|
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN
|
Facility
|
IP
|
$77.62
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.45 |
| Max. Negotiated Rate |
$69.86 |
| Rate for Payer: Aetna Commercial |
$65.98
|
| Rate for Payer: BCBS Trust/PPO |
$63.36
|
| Rate for Payer: BCN Commercial |
$59.98
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cofinity Commercial |
$66.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.10
|
| Rate for Payer: Healthscope Commercial |
$69.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.98
|
| Rate for Payer: Nomi Health Commercial |
$63.65
|
| Rate for Payer: PHP Commercial |
$65.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.45
|
| Rate for Payer: Priority Health HMO/PPO |
$67.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.31
|
| Rate for Payer: UHC Core |
$64.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.22
|
|
|
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN
|
Facility
|
OP
|
$77.62
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.43 |
| Max. Negotiated Rate |
$69.86 |
| Rate for Payer: Aetna Commercial |
$65.98
|
| Rate for Payer: Aetna Medicare |
$20.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.26
|
| Rate for Payer: BCBS Complete |
$31.05
|
| Rate for Payer: BCBS MAPPO |
$19.40
|
| Rate for Payer: BCBS Trust/PPO |
$63.81
|
| Rate for Payer: BCN Commercial |
$60.35
|
| Rate for Payer: BCN Medicare Advantage |
$19.40
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cofinity Commercial |
$66.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.40
|
| Rate for Payer: Healthscope Commercial |
$69.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.98
|
| Rate for Payer: Nomi Health Commercial |
$63.65
|
| Rate for Payer: PACE Senior Care Partners |
$18.43
|
| Rate for Payer: PACE SWMI |
$19.40
|
| Rate for Payer: PHP Commercial |
$65.98
|
| Rate for Payer: PHP Medicare Advantage |
$19.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.45
|
| Rate for Payer: Priority Health HMO/PPO |
$67.53
|
| Rate for Payer: Priority Health Medicare |
$19.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.01
|
| Rate for Payer: Railroad Medicare Medicare |
$19.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.31
|
| Rate for Payer: UHC Core |
$64.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.40
|
| Rate for Payer: UHC Exchange |
$19.40
|
| Rate for Payer: UHC Medicare Advantage |
$19.40
|
| Rate for Payer: VA VA |
$19.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.22
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.02 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: Aetna Medicare |
$164.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$197.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$197.40
|
| Rate for Payer: BCBS Complete |
$252.67
|
| Rate for Payer: BCBS MAPPO |
$157.92
|
| Rate for Payer: BCBS Trust/PPO |
$519.30
|
| Rate for Payer: BCN Commercial |
$491.13
|
| Rate for Payer: BCN Medicare Advantage |
$157.92
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$165.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$181.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: Nomi Health Commercial |
$517.98
|
| Rate for Payer: PACE Senior Care Partners |
$150.02
|
| Rate for Payer: PACE SWMI |
$157.92
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: PHP Medicare Advantage |
$157.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.59
|
| Rate for Payer: Priority Health HMO/PPO |
$549.56
|
| Rate for Payer: Priority Health Medicare |
$159.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$423.23
|
| Rate for Payer: Railroad Medicare Medicare |
$157.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$555.88
|
| Rate for Payer: UHC Core |
$527.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$157.92
|
| Rate for Payer: UHC Exchange |
$157.92
|
| Rate for Payer: UHC Medicare Advantage |
$157.92
|
| Rate for Payer: VA VA |
$157.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.76
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$410.59 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: BCBS Trust/PPO |
$515.64
|
| Rate for Payer: BCN Commercial |
$488.16
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: Nomi Health Commercial |
$517.98
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.59
|
| Rate for Payer: Priority Health HMO/PPO |
$549.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$423.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$555.88
|
| Rate for Payer: UHC Core |
$527.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.76
