|
PROCHLORPERAZINE MALEATE 5 MG TABLET
|
Facility
|
IP
|
$5.17
|
|
|
Service Code
|
NDC 50268068411
|
| Hospital Charge Code |
6583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: BCBS Trust/PPO |
$4.27
|
| Rate for Payer: BCN Commercial |
$4.27
|
| Rate for Payer: Cash Price |
$4.14
|
| Rate for Payer: Cofinity Commercial |
$4.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.14
|
| Rate for Payer: Healthscope Commercial |
$4.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Nomi Health Commercial |
$4.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.88
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.55
|
| Rate for Payer: UHC Core |
$4.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.88
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET
|
Facility
|
OP
|
$258.24
|
|
|
Service Code
|
NDC 50268068415
|
| Hospital Charge Code |
6583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.53 |
| Max. Negotiated Rate |
$232.42 |
| Rate for Payer: Aetna Commercial |
$219.50
|
| Rate for Payer: Aetna Medicare |
$67.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$80.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$80.70
|
| Rate for Payer: BCBS Complete |
$47.80
|
| Rate for Payer: BCBS MAPPO |
$64.56
|
| Rate for Payer: BCBS Trust/PPO |
$212.30
|
| Rate for Payer: BCN Commercial |
$212.30
|
| Rate for Payer: BCN Medicare Advantage |
$64.56
|
| Rate for Payer: Cash Price |
$206.59
|
| Rate for Payer: Cofinity Commercial |
$222.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$64.56
|
| Rate for Payer: Healthscope Commercial |
$232.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.68
|
| Rate for Payer: Mclaren Medicaid |
$45.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$67.79
|
| Rate for Payer: Meridian Medicaid |
$47.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.24
|
| Rate for Payer: Molina Medicare/Medicaid |
$71.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.50
|
| Rate for Payer: Nomi Health Commercial |
$211.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.68
|
| Rate for Payer: PACE Senior Care Partners |
$61.33
|
| Rate for Payer: PACE SWMI |
$64.56
|
| Rate for Payer: PHP Commercial |
$219.50
|
| Rate for Payer: PHP Medicare Advantage |
$64.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$224.67
|
| Rate for Payer: Priority Health Medicare |
$65.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$179.74
|
| Rate for Payer: Railroad Medicare Medicare |
$64.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.25
|
| Rate for Payer: UHC Core |
$215.63
|
| Rate for Payer: UHC Exchange |
$64.56
|
| Rate for Payer: UHC Medicaid |
$45.53
|
| Rate for Payer: UHC Medicare Advantage |
$64.56
|
| Rate for Payer: UHCCP Medicaid |
$45.53
|
| Rate for Payer: VA VA |
$64.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.68
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
NDC 50268068411
|
| Hospital Charge Code |
6583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna Medicare |
$1.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.62
|
| Rate for Payer: BCBS Complete |
$0.96
|
| Rate for Payer: BCBS MAPPO |
$1.29
|
| Rate for Payer: BCBS Trust/PPO |
$4.25
|
| Rate for Payer: BCN Commercial |
$4.25
|
| Rate for Payer: BCN Medicare Advantage |
$1.29
|
| Rate for Payer: Cash Price |
$4.14
|
| Rate for Payer: Cofinity Commercial |
$4.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.29
|
| Rate for Payer: Healthscope Commercial |
$4.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.88
|
| Rate for Payer: Mclaren Medicaid |
$0.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.36
|
| Rate for Payer: Meridian Medicaid |
$0.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.49
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Nomi Health Commercial |
$4.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.88
|
| Rate for Payer: PACE Senior Care Partners |
$1.23
|
| Rate for Payer: PACE SWMI |
$1.29
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: PHP Medicare Advantage |
$1.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.50
|
| Rate for Payer: Priority Health Medicare |
$1.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.60
|
| Rate for Payer: Railroad Medicare Medicare |
$1.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.55
|
| Rate for Payer: UHC Core |
$4.32
|
| Rate for Payer: UHC Exchange |
$1.29
|
| Rate for Payer: UHC Medicaid |
$0.91
|
| Rate for Payer: UHC Medicare Advantage |
$1.29
|
| Rate for Payer: UHCCP Medicaid |
$0.91
|
| Rate for Payer: VA VA |
$1.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.88
|
|
|
PR OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS 99241
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$87.00 |
| Rate for Payer: Aetna Medicare |
$58.00
|
| Rate for Payer: BCBS Complete |
$46.40
|
| Rate for Payer: Cash Price |
