|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna Medicare |
$53.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$64.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$64.52
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: BCBS MAPPO |
$51.62
|
| Rate for Payer: BCBS Trust/PPO |
$169.73
|
| Rate for Payer: BCN Commercial |
$160.52
|
| Rate for Payer: BCN Medicare Advantage |
$51.62
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$51.62
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$54.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: PACE Senior Care Partners |
$49.03
|
| Rate for Payer: PACE SWMI |
$51.62
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: PHP Medicare Advantage |
$51.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO |
$179.62
|
| Rate for Payer: Priority Health Medicare |
$52.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$138.33
|
| Rate for Payer: Railroad Medicare Medicare |
$51.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.68
|
| Rate for Payer: UHC Core |
$172.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$51.62
|
| Rate for Payer: UHC Exchange |
$51.62
|
| Rate for Payer: UHC Medicare Advantage |
$51.62
|
| Rate for Payer: VA VA |
$51.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$194.25
|
|
|
Service Code
|
NDC 70700026899
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.13 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: Aetna Medicare |
$50.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$60.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$60.70
|
| Rate for Payer: BCBS Complete |
$77.70
|
| Rate for Payer: BCBS MAPPO |
$48.56
|
| Rate for Payer: BCBS Trust/PPO |
$159.69
|
| Rate for Payer: BCN Commercial |
$151.03
|
| Rate for Payer: BCN Medicare Advantage |
$48.56
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.56
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$50.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: PACE Senior Care Partners |
$46.13
|
| Rate for Payer: PACE SWMI |
$48.56
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: PHP Medicare Advantage |
$48.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO |
$169.00
|
| Rate for Payer: Priority Health Medicare |
$49.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.15
|
| Rate for Payer: Railroad Medicare Medicare |
$48.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.94
|
| Rate for Payer: UHC Core |
$162.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.56
|
| Rate for Payer: UHC Exchange |
$48.56
|
| Rate for Payer: UHC Medicare Advantage |
$48.56
|
| Rate for Payer: VA VA |
$48.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$194.25
|
|
|
Service Code
|
NDC 70700026894
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: BCBS Trust/PPO |
$158.57
|
| Rate for Payer: BCN Commercial |
$150.12
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO |
$169.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.94
|
| Rate for Payer: UHC Core |
$162.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$19.87
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: Aetna Medicare |
$5.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.21
|
| Rate for Payer: BCBS Complete |
$7.95
|
| Rate for Payer: BCBS MAPPO |
$4.97
|
| Rate for Payer: BCBS Trust/PPO |
$16.34
|
| Rate for Payer: BCN Commercial |
$15.45
|
| Rate for Payer: BCN Medicare Advantage |
$4.97
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.97
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: Nomi Health Commercial |
$16.29
|
| Rate for Payer: PACE Senior Care Partners |
$4.72
|
| Rate for Payer: PACE SWMI |
$4.97
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: PHP Medicare Advantage |
$4.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health HMO/PPO |
$17.29
|
| Rate for Payer: Priority Health Medicare |
$5.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.31
|
| Rate for Payer: Railroad Medicare Medicare |
$4.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.49
|
| Rate for Payer: UHC Core |
$16.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.97
|
| Rate for Payer: UHC Exchange |
$4.97
|
| Rate for Payer: UHC Medicare Advantage |
$4.97
|
| Rate for Payer: VA VA |
$4.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.90
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$19.87
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.92 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: BCBS Trust/PPO |
$16.22
|
| Rate for Payer: BCN Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: Nomi Health Commercial |
$16.29
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health HMO/PPO |
$17.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.49