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$361.31
|
|
|
Service Code
|
NDC 68084072921
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.85 |
| Max. Negotiated Rate |
$325.18 |
| Rate for Payer: Aetna Commercial |
$307.11
|
| Rate for Payer: BCBS Trust/PPO |
$294.94
|
| Rate for Payer: BCN Commercial |
$279.22
|
| Rate for Payer: Cash Price |
$289.05
|
| Rate for Payer: Cofinity Commercial |
$310.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.05
|
| Rate for Payer: Healthscope Commercial |
$325.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.11
|
| Rate for Payer: Nomi Health Commercial |
$296.27
|
| Rate for Payer: PHP Commercial |
$307.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.85
|
| Rate for Payer: Priority Health HMO/PPO |
$314.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$242.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.95
|
| Rate for Payer: UHC Core |
$301.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.98
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$361.31
|
|
|
Service Code
|
NDC 68084072921
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.81 |
| Max. Negotiated Rate |
$325.18 |
| Rate for Payer: Aetna Commercial |
$307.11
|
| Rate for Payer: Aetna Medicare |
$93.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$112.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$112.91
|
| Rate for Payer: BCBS Complete |
$144.52
|
| Rate for Payer: BCBS MAPPO |
$90.33
|
| Rate for Payer: BCBS Trust/PPO |
$297.03
|
| Rate for Payer: BCN Commercial |
$280.92
|
| Rate for Payer: BCN Medicare Advantage |
$90.33
|
| Rate for Payer: Cash Price |
$289.05
|
| Rate for Payer: Cofinity Commercial |
$310.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$90.33
|
| Rate for Payer: Healthscope Commercial |
$325.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$94.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.11
|
| Rate for Payer: Nomi Health Commercial |
$296.27
|
| Rate for Payer: PACE Senior Care Partners |
$85.81
|
| Rate for Payer: PACE SWMI |
$90.33
|
| Rate for Payer: PHP Commercial |
$307.11
|
| Rate for Payer: PHP Medicare Advantage |
$90.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.85
|
| Rate for Payer: Priority Health HMO/PPO |
$314.34
|
| Rate for Payer: Priority Health Medicare |
$91.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$242.08
|
| Rate for Payer: Railroad Medicare Medicare |
$90.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.95
|
| Rate for Payer: UHC Core |
$301.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$90.33
|
| Rate for Payer: UHC Exchange |
$90.33
|
| Rate for Payer: UHC Medicare Advantage |
$90.33
|
| Rate for Payer: VA VA |
$90.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.98
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$12.05
|
|
|
Service Code
|
NDC 68084072911
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: BCBS Trust/PPO |
$9.84
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: Nomi Health Commercial |
$9.88
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.83
|
| Rate for Payer: Priority Health HMO/PPO |
$10.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 68084072911
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$3.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.77
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: BCBS MAPPO |
$3.01
|
| Rate for Payer: BCBS Trust/PPO |
$9.91
|
| Rate for Payer: BCN Commercial |
$9.37
|
| Rate for Payer: BCN Medicare Advantage |
$3.01
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.01
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: Nomi Health Commercial |
$9.88
|
| Rate for Payer: PACE Senior Care Partners |
$2.86
|
| Rate for Payer: PACE SWMI |
$3.01
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: PHP Medicare Advantage |
$3.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.83
|
| Rate for Payer: Priority Health HMO/PPO |
$10.48
|
| Rate for Payer: Priority Health Medicare |
$3.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.07
|
| Rate for Payer: Railroad Medicare Medicare |
$3.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.01
|
| Rate for Payer: UHC Exchange |
$3.01
|
| Rate for Payer: UHC Medicare Advantage |
$3.01
|
| Rate for Payer: VA VA |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.77
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.45 |
| Max. Negotiated Rate |
$179.79 |
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: Aetna Medicare |
$51.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.43
|
| Rate for Payer: BCBS Complete |
$79.91
|
| Rate for Payer: BCBS MAPPO |