$92.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.00
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
HCPCS 99245
|
| Min. Negotiated Rate |
$113.96 |
| Max. Negotiated Rate |
$286.50 |
| Rate for Payer: Aetna Commercial |
$196.80
|
| Rate for Payer: Aetna Medicare |
$191.00
|
| Rate for Payer: BCBS Complete |
$119.66
|
| Rate for Payer: BCN Commercial |
$266.42
|
| Rate for Payer: Cash Price |
$305.60
|
| Rate for Payer: Cash Price |
$305.60
|
| Rate for Payer: Mclaren Medicaid |
$113.96
|
| Rate for Payer: Meridian Medicaid |
$119.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$113.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$239.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$239.64
|
| Rate for Payer: UHC Medicaid |
$113.96
|
| Rate for Payer: UHCCP Medicaid |
$113.96
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT LOW MDM 30 MINUTES
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
HCPCS 99243
|
| Min. Negotiated Rate |
$55.81 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna Commercial |
$98.89
|
| Rate for Payer: Aetna Medicare |
$105.00
|
| Rate for Payer: BCBS Complete |
$58.60
|
| Rate for Payer: BCN Commercial |
$130.97
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Mclaren Medicaid |
$55.81
|
| Rate for Payer: Meridian Medicaid |
$58.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$55.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$117.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$117.81
|
| Rate for Payer: UHC Medicaid |
$55.81
|
| Rate for Payer: UHCCP Medicaid |
$55.81
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES
|
Professional
|
Both
|
$308.00
|
|
|
Service Code
|
HCPCS 99244
|
| Min. Negotiated Rate |
$85.20 |
| Max. Negotiated Rate |
$231.00 |
| Rate for Payer: Aetna Commercial |
$159.16
|
| Rate for Payer: Aetna Medicare |
$154.00
|
| Rate for Payer: BCBS Complete |
$89.46
|
| Rate for Payer: BCN Commercial |
$198.70
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Mclaren Medicaid |
$85.20
|
| Rate for Payer: Meridian Medicaid |
$89.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$85.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$178.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$178.72
|
| Rate for Payer: UHC Medicaid |
$85.20
|
| Rate for Payer: UHCCP Medicaid |
$85.20
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
HCPCS 99242
|
| Min. Negotiated Rate |
$35.36 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna Commercial |
$70.73
|
| Rate for Payer: Aetna Medicare |
$78.00
|
| Rate for Payer: BCBS Complete |
$37.13
|
| Rate for Payer: BCN Commercial |
$82.17
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Mclaren Medicaid |
$35.36
|
| Rate for Payer: Meridian Medicaid |
$37.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$35.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$73.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$73.91
|
| Rate for Payer: UHC Medicaid |
$35.36
|
| Rate for Payer: UHCCP Medicaid |
$35.36
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN
|
Professional
|
Both
|
$222.00
|
|
|
Service Code
|
HCPCS 99215
|
| Min. Negotiated Rate |
$110.52 |
| Max. Negotiated Rate |
$166.50 |
| Rate for Payer: Aetna Commercial |
$145.41
|
| Rate for Payer: Aetna Medicare |
$111.00
|
| Rate for Payer: BCBS Complete |
$116.05
|
| Rate for Payer: BCN Commercial |
$157.73
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Mclaren Medicaid |
$110.52
|
| Rate for Payer: Meridian Medicaid |
$116.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$110.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$162.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$162.63
|
| Rate for Payer: UHC Medicaid |
$110.52
|
| Rate for Payer: UHCCP Medicaid |
$110.52
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS 99213
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$86.25 |
| Rate for Payer: Aetna Commercial |
$66.92
|
| Rate for Payer: Aetna Medicare |
$57.50
|
| Rate for Payer: BCBS Complete |
$53.09
|
| Rate for Payer: BCN Commercial |
$80.24
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Mclaren Medicaid |
$50.56
|
| Rate for Payer: Meridian Medicaid |
$53.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$86.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$50.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$74.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.68
|
| Rate for Payer: UHC Medicaid |
$50.56
|
| Rate for Payer: UHCCP Medicaid |
$50.56
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
HCPCS 99214
|
| Min. Negotiated Rate |
$74.36 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna Commercial |
$98.82
|
| Rate for Payer: Aetna Medicare |
$84.00
|
| Rate for Payer: BCBS Complete |
$78.08
|
| Rate for Payer: BCN Commercial |
$116.36
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Mclaren Medicaid |
