Payer: UHCCP Medicaid |
$2.36
|
| Rate for Payer: VA VA |
$4.52
|
|
|
HC KETONES (ACETONE)
|
Facility
|
IP
|
$37.56
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
30100067
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.66 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.41
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cofinity Advantage |
$26.29
|
| Rate for Payer: Cofinity Commercial |
$32.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.05
|
| Rate for Payer: Healthscope Commercial |
$33.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.17
|
| Rate for Payer: PHP Commercial |
$31.93
|
| Rate for Payer: Priority Health SBD |
$23.66
|
|
|
HC KIDNEY ENDOSCOPY
|
Facility
|
OP
|
$6,089.22
|
|
|
Service Code
|
CPT 50551
|
| Hospital Charge Code |
76100307
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,992.53 |
| Max. Negotiated Rate |
$17,277.20 |
| Rate for Payer: Aetna Commercial |
$5,175.84
|
| Rate for Payer: Aetna Medicare |
$5,556.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,957.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,678.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,678.15
|
| Rate for Payer: BCBS Complete |
$2,934.11
|
| Rate for Payer: BCBS MAPPO |
$5,342.52
|
| Rate for Payer: BCBS Trust/PPO |
$1,992.53
|
| Rate for Payer: BCN Commercial |
$1,992.53
|
| Rate for Payer: BCN Medicare Advantage |
$5,342.52
|
| Rate for Payer: Cash Price |
$4,871.38
|
| Rate for Payer: Cash Price |
$4,871.38
|
| Rate for Payer: Cash Price |
$4,871.38
|
| Rate for Payer: Cofinity Advantage |
$4,262.45
|
| Rate for Payer: Cofinity Commercial |
$5,236.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,871.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,342.52
|
| Rate for Payer: Healthscope Commercial |
$5,480.30
|
| Rate for Payer: Mclaren Medicaid |
$2,794.14
|
| Rate for Payer: Mclaren Medicare |
$5,342.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,609.65
|
| Rate for Payer: Meridian Medicaid |
$5,609.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,143.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$5,876.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,175.84
|
| Rate for Payer: Nomi Health Commercial |
$16,027.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,566.91
|
| Rate for Payer: PACE Medicare |
$5,075.39
|
| Rate for Payer: PACE SWMI |
$5,342.52
|
| Rate for Payer: PHP Commercial |
$5,175.84
|
| Rate for Payer: PHP Medicare Advantage |
$5,342.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,794.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$17,277.20
|
| Rate for Payer: Priority Health Medicare |
$5,342.52
|
| Rate for Payer: Priority Health SBD |
$3,836.21
|
| Rate for Payer: Priority Health Tiered Network |
$13,821.76
|
| Rate for Payer: Railroad Medicare Medicare |
$5,342.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,957.99
|
| Rate for Payer: UHC Core |
$3,172.48
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,342.52
|
| Rate for Payer: UHC Exchange |
$2,393.06
|
| Rate for Payer: UHC Medicaid |
$2,794.14
|
| Rate for Payer: UHCCP Medicaid |
$2,794.14
|
| Rate for Payer: VA VA |
$5,342.52
|
|
|
HC KIDNEY ENDOSCOPY
|
Facility
|
IP
|
$6,089.22
|
|
|
Service Code
|
CPT 50551
|
| Hospital Charge Code |
76100307
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$3,836.21 |
| Max. Negotiated Rate |
$5,480.30 |
| Rate for Payer: Aetna Commercial |
$5,175.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,957.99
|
| Rate for Payer: Cash Price |
$4,871.38
|
| Rate for Payer: Cofinity Advantage |
$4,262.45
|
| Rate for Payer: Cofinity Commercial |
$5,236.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,871.38
|
| Rate for Payer: Healthscope Commercial |
$5,480.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,175.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,566.91
|
| Rate for Payer: PHP Commercial |
$5,175.84
|
| Rate for Payer: Priority Health SBD |
$3,836.21
|
|
|
HC KINEVAC 5 MCG IV
|
Facility
|
OP
|
$141.20
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
63600014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.48 |
| Max. Negotiated Rate |
$276.28 |
| Rate for Payer: Aetna Commercial |
$120.02
|
| Rate for Payer: Aetna Medicare |
$70.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.78
|
| Rate for Payer: BCBS Complete |
$56.48
|
| Rate for Payer: BCBS Trust/PPO |
$276.28
|
| Rate for Payer: BCN Commercial |
$276.28
|
| Rate for Payer: Cash Price |
$112.96
|
| Rate for Payer: Cash Price |
$112.96
|
| Rate for Payer: Cofinity Advantage |
$98.84
|
| Rate for Payer: Cofinity Commercial |