$49.94
|
| Rate for Payer: BCBS Trust/PPO |
$164.23
|
| Rate for Payer: BCN Commercial |
$155.32
|
| Rate for Payer: BCN Medicare Advantage |
$49.94
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.94
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: Nomi Health Commercial |
$163.81
|
| Rate for Payer: PACE Senior Care Partners |
$47.45
|
| Rate for Payer: PACE SWMI |
$49.94
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: PHP Medicare Advantage |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.85
|
| Rate for Payer: Priority Health HMO/PPO |
$173.80
|
| Rate for Payer: Priority Health Medicare |
$50.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.85
|
| Rate for Payer: Railroad Medicare Medicare |
$49.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.80
|
| Rate for Payer: UHC Core |
$166.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$49.94
|
| Rate for Payer: UHC Exchange |
$49.94
|
| Rate for Payer: UHC Medicare Advantage |
$49.94
|
| Rate for Payer: VA VA |
$49.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.83
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$199.77
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.85 |
| Max. Negotiated Rate |
$179.79 |
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: BCBS Trust/PPO |
$163.07
|
| Rate for Payer: BCN Commercial |
$154.38
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: Nomi Health Commercial |
$163.81
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.85
|
| Rate for Payer: Priority Health HMO/PPO |
$173.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.80
|
| Rate for Payer: UHC Core |
$166.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.83
|
|
|
GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$148.68
|
|
|
Service Code
|
NDC 25021018510
|
| Hospital Charge Code |
186410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.64 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: BCBS Trust/PPO |
$121.37
|
| Rate for Payer: BCN Commercial |
$114.90
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.38
|
| Rate for Payer: Nomi Health Commercial |
$121.92
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.64
|
| Rate for Payer: Priority Health HMO/PPO |
$129.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.84
|
| Rate for Payer: UHC Core |
$124.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.51
|
|
|
GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$148.68
|
|
|
Service Code
|
NDC 25021018510
|
| Hospital Charge Code |
186410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.31 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: Aetna Medicare |
$38.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.46
|
| Rate for Payer: BCBS Complete |
$59.47
|
| Rate for Payer: BCBS MAPPO |
$37.17
|
| Rate for Payer: BCBS Trust/PPO |
$122.23
|
| Rate for Payer: BCN Commercial |
$115.60
|
| Rate for Payer: BCN Medicare Advantage |
$37.17
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.17
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.38
|
| Rate for Payer: Nomi Health Commercial |
$121.92
|
| Rate for Payer: PACE Senior Care Partners |
$35.31
|
| Rate for Payer: PACE SWMI |
$37.17
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: PHP Medicare Advantage |
$37.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.64
|
| Rate for Payer: Priority Health HMO/PPO |
$129.35
|
| Rate for Payer: Priority Health Medicare |
$37.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.62
|
| Rate for Payer: Railroad Medicare Medicare |
$37.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.84
|
| Rate for Payer: UHC Core |
$124.15
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.17
|
| Rate for Payer: UHC Exchange |
$37.17
|
| Rate for Payer: UHC Medicare Advantage |
$37.17
|
| Rate for Payer: VA VA |
$37.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.51
|
|
|
GELATIN ABSORBABLE EYE FILM
|
Facility
|
OP
|
$999.82
|
|
|
Service Code
|
NDC 00009029703
|
| Hospital Charge Code |
28028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.46 |
| Max. Negotiated Rate |
$899.84 |
| Rate for Payer: Aetna Commercial |
$849.85
|
| Rate for Payer: Aetna Medicare |
$259.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$312.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$312.44
|
| Rate for Payer: BCBS Complete |
$399.93
|
| Rate for Payer: BCBS MAPPO |
$249.96
|
| Rate for Payer: BCBS Trust/PPO |
$821.95
|
| Rate for Payer: BCN Commercial |
$777.36
|
| Rate for Payer: BCN Medicare Advantage |
$249.96
|
| Rate for Payer: Cash Price |
$799.86
|
| Rate for Payer: Cofinity Commercial |