|
| Rate for Payer: UHC Core |
$16.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.90
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
OP
|
$53.14
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.62 |
| Max. Negotiated Rate |
$47.83 |
| Rate for Payer: Aetna Commercial |
$45.17
|
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Medicare |
$13.82
|
| Rate for Payer: Aetna Medicare |
$104.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$125.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$125.14
|
| Rate for Payer: BCBS Complete |
$160.18
|
| Rate for Payer: BCBS Complete |
$21.26
|
| Rate for Payer: BCBS MAPPO |
$100.11
|
| Rate for Payer: BCBS MAPPO |
$13.29
|
| Rate for Payer: BCBS Trust/PPO |
$43.69
|
| Rate for Payer: BCBS Trust/PPO |
$329.20
|
| Rate for Payer: BCN Commercial |
$41.32
|
| Rate for Payer: BCN Commercial |
$311.34
|
| Rate for Payer: BCN Medicare Advantage |
$13.29
|
| Rate for Payer: BCN Medicare Advantage |
$100.11
|
| Rate for Payer: Cash Price |
$42.51
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Cofinity Commercial |
$45.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$100.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.29
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$47.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$105.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$115.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Nomi Health Commercial |
$43.57
|
| Rate for Payer: Nomi Health Commercial |
$328.36
|
| Rate for Payer: PACE Senior Care Partners |
$12.62
|
| Rate for Payer: PACE Senior Care Partners |
$95.10
|
| Rate for Payer: PACE SWMI |
$13.29
|
| Rate for Payer: PACE SWMI |
$100.11
|
| Rate for Payer: PHP Commercial |
$45.17
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: PHP Medicare Advantage |
$100.11
|
| Rate for Payer: PHP Medicare Advantage |
$13.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health HMO/PPO |
$348.38
|
| Rate for Payer: Priority Health HMO/PPO |
$46.23
|
| Rate for Payer: Priority Health Medicare |
$13.42
|
| Rate for Payer: Priority Health Medicare |
$101.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.29
|
| Rate for Payer: Railroad Medicare Medicare |
$100.11
|
| Rate for Payer: Railroad Medicare Medicare |
$13.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.76
|
| Rate for Payer: UHC Core |
$44.37
|
| Rate for Payer: UHC Core |
$334.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$100.11
|
| Rate for Payer: UHC Exchange |
$100.11
|
| Rate for Payer: UHC Exchange |
$13.29
|
| Rate for Payer: UHC Medicare Advantage |
$100.11
|
| Rate for Payer: UHC Medicare Advantage |
$13.29
|
| Rate for Payer: VA VA |
$100.11
|
| Rate for Payer: VA VA |
$13.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.33
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
IP
|
$400.44
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$260.29 |
| Max. Negotiated Rate |
$360.40 |
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Commercial |
$45.17
|
| Rate for Payer: BCBS Trust/PPO |
$326.88
|
| Rate for Payer: BCBS Trust/PPO |
$43.38
|
| Rate for Payer: BCN Commercial |
$309.46
|
| Rate for Payer: BCN Commercial |
$41.07
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$42.51
|
| Rate for Payer: Cofinity Commercial |
$45.70
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$47.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.17
|
| Rate for Payer: Nomi Health Commercial |
$328.36
|
| Rate for Payer: Nomi Health Commercial |
$43.57
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: PHP Commercial |
$45.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health HMO/PPO |
$46.23
|
| Rate for Payer: Priority Health HMO/PPO |
$348.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.76
|
| Rate for Payer: UHC Core |
$334.37
|
| Rate for Payer: UHC Core |
$44.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.85
|
|
|
FRAXEL ARMS - BILATERAL
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00166
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL CHEST
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00155
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL FACE & NECK
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00162
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL FULL FACE
|
Professional
|
Both
|
$612.00
|
|
|
Service Code
|
HCPCS 00152
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna Medicare |
$306.00
|
| Rate for Payer: BCBS Complete |
$244.80
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.80
|
|
|
FRAXEL HANDS
|
Professional
|
Both
|
$357.00
|
|
|
Service Code
|
HCPCS 00154
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$232.05 |