$121.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.96
|
| Rate for Payer: Healthscope Commercial |
$127.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$112.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$105.90
|
| Rate for Payer: PHP Commercial |
$120.02
|
| Rate for Payer: Priority Health SBD |
$88.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.71
|
| Rate for Payer: UHC Core |
$181.71
|
| Rate for Payer: UHC Exchange |
$181.71
|
|
|
HC KINEVAC 5 MCG IV
|
Facility
|
IP
|
$141.20
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
63600014
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.96 |
| Max. Negotiated Rate |
$127.08 |
| Rate for Payer: Aetna Commercial |
$120.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.78
|
| Rate for Payer: Cash Price |
$112.96
|
| Rate for Payer: Cofinity Advantage |
$98.84
|
| Rate for Payer: Cofinity Commercial |
$121.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.96
|
| Rate for Payer: Healthscope Commercial |
$127.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$105.90
|
| Rate for Payer: PHP Commercial |
$120.02
|
| Rate for Payer: Priority Health SBD |
$88.96
|
|
|
HC KIT ATS
|
Facility
|
IP
|
$156.06
|
|
| Hospital Charge Code |
27000666
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$98.32 |
| Max. Negotiated Rate |
$140.45 |
| Rate for Payer: Aetna Commercial |
$132.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.44
|
| Rate for Payer: Cash Price |
$124.85
|
| Rate for Payer: Cofinity Advantage |
$109.24
|
| Rate for Payer: Cofinity Commercial |
$134.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.85
|
| Rate for Payer: Healthscope Commercial |
$140.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.05
|
| Rate for Payer: PHP Commercial |
$132.65
|
| Rate for Payer: Priority Health SBD |
$98.32
|
|
|
HC KIT ATS
|
Facility
|
OP
|
$156.06
|
|
| Hospital Charge Code |
27000666
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$61.33 |
| Max. Negotiated Rate |
$140.45 |
| Rate for Payer: Aetna Commercial |
$132.65
|
| Rate for Payer: Aetna Medicare |
$78.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.44
|
| Rate for Payer: BCBS Complete |
$62.42
|
| Rate for Payer: Cash Price |
$124.85
|
| Rate for Payer: Cofinity Advantage |
$109.24
|
| Rate for Payer: Cofinity Commercial |
$134.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.85
|
| Rate for Payer: Healthscope Commercial |
$140.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$124.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.05
|
| Rate for Payer: PHP Commercial |
$132.65
|
| Rate for Payer: Priority Health SBD |
$98.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.44
|
| Rate for Payer: UHC Core |
$81.31
|
| Rate for Payer: UHC Exchange |
$61.33
|
|
|
HC KIT DILATOR VASC
|
Facility
|
OP
|
$546.21
|
|
| Hospital Charge Code |
27000101
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$214.66 |
| Max. Negotiated Rate |
$491.59 |
| Rate for Payer: Aetna Commercial |
$464.28
|
| Rate for Payer: Aetna Medicare |
$273.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.04
|
| Rate for Payer: BCBS Complete |
$218.48
|
| Rate for Payer: Cash Price |
$436.97
|
| Rate for Payer: Cofinity Advantage |
$382.35
|
| Rate for Payer: Cofinity Commercial |
$469.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$436.97
|
| Rate for Payer: Healthscope Commercial |
$491.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$436.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$464.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$409.66
|
| Rate for Payer: PHP Commercial |
$464.28
|
| Rate for Payer: Priority Health SBD |
$344.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$355.04
|
| Rate for Payer: UHC Core |
$284.58
|
| Rate for Payer: UHC Exchange |
$214.66
|
|
|
HC KIT DILATOR VASC
|
Facility
|
IP
|
$546.21
|
|
| Hospital Charge Code |
27000101
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$344.11 |
| Max. Negotiated Rate |
$491.59 |
| Rate for Payer: Aetna Commercial |
$464.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.04
|
| Rate for Payer: Cash Price |
$436.97
|
| Rate for Payer: Cofinity Advantage |
$382.35
|
| Rate for Payer: Cofinity Commercial |
$469.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$436.97
|
| Rate for Payer: Healthscope Commercial |
$491.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$464.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$409.66
|
| Rate for Payer: PHP Commercial |
$464.28
|
| Rate for Payer: Priority Health SBD |
$344.11
|
|
|
HC KLEIHAUER-BETKE STAIN
|
Facility
|
IP
|
$125.68
|
|
|
Service Code
|