$859.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$799.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$249.96
|
| Rate for Payer: Healthscope Commercial |
$899.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$749.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$262.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$287.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$849.85
|
| Rate for Payer: Nomi Health Commercial |
$819.85
|
| Rate for Payer: PACE Senior Care Partners |
$237.46
|
| Rate for Payer: PACE SWMI |
$249.96
|
| Rate for Payer: PHP Commercial |
$849.85
|
| Rate for Payer: PHP Medicare Advantage |
$249.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.88
|
| Rate for Payer: Priority Health HMO/PPO |
$869.84
|
| Rate for Payer: Priority Health Medicare |
$252.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$669.88
|
| Rate for Payer: Railroad Medicare Medicare |
$249.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$879.84
|
| Rate for Payer: UHC Core |
$834.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$249.96
|
| Rate for Payer: UHC Exchange |
$249.96
|
| Rate for Payer: UHC Medicare Advantage |
$249.96
|
| Rate for Payer: VA VA |
$249.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$749.86
|
|
|
GELATIN ABSORBABLE EYE FILM
|
Facility
|
IP
|
$999.82
|
|
|
Service Code
|
NDC 00009029703
|
| Hospital Charge Code |
28028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$649.88 |
| Max. Negotiated Rate |
$899.84 |
| Rate for Payer: Aetna Commercial |
$849.85
|
| Rate for Payer: BCBS Trust/PPO |
$816.15
|
| Rate for Payer: BCN Commercial |
$772.66
|
| Rate for Payer: Cash Price |
$799.86
|
| Rate for Payer: Cofinity Commercial |
$859.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$799.86
|
| Rate for Payer: Healthscope Commercial |
$899.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$749.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$849.85
|
| Rate for Payer: Nomi Health Commercial |
$819.85
|
| Rate for Payer: PHP Commercial |
$849.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.88
|
| Rate for Payer: Priority Health HMO/PPO |
$869.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$669.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$879.84
|
| Rate for Payer: UHC Core |
$834.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$749.86
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER
|
Facility
|
IP
|
$273.09
|
|
|
Service Code
|
NDC 00009043304
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.51 |
| Max. Negotiated Rate |
$245.78 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: BCBS Trust/PPO |
$222.92
|
| Rate for Payer: BCN Commercial |
$211.04
|
| Rate for Payer: Cash Price |
$218.47
|
| Rate for Payer: Cofinity Commercial |
$234.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.47
|
| Rate for Payer: Healthscope Commercial |
$245.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.13
|
| Rate for Payer: Nomi Health Commercial |
$223.93
|
| Rate for Payer: PHP Commercial |
$232.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.51
|
| Rate for Payer: Priority Health HMO/PPO |
$237.59
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$182.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$240.32
|
| Rate for Payer: UHC Core |
$228.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.82
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER
|
Facility
|
OP
|
$273.09
|
|
|
Service Code
|
NDC 00009043304
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.86 |
| Max. Negotiated Rate |
$245.78 |
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Medicare |
$71.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$85.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$85.34
|
| Rate for Payer: BCBS Complete |
$109.24
|
| Rate for Payer: BCBS MAPPO |
$68.27
|
| Rate for Payer: BCBS Trust/PPO |
$224.51
|
| Rate for Payer: BCN Commercial |
$212.33
|
| Rate for Payer: BCN Medicare Advantage |
$68.27
|
| Rate for Payer: Cash Price |
$218.47
|
| Rate for Payer: Cofinity Commercial |
$234.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$68.27
|
| Rate for Payer: Healthscope Commercial |
$245.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$71.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.13
|
| Rate for Payer: Nomi Health Commercial |
$223.93
|
| Rate for Payer: PACE Senior Care Partners |
$64.86
|
| Rate for Payer: PACE SWMI |
$68.27
|
| Rate for Payer: PHP Commercial |
$232.13
|
| Rate for Payer: PHP Medicare Advantage |
$68.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.51
|