| Rate for Payer: Aetna Medicare |
$178.50
|
| Rate for Payer: BCBS Complete |
$142.80
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.05
|
|
|
FRAXEL LARGE SCAR
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00161
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL MEDIUM SCAR
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00160
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
|
|
FRAXEL NECK
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 00153
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Aetna Medicare |
$204.00
|
| Rate for Payer: BCBS Complete |
$163.20
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.20
|
|
|
FRAXEL NECK & CHEST
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00163
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
|
|
FRAXEL PARTIAL TREATMENT - BILATERAL EYES
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00157
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
|
|
FRAXEL PARTIAL TREATMENT - PERI-ORAL
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
HCPCS 00156
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$204.00 |
| Max. Negotiated Rate |
$331.50 |
| Rate for Payer: Aetna Medicare |
$255.00
|
| Rate for Payer: BCBS Complete |
$204.00
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$331.50
|
|
|
FRAXEL PARTIAL TREATMENT - UPPER LIP
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 00158
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
|
|
FRAXEL RESTORE
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 00168
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
|
|
FRAXEL SMALL SCAR
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
HCPCS 00159
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$51.20 |
| Max. Negotiated Rate |
$83.20 |
| Rate for Payer: Aetna Medicare |
$64.00
|
| Rate for Payer: BCBS Complete |
$51.20
|
| Rate for Payer: Cash Price |
$102.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.20
|
|
|
FRAXEL STRETCH MARKS - ENTIRE ABDOMEN
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00165
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL STRETCH MARKS - PERI-UMBILICAL
|
Professional
|
Both
|
$612.00
|
|
|
Service Code
|
HCPCS 00164
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna Medicare |
$306.00
|
| Rate for Payer: BCBS Complete |
$244.80
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.80
|
|
|
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS
|
Facility
|
OP
|
$1,388.75
|
|
|
Service Code
|
CPT 15240
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,322.53 |
| Max. Negotiated Rate |
$1,388.75 |
| Rate for Payer: BCBS Complete |
$1,388.75
|
| Rate for Payer: Mclaren Medicaid |
$1,322.53
|
| Rate for Payer: Meridian Medicaid |
$1,388.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,322.53
|
| Rate for Payer: UHCCP Medicaid |
$1,322.53
|
|
|
FUROSEMIDE 10 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$13.11
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
163713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$11.80 |
| Rate for Payer: Aetna Commercial |
$11.14
|
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Aetna Commercial |
$21.65
|
| Rate for Payer: Aetna Commercial |
$10.37
|
| Rate for Payer: Aetna Commercial |
$9.27
|
| Rate for Payer: Aetna Commercial |
$18.96
|
| Rate for Payer: Aetna Medicare |
$6.62
|
| Rate for Payer: Aetna Medicare |
$3.41
|
| Rate for Payer: Aetna Medicare |
$3.17
|
| Rate for Payer: Aetna Medicare |
$2.83
|
| Rate for Payer: Aetna Medicare |
$5.80
|
| Rate for Payer: Aetna Medicare |
$2.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.41
|
| Rate for Payer: BCBS Complete |
$5.24
|
| Rate for Payer: BCBS Complete |
$10.19
|
| Rate for Payer: BCBS Complete |
$4.88
|
| Rate for Payer: BCBS Complete |
$4.36
|
| Rate for Payer: BCBS Complete |
$8.92
|
| Rate for Payer: BCBS Complete |
$3.18
|
| Rate for Payer: BCBS MAPPO |
$5.58
|
| Rate for Payer: BCBS MAPPO |
$2.73
|
| Rate for Payer: BCBS MAPPO |
$3.05
|
| Rate for Payer: BCBS MAPPO |
$1.99
|
| Rate for Payer: BCBS MAPPO |
$6.37
|
| Rate for Payer: BCBS MAPPO |
$3.28
|
| Rate for Payer: BCBS Trust/PPO |
$18.34
|
| Rate for Payer: BCBS Trust/PPO |
$10.03
|
| Rate for Payer: BCBS Trust/PPO |
$8.96
|
| Rate for Payer: BCBS Trust/PPO |
$20.94
|
| Rate for Payer: BCBS Trust/PPO |
$6.54
|
| Rate for Payer: BCBS Trust/PPO |
$10.78
|
| Rate for Payer: BCN Commercial |
$17.35
|
| Rate for Payer: BCN Commercial |
$9.49
|
| Rate for Payer: BCN Commercial |
$8.47
|
| Rate for Payer: BCN Commercial |
$6.18
|
| Rate for Payer: BCN Commercial |
$19.80
|
| Rate for Payer: BCN Commercial |
$10.19
|
| Rate for Payer: BCN Medicare Advantage |
$3.28
|