$74.36
|
| Rate for Payer: Meridian Medicaid |
$78.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$74.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$109.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$109.94
|
| Rate for Payer: UHC Medicaid |
$74.36
|
| Rate for Payer: UHCCP Medicaid |
$74.36
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 99212
|
| Min. Negotiated Rate |
$27.33 |
| Max. Negotiated Rate |
$51.06 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Aetna Medicare |
$32.50
|
| Rate for Payer: BCBS Complete |
$28.70
|
| Rate for Payer: BCN Commercial |
$51.06
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Mclaren Medicaid |
$27.33
|
| Rate for Payer: Meridian Medicaid |
$28.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$27.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$39.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.81
|
| Rate for Payer: UHC Medicaid |
$27.33
|
| Rate for Payer: UHCCP Medicaid |
$27.33
|
|
|
PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
HCPCS 99211
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$8.94
|
| Rate for Payer: Aetna Medicare |
$21.00
|
| Rate for Payer: BCBS Complete |
$7.10
|
| Rate for Payer: BCN Commercial |
$23.53
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Mclaren Medicaid |
$6.76
|
| Rate for Payer: Meridian Medicaid |
$7.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$9.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.86
|
| Rate for Payer: UHC Medicaid |
$6.76
|
| Rate for Payer: UHCCP Medicaid |
$6.76
|
|
|
PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 99205
|
| Min. Negotiated Rate |
$141.08 |
| Max. Negotiated Rate |
$243.75 |
| Rate for Payer: Aetna Commercial |
$183.49
|
| Rate for Payer: Aetna Medicare |
$162.50
|
| Rate for Payer: BCBS Complete |
$148.13
|
| Rate for Payer: BCN Commercial |
$211.86
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Mclaren Medicaid |
$141.08
|
| Rate for Payer: Meridian Medicaid |
$148.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$243.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$141.08
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$205.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$205.84
|
| Rate for Payer: UHC Medicaid |
$141.08
|
| Rate for Payer: UHCCP Medicaid |
$141.08
|
|
|
PR OFFICE OUTPATIENT NEW LEVL I
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 99201
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$54.75 |
| Rate for Payer: Aetna Medicare |
$36.50
|
| Rate for Payer: BCBS Complete |
$29.20
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$54.75
|
|
|
PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
HCPCS 99203
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna Commercial |
$83.07
|
| Rate for Payer: Aetna Medicare |
$84.00
|
| Rate for Payer: BCBS Complete |
$66.05
|
| Rate for Payer: BCN Commercial |
$109.72
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Mclaren Medicaid |
$62.90
|
| Rate for Payer: Meridian Medicaid |
$66.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$62.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$92.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$92.88
|
| Rate for Payer: UHC Medicaid |
$62.90
|
| Rate for Payer: UHCCP Medicaid |
$62.90
|
|
|
PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
HCPCS 99204
|
| Min. Negotiated Rate |
$102.87 |
| Max. Negotiated Rate |
$197.25 |
| Rate for Payer: Aetna Commercial |
$135.20
|
| Rate for Payer: Aetna Medicare |
$131.50
|
| Rate for Payer: BCBS Complete |
$108.01
|
| Rate for Payer: BCN Commercial |
$167.67
|
| Rate for Payer: Cash Price |
$210.40
|
| Rate for Payer: Cash Price |
$210.40
|
| Rate for Payer: Mclaren Medicaid |
$102.87
|
| Rate for Payer: Meridian Medicaid |
$108.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$197.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$102.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$151.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$151.25
|
| Rate for Payer: UHC Medicaid |
$102.87
|
| Rate for Payer: UHCCP Medicaid |
$102.87
|
|
|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS 99202
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$86.25 |
| Rate for Payer: Aetna Commercial |
$49.04
|
| Rate for Payer: Aetna Medicare |
$57.50
|
| Rate for Payer: BCBS Complete |
$37.96
|
| Rate for Payer: BCN Commercial |
$77.49
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Mclaren Medicaid |
$36.15
|
| Rate for Payer: Meridian Medicaid |
$37.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$86.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$36.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$53.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.08
|
| Rate for Payer: UHC Medicaid |
$36.15
|
| Rate for Payer: UHCCP Medicaid |
$36.15