| Rate for Payer: Priority Health HMO/PPO |
$237.59
|
| Rate for Payer: Priority Health Medicare |
$68.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$182.97
|
| Rate for Payer: Railroad Medicare Medicare |
$68.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$240.32
|
| Rate for Payer: UHC Core |
$228.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$68.27
|
| Rate for Payer: UHC Exchange |
$68.27
|
| Rate for Payer: UHC Medicare Advantage |
$68.27
|
| Rate for Payer: VA VA |
$68.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.82
|
|
|
GELATIN POWDER 1G WITH THROMBIN 5000 UNITS IN 6 ML NS
|
Facility
|
OP
|
$277.21
|
|
|
Service Code
|
NDC 00009000301
|
| Hospital Charge Code |
500530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.84 |
| Max. Negotiated Rate |
$249.49 |
| Rate for Payer: Aetna Commercial |
$235.63
|
| Rate for Payer: Aetna Medicare |
$72.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$86.63
|
| Rate for Payer: Amish Plain Church Group Commercial |
$86.63
|
| Rate for Payer: BCBS Complete |
$110.88
|
| Rate for Payer: BCBS MAPPO |
$69.30
|
| Rate for Payer: BCBS Trust/PPO |
$227.89
|
| Rate for Payer: BCN Commercial |
$215.53
|
| Rate for Payer: BCN Medicare Advantage |
$69.30
|
| Rate for Payer: Cash Price |
$221.77
|
| Rate for Payer: Cofinity Commercial |
$238.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$69.30
|
| Rate for Payer: Healthscope Commercial |
$249.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$72.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.63
|
| Rate for Payer: Nomi Health Commercial |
$227.31
|
| Rate for Payer: PACE Senior Care Partners |
$65.84
|
| Rate for Payer: PACE SWMI |
$69.30
|
| Rate for Payer: PHP Commercial |
$235.63
|
| Rate for Payer: PHP Medicare Advantage |
$69.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.19
|
| Rate for Payer: Priority Health HMO/PPO |
$241.17
|
| Rate for Payer: Priority Health Medicare |
$70.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.73
|
| Rate for Payer: Railroad Medicare Medicare |
$69.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.94
|
| Rate for Payer: UHC Core |
$231.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$69.30
|
| Rate for Payer: UHC Exchange |
$69.30
|
| Rate for Payer: UHC Medicare Advantage |
$69.30
|
| Rate for Payer: VA VA |
$69.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.91
|
|
|
GELATIN POWDER 1G WITH THROMBIN 5000 UNITS IN 6 ML NS
|
Facility
|
IP
|
$277.21
|
|
|
Service Code
|
NDC 00009000301
|
| Hospital Charge Code |
500530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$180.19 |
| Max. Negotiated Rate |
$249.49 |
| Rate for Payer: Aetna Commercial |
$235.63
|
| Rate for Payer: BCBS Trust/PPO |
$226.29
|
| Rate for Payer: BCN Commercial |
$214.23
|
| Rate for Payer: Cash Price |
$221.77
|
| Rate for Payer: Cofinity Commercial |
$238.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.77
|
| Rate for Payer: Healthscope Commercial |
$249.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.63
|
| Rate for Payer: Nomi Health Commercial |
$227.31
|
| Rate for Payer: PHP Commercial |
$235.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.19
|
| Rate for Payer: Priority Health HMO/PPO |
$241.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.94
|
| Rate for Payer: UHC Core |
$231.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.91
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
OP
|
$659.90
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.73 |
| Max. Negotiated Rate |
$593.91 |
| Rate for Payer: Aetna Commercial |
$560.92
|
| Rate for Payer: Aetna Medicare |
$171.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$206.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$206.22
|
| Rate for Payer: BCBS Complete |
$263.96
|
| Rate for Payer: BCBS MAPPO |
$164.98
|
| Rate for Payer: BCBS Trust/PPO |
$542.50
|
| Rate for Payer: BCN Commercial |
$513.07
|
| Rate for Payer: BCN Medicare Advantage |
$164.98
|
| Rate for Payer: Cash Price |
$527.92
|
| Rate for Payer: Cofinity Commercial |
$567.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$527.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$164.98
|
| Rate for Payer: Healthscope Commercial |
$593.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$494.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$173.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$189.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$560.92
|
| Rate for Payer: Nomi Health Commercial |
$541.12
|
| Rate for Payer: PACE Senior Care Partners |
$156.73
|
| Rate for Payer: PACE SWMI |
$164.98
|