CPT 85460
|
| Hospital Charge Code |
30500046
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$79.18 |
| Max. Negotiated Rate |
$113.11 |
| Rate for Payer: Aetna Commercial |
$106.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.69
|
| Rate for Payer: Cash Price |
$100.54
|
| Rate for Payer: Cofinity Advantage |
$87.98
|
| Rate for Payer: Cofinity Commercial |
$108.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.54
|
| Rate for Payer: Healthscope Commercial |
$113.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.26
|
| Rate for Payer: PHP Commercial |
$106.83
|
| Rate for Payer: Priority Health SBD |
$79.18
|
|
|
HC KLEIHAUER-BETKE STAIN
|
Facility
|
OP
|
$125.68
|
|
|
Service Code
|
CPT 85460
|
| Hospital Charge Code |
30500046
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$113.11 |
| Rate for Payer: Aetna Commercial |
$106.83
|
| Rate for Payer: Aetna Medicare |
$8.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.66
|
| Rate for Payer: BCBS Complete |
$4.25
|
| Rate for Payer: BCBS MAPPO |
$7.73
|
| Rate for Payer: BCBS Trust/PPO |
$8.25
|
| Rate for Payer: BCN Commercial |
$8.25
|
| Rate for Payer: BCN Medicare Advantage |
$7.73
|
| Rate for Payer: Cash Price |
$100.54
|
| Rate for Payer: Cash Price |
$100.54
|
| Rate for Payer: Cofinity Advantage |
$87.98
|
| Rate for Payer: Cofinity Commercial |
$108.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.73
|
| Rate for Payer: Healthscope Commercial |
$113.11
|
| Rate for Payer: Mclaren Medicaid |
$4.04
|
| Rate for Payer: Mclaren Medicare |
$7.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.12
|
| Rate for Payer: Meridian Medicaid |
$8.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.89
|
| Rate for Payer: Molina Medicare/Medicaid |
$8.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.83
|
| Rate for Payer: Nomi Health Commercial |
$11.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.26
|
| Rate for Payer: PACE Medicare |
$7.34
|
| Rate for Payer: PACE SWMI |
$7.73
|
| Rate for Payer: PHP Commercial |
$106.83
|
| Rate for Payer: PHP Medicare Advantage |
$7.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$7.73
|
| Rate for Payer: Priority Health Medicare |
$7.73
|
| Rate for Payer: Priority Health SBD |
$79.18
|
| Rate for Payer: Priority Health Tiered Network |
$6.18
|
| Rate for Payer: Railroad Medicare Medicare |
$7.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.60
|
| Rate for Payer: UHC Core |
$11.60
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7.73
|
| Rate for Payer: UHC Exchange |
$11.60
|
| Rate for Payer: UHC Medicaid |
$4.04
|
| Rate for Payer: UHCCP Medicaid |
$4.04
|
| Rate for Payer: VA VA |
$7.73
|
|
|
HC KOH PREPARATION
|
Facility
|
IP
|
$24.41
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
30600111
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$15.38 |
| Max. Negotiated Rate |
$21.97 |
| Rate for Payer: Aetna Commercial |
$20.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.87
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Cofinity Advantage |
$17.09
|
| Rate for Payer: Cofinity Commercial |
$20.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.53
|
| Rate for Payer: Healthscope Commercial |
$21.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.31
|
| Rate for Payer: PHP Commercial |
$20.75
|
| Rate for Payer: Priority Health SBD |
$15.38
|
|
|
HC KOH PREPARATION
|
Facility
|
OP
|
$24.41
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
30600111
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$21.97 |
| Rate for Payer: Aetna Commercial |
$20.75
|
| Rate for Payer: Aetna Medicare |
$4.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.34
|
| Rate for Payer: BCBS Complete |
$2.35
|
| Rate for Payer: BCBS MAPPO |
$4.27
|
| Rate for Payer: BCBS Trust/PPO |
$4.55
|
| Rate for Payer: BCN Commercial |
$4.55
|
| Rate for Payer: BCN Medicare Advantage |
$4.27
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Cofinity Advantage |
$17.09
|
| Rate for Payer: Cofinity Commercial |
$20.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.27
|
| Rate for Payer: Healthscope Commercial |
$21.97
|
| Rate for Payer: Mclaren Medicaid |
$2.23
|
| Rate for Payer: Mclaren Medicare |
$4.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.48
|
| Rate for Payer: Meridian Medicaid |
$4.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.91
|
| Rate for Payer: Molina Medicare/Medicaid |
$4.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.75
|
| Rate for Payer: Nomi Health Commercial |
$6.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.31
|
| Rate for Payer: PACE Medicare |
$4.06
|