| Rate for Payer: BCN Medicare Advantage |
$5.58
|
| Rate for Payer: BCN Medicare Advantage |
$3.05
|
| Rate for Payer: BCN Medicare Advantage |
$2.73
|
| Rate for Payer: BCN Medicare Advantage |
$1.99
|
| Rate for Payer: BCN Medicare Advantage |
$6.37
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Cash Price |
$6.36
|
| Rate for Payer: Cash Price |
$17.85
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cofinity Commercial |
$6.84
|
| Rate for Payer: Cofinity Commercial |
$11.27
|
| Rate for Payer: Cofinity Commercial |
$10.49
|
| Rate for Payer: Cofinity Commercial |
$9.37
|
| Rate for Payer: Cofinity Commercial |
$21.90
|
| Rate for Payer: Cofinity Commercial |
$19.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.37
|
| Rate for Payer: Healthscope Commercial |
$9.81
|
| Rate for Payer: Healthscope Commercial |
$10.98
|
| Rate for Payer: Healthscope Commercial |
$11.80
|
| Rate for Payer: Healthscope Commercial |
$20.08
|
| Rate for Payer: Healthscope Commercial |
$22.92
|
| Rate for Payer: Healthscope Commercial |
$7.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.96
|
| Rate for Payer: Nomi Health Commercial |
$8.94
|
| Rate for Payer: Nomi Health Commercial |
$20.89
|
| Rate for Payer: Nomi Health Commercial |
$10.00
|
| Rate for Payer: Nomi Health Commercial |
$10.75
|
| Rate for Payer: Nomi Health Commercial |
$6.52
|
| Rate for Payer: Nomi Health Commercial |
$18.29
|
| Rate for Payer: PACE Senior Care Partners |
$1.89
|
| Rate for Payer: PACE Senior Care Partners |
$5.30
|
| Rate for Payer: PACE Senior Care Partners |
$2.90
|
| Rate for Payer: PACE Senior Care Partners |
$2.59
|
| Rate for Payer: PACE Senior Care Partners |
$3.11
|
| Rate for Payer: PACE Senior Care Partners |
$6.05
|
| Rate for Payer: PACE SWMI |
$5.58
|
| Rate for Payer: PACE SWMI |
$3.28
|
| Rate for Payer: PACE SWMI |
$1.99
|
| Rate for Payer: PACE SWMI |
$3.05
|
| Rate for Payer: PACE SWMI |
$6.37
|
| Rate for Payer: PACE SWMI |
$2.73
|
| Rate for Payer: PHP Commercial |
$6.76
|
| Rate for Payer: PHP Commercial |
$11.14
|
| Rate for Payer: PHP Commercial |
$21.65
|
| Rate for Payer: PHP Commercial |
$9.27
|
| Rate for Payer: PHP Commercial |
$10.37
|
| Rate for Payer: PHP Commercial |
$18.96
|
| Rate for Payer: PHP Medicare Advantage |
$2.73
|
| Rate for Payer: PHP Medicare Advantage |
$5.58
|
| Rate for Payer: PHP Medicare Advantage |
$6.37
|
| Rate for Payer: PHP Medicare Advantage |
$1.99
|
| Rate for Payer: PHP Medicare Advantage |
$3.28
|
| Rate for Payer: PHP Medicare Advantage |
$3.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.17
|
| Rate for Payer: Priority Health HMO/PPO |
$11.41
|
| Rate for Payer: Priority Health HMO/PPO |
$10.61
|
| Rate for Payer: Priority Health HMO/PPO |
$6.92
|
| Rate for Payer: Priority Health HMO/PPO |
$19.41
|
| Rate for Payer: Priority Health HMO/PPO |
$9.48
|
| Rate for Payer: Priority Health HMO/PPO |
$22.16
|
| Rate for Payer: Priority Health Medicare |
$2.01
|
| Rate for Payer: Priority Health Medicare |
$6.43
|
| Rate for Payer: Priority Health Medicare |
$2.75
|
| Rate for Payer: Priority Health Medicare |
$3.08
|
| Rate for Payer: Priority Health Medicare |
$3.31
|
| Rate for Payer: Priority Health Medicare |
$5.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.17
|
| Rate for Payer: Railroad Medicare Medicare |
$6.37
|
| Rate for Payer: Railroad Medicare Medicare |
$3.28
|
| Rate for Payer: Railroad Medicare Medicare |
$1.99
|
| Rate for Payer: Railroad Medicare Medicare |
$5.58
|
| Rate for Payer: Railroad Medicare Medicare |
$3.05
|
| Rate for Payer: Railroad Medicare Medicare |
$2.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.74
|
| Rate for Payer: UHC Core |
$21.27
|
| Rate for Payer: UHC Core |
$18.63
|
| Rate for Payer: UHC Core |
$10.19
|
| Rate for Payer: UHC Core |
$9.10
|
| Rate for Payer: UHC Core |
$10.95
|
| Rate for Payer: UHC Core |
$6.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.73
|
| Rate for Payer: UHC Exchange |
$6.37
|
| Rate for Payer: UHC Exchange |
$3.05
|
| Rate for Payer: UHC Exchange |
$3.28
|
| Rate for Payer: UHC Exchange |
$2.73
|
| Rate for Payer: UHC Exchange |
$1.99
|
| Rate for Payer: UHC Exchange |
$5.58
|
| Rate for Payer: UHC Medicare Advantage |
$3.28
|
| Rate for Payer: UHC Medicare Advantage |
$1.99
|
| Rate for Payer: UHC Medicare Advantage |
$3.05
|
| Rate for Payer: UHC Medicare Advantage |
$6.37
|
| Rate for Payer: UHC Medicare Advantage |
$2.73
|
| Rate for Payer: UHC Medicare Advantage |
$5.58
|
| Rate for Payer: VA VA |
$5.58
|
| Rate for Payer: VA VA |
$2.73
|
| Rate for Payer: VA VA |
$3.28
|
| Rate for Payer: VA VA |
$3.05
|
| Rate for Payer: VA VA |
$1.99
|
| Rate for Payer: VA VA |
$6.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.10
|
|