| Rate for Payer: PHP Commercial |
$560.92
|
| Rate for Payer: PHP Medicare Advantage |
$164.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$428.94
|
| Rate for Payer: Priority Health HMO/PPO |
$574.11
|
| Rate for Payer: Priority Health Medicare |
$166.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$442.13
|
| Rate for Payer: Railroad Medicare Medicare |
$164.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$580.71
|
| Rate for Payer: UHC Core |
$551.02
|
| Rate for Payer: UHC Dual Complete DSNP |
$164.98
|
| Rate for Payer: UHC Exchange |
$164.98
|
| Rate for Payer: UHC Medicare Advantage |
$164.98
|
| Rate for Payer: VA VA |
$164.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$494.92
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
OP
|
$898.28
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.34 |
| Max. Negotiated Rate |
$808.45 |
| Rate for Payer: Aetna Commercial |
$763.54
|
| Rate for Payer: Aetna Medicare |
$233.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$280.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$280.71
|
| Rate for Payer: BCBS Complete |
$359.31
|
| Rate for Payer: BCBS MAPPO |
$224.57
|
| Rate for Payer: BCBS Trust/PPO |
$738.48
|
| Rate for Payer: BCN Commercial |
$698.41
|
| Rate for Payer: BCN Medicare Advantage |
$224.57
|
| Rate for Payer: Cash Price |
$718.62
|
| Rate for Payer: Cofinity Commercial |
$772.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$224.57
|
| Rate for Payer: Healthscope Commercial |
$808.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$673.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$235.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$258.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.54
|
| Rate for Payer: Nomi Health Commercial |
$736.59
|
| Rate for Payer: PACE Senior Care Partners |
$213.34
|
| Rate for Payer: PACE SWMI |
$224.57
|
| Rate for Payer: PHP Commercial |
$763.54
|
| Rate for Payer: PHP Medicare Advantage |
$224.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.88
|
| Rate for Payer: Priority Health HMO/PPO |
$781.50
|
| Rate for Payer: Priority Health Medicare |
$226.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$601.85
|
| Rate for Payer: Railroad Medicare Medicare |
$224.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$790.49
|
| Rate for Payer: UHC Core |
$750.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$224.57
|
| Rate for Payer: UHC Exchange |
$224.57
|
| Rate for Payer: UHC Medicare Advantage |
$224.57
|
| Rate for Payer: VA VA |
$224.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$673.71
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$659.90
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$428.94 |
| Max. Negotiated Rate |
$593.91 |
| Rate for Payer: Aetna Commercial |
$560.92
|
| Rate for Payer: BCBS Trust/PPO |
$538.68
|
| Rate for Payer: BCN Commercial |
$509.97
|
| Rate for Payer: Cash Price |
$527.92
|
| Rate for Payer: Cofinity Commercial |
$567.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$527.92
|
| Rate for Payer: Healthscope Commercial |
$593.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$494.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$560.92
|
| Rate for Payer: Nomi Health Commercial |
$541.12
|
| Rate for Payer: PHP Commercial |
$560.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$428.94
|
| Rate for Payer: Priority Health HMO/PPO |
$574.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$442.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$580.71
|
| Rate for Payer: UHC Core |
$551.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$494.92
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$898.28
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$583.88 |
| Max. Negotiated Rate |
$808.45 |
| Rate for Payer: Aetna Commercial |
$763.54
|
| Rate for Payer: BCBS Trust/PPO |
$733.27
|
| Rate for Payer: BCN Commercial |
$694.19
|
| Rate for Payer: Cash Price |
$718.62
|
| Rate for Payer: Cofinity Commercial |
$772.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.62
|
| Rate for Payer: Healthscope Commercial |
$808.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$673.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.54
|
| Rate for Payer: Nomi Health Commercial |
$736.59
|
| Rate for Payer: PHP Commercial |
$763.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.88
|
| Rate for Payer: Priority Health HMO/PPO |
$781.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$601.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$790.49
|
| Rate for Payer: UHC Core |
$750.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$673.71