| Rate for Payer: PACE SWMI |
$4.27
|
| Rate for Payer: PHP Commercial |
$20.75
|
| Rate for Payer: PHP Medicare Advantage |
$4.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$4.27
|
| Rate for Payer: Priority Health Medicare |
$4.27
|
| Rate for Payer: Priority Health SBD |
$15.38
|
| Rate for Payer: Priority Health Tiered Network |
$3.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.41
|
| Rate for Payer: UHC Core |
$6.41
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$4.27
|
| Rate for Payer: UHC Exchange |
$6.41
|
| Rate for Payer: UHC Medicaid |
$2.23
|
| Rate for Payer: UHCCP Medicaid |
$2.23
|
| Rate for Payer: VA VA |
$4.27
|
|
|
HC KYLEENA 19.5MG
|
Facility
|
OP
|
$2,995.16
|
|
|
Service Code
|
CPT J7296
|
| Hospital Charge Code |
63600165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,030.01 |
| Max. Negotiated Rate |
$3,042.47 |
| Rate for Payer: Aetna Commercial |
$2,545.89
|
| Rate for Payer: Aetna Medicare |
$1,497.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,946.85
|
| Rate for Payer: BCBS Complete |
$1,198.06
|
| Rate for Payer: BCBS Trust/PPO |
$3,042.47
|
| Rate for Payer: BCN Commercial |
$3,042.47
|
| Rate for Payer: Cash Price |
$2,396.13
|
| Rate for Payer: Cash Price |
$2,396.13
|
| Rate for Payer: Cofinity Advantage |
$2,096.61
|
| Rate for Payer: Cofinity Commercial |
$2,575.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,396.13
|
| Rate for Payer: Healthscope Commercial |
$2,695.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,396.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,545.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,246.37
|
| Rate for Payer: PHP Commercial |
$2,545.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,287.51
|
| Rate for Payer: Priority Health SBD |
$1,886.95
|
| Rate for Payer: Priority Health Tiered Network |
$1,030.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,519.43
|
| Rate for Payer: UHC Core |
$2,519.43
|
| Rate for Payer: UHC Exchange |
$2,519.43
|
|
|
HC KYLEENA 19.5MG
|
Facility
|
IP
|
$2,995.16
|
|
|
Service Code
|
CPT J7296
|
| Hospital Charge Code |
63600165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,886.95 |
| Max. Negotiated Rate |
$2,695.64 |
| Rate for Payer: Aetna Commercial |
$2,545.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,946.85
|
| Rate for Payer: Cash Price |
$2,396.13
|
| Rate for Payer: Cofinity Advantage |
$2,096.61
|
| Rate for Payer: Cofinity Commercial |
$2,575.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,396.13
|
| Rate for Payer: Healthscope Commercial |
$2,695.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,545.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,246.37
|
| Rate for Payer: PHP Commercial |
$2,545.89
|
| Rate for Payer: Priority Health SBD |
$1,886.95
|
|
|
HC LAAC IMPLANT
|
Facility
|
OP
|
$18,942.56
|
|
| Hospital Charge Code |
27800117
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,444.43 |
| Max. Negotiated Rate |
$17,048.30 |
| Rate for Payer: Aetna Commercial |
$16,101.18
|
| Rate for Payer: Aetna Medicare |
$9,471.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,312.66
|
| Rate for Payer: BCBS Complete |
$7,577.02
|
| Rate for Payer: Cash Price |
$15,154.05
|
| Rate for Payer: Cofinity Advantage |
$13,259.79
|
| Rate for Payer: Cofinity Commercial |
$16,290.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,154.05
|
| Rate for Payer: Healthscope Commercial |
$17,048.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,154.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,101.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,206.92
|
| Rate for Payer: PHP Commercial |
$16,101.18
|
| Rate for Payer: Priority Health SBD |
$11,933.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,312.66
|
| Rate for Payer: UHC Core |
$9,869.07
|
| Rate for Payer: UHC Exchange |
$7,444.43
|
|
|
HC LAAC IMPLANT
|
Facility
|
IP
|
$18,942.56
|
|
| Hospital Charge Code |
27800117
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,933.81 |
| Max. Negotiated Rate |
$17,048.30 |
| Rate for Payer: Aetna Commercial |
$16,101.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,312.66
|
| Rate for Payer: Cash Price |
$15,154.05
|
| Rate for Payer: Cofinity Advantage |
$13,259.79
|
| Rate for Payer: Cofinity Commercial |
$16,290.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,154.05
|
| Rate for Payer: Healthscope Commercial |
$17,048.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,101.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,206.92
|
| Rate for Payer: PHP Commercial |
$16,101.18
|
| Rate for Payer: Priority Health SBD |
$11,933.81
|
|