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$370.88
|
|
|
Service Code
|
NDC 00009031508
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.07 |
| Max. Negotiated Rate |
$333.79 |
| Rate for Payer: Aetna Commercial |
$315.25
|
| Rate for Payer: BCBS Trust/PPO |
$302.75
|
| Rate for Payer: BCN Commercial |
$286.62
|
| Rate for Payer: Cash Price |
$296.70
|
| Rate for Payer: Cofinity Commercial |
$318.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$296.70
|
| Rate for Payer: Healthscope Commercial |
$333.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.25
|
| Rate for Payer: Nomi Health Commercial |
$304.12
|
| Rate for Payer: PHP Commercial |
$315.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.07
|
| Rate for Payer: Priority Health HMO/PPO |
$322.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$326.37
|
| Rate for Payer: UHC Core |
$309.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.16
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
OP
|
$270.31
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.20 |
| Max. Negotiated Rate |
$243.28 |
| Rate for Payer: Aetna Commercial |
$229.76
|
| Rate for Payer: Aetna Medicare |
$70.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$84.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$84.47
|
| Rate for Payer: BCBS Complete |
$108.12
|
| Rate for Payer: BCBS MAPPO |
$67.58
|
| Rate for Payer: BCBS Trust/PPO |
$222.22
|
| Rate for Payer: BCN Commercial |
$210.17
|
| Rate for Payer: BCN Medicare Advantage |
$67.58
|
| Rate for Payer: Cash Price |
$216.25
|
| Rate for Payer: Cofinity Commercial |
$232.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$67.58
|
| Rate for Payer: Healthscope Commercial |
$243.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$70.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.76
|
| Rate for Payer: Nomi Health Commercial |
$221.65
|
| Rate for Payer: PACE Senior Care Partners |
$64.20
|
| Rate for Payer: PACE SWMI |
$67.58
|
| Rate for Payer: PHP Commercial |
$229.76
|
| Rate for Payer: PHP Medicare Advantage |
$67.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.70
|
| Rate for Payer: Priority Health HMO/PPO |
$235.17
|
| Rate for Payer: Priority Health Medicare |
$68.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$181.11
|
| Rate for Payer: Railroad Medicare Medicare |
$67.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$237.87
|
| Rate for Payer: UHC Core |
$225.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$67.58
|
| Rate for Payer: UHC Exchange |
$67.58
|
| Rate for Payer: UHC Medicare Advantage |
$67.58
|
| Rate for Payer: VA VA |
$67.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.73
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
OP
|
$370.88
|
|
|
Service Code
|
NDC 00009031508
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.08 |
| Max. Negotiated Rate |
$333.79 |
| Rate for Payer: Aetna Commercial |
$315.25
|
| Rate for Payer: Aetna Medicare |
$96.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$115.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$115.90
|
| Rate for Payer: BCBS Complete |
$148.35
|
| Rate for Payer: BCBS MAPPO |
$92.72
|
| Rate for Payer: BCBS Trust/PPO |
$304.90
|
| Rate for Payer: BCN Commercial |
$288.36
|
| Rate for Payer: BCN Medicare Advantage |
$92.72
|
| Rate for Payer: Cash Price |
$296.70
|
| Rate for Payer: Cofinity Commercial |
$318.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$296.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$92.72
|
| Rate for Payer: Healthscope Commercial |
$333.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$97.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$106.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.25
|
| Rate for Payer: Nomi Health Commercial |
$304.12
|
| Rate for Payer: PACE Senior Care Partners |
$88.08
|
| Rate for Payer: PACE SWMI |
$92.72
|
| Rate for Payer: PHP Commercial |
$315.25
|
| Rate for Payer: PHP Medicare Advantage |
$92.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.07
|
| Rate for Payer: Priority Health HMO/PPO |
$322.67
|
| Rate for Payer: Priority Health Medicare |
$93.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.49
|
| Rate for Payer: Railroad Medicare Medicare |
$92.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$326.37
|
| Rate for Payer: UHC Core |
$309.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$92.72
|
| Rate for Payer: UHC Exchange |
$92.72
|
| Rate for Payer: UHC Medicare Advantage |
$92.72
|
| Rate for Payer: VA VA |
$92.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.16
|
|