|
|
|
PR OMALIZUMAB INJECTION
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS J2357
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$46.35 |
| Rate for Payer: Aetna Commercial |
$40.64
|
| Rate for Payer: Aetna Medicare |
$16.00
|
| Rate for Payer: BCBS Trust/PPO |
$46.35
|
| Rate for Payer: BCN Commercial |
$40.87
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.00
|
|
|
PR OMENTAL FLAP INTRA-ABDOMINAL
|
Professional
|
Both
|
$661.00
|
|
|
Service Code
|
HCPCS 49905
|
| Min. Negotiated Rate |
$200.86 |
| Max. Negotiated Rate |
$636.48 |
| Rate for Payer: Aetna Commercial |
$477.01
|
| Rate for Payer: Aetna Medicare |
$330.50
|
| Rate for Payer: BCBS Complete |
$210.90
|
| Rate for Payer: BCN Commercial |
$522.38
|
| Rate for Payer: Cash Price |
$528.80
|
| Rate for Payer: Cash Price |
$528.80
|
| Rate for Payer: Mclaren Medicaid |
$200.86
|
| Rate for Payer: Meridian Medicaid |
$210.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$495.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$200.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$636.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$636.48
|
| Rate for Payer: UHC Medicaid |
$200.86
|
| Rate for Payer: UHCCP Medicaid |
$200.86
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$185.15
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.64 |
| Max. Negotiated Rate |
$166.63 |
| Rate for Payer: Aetna Commercial |
$157.38
|
| Rate for Payer: Aetna Medicare |
$48.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$57.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$57.86
|
| Rate for Payer: BCBS Complete |
$34.27
|
| Rate for Payer: BCBS MAPPO |
$46.29
|
| Rate for Payer: BCBS Trust/PPO |
$152.21
|
| Rate for Payer: BCN Commercial |
$152.21
|
| Rate for Payer: BCN Medicare Advantage |
$46.29
|
| Rate for Payer: Cash Price |
$148.12
|
| Rate for Payer: Cofinity Commercial |
$159.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$46.29
|
| Rate for Payer: Healthscope Commercial |
$166.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.86
|
| Rate for Payer: Mclaren Medicaid |
$32.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$48.60
|
| Rate for Payer: Meridian Medicaid |
$34.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$53.23
|
| Rate for Payer: Molina Medicare/Medicaid |
$50.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.38
|
| Rate for Payer: Nomi Health Commercial |
$151.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$138.86
|
| Rate for Payer: PACE Senior Care Partners |
$43.97
|
| Rate for Payer: PACE SWMI |
$46.29
|
| Rate for Payer: PHP Commercial |
$157.38
|
| Rate for Payer: PHP Medicare Advantage |
$46.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$32.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$161.08
|
| Rate for Payer: Priority Health Medicare |
$46.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$128.86
|
| Rate for Payer: Railroad Medicare Medicare |
$46.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$162.93
|
| Rate for Payer: UHC Core |
$154.60
|
| Rate for Payer: UHC Exchange |
$46.29
|
| Rate for Payer: UHC Medicaid |
$32.64
|
| Rate for Payer: UHC Medicare Advantage |
$46.29
|
| Rate for Payer: UHCCP Medicaid |
$32.64
|
| Rate for Payer: VA VA |
$46.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.86
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$185.15
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.86 |
| Max. Negotiated Rate |
$166.63 |
| Rate for Payer: Aetna Commercial |
$157.38
|
| Rate for Payer: BCBS Trust/PPO |
$152.92
|
| Rate for Payer: BCN Commercial |
$152.92
|
| Rate for Payer: Cash Price |
$148.12
|
| Rate for Payer: Cofinity Commercial |
$159.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.12
|
| Rate for Payer: Healthscope Commercial |
$166.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.38
|
| Rate for Payer: Nomi Health Commercial |
$151.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$138.86
|
| Rate for Payer: PHP Commercial |
$157.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$161.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$128.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$162.93
|
| Rate for Payer: UHC Core |
$154.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.86
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$4.02
|
|
|
Service Code
|
NDC 60687066011
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.26
|
| Rate for Payer: BCBS Complete |
$0.74
|
| Rate for Payer: BCBS MAPPO |
$1.00
|
| Rate for Payer: BCBS Trust/PPO |
$3.30
|
| Rate for Payer: BCN Commercial |
$3.30
|
| Rate for Payer: BCN Medicare Advantage |
$1.00
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.00
|
| Rate for Payer: Healthscope Commercial |
$3.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.02
|
| Rate for Payer: Mclaren Medicaid |
$0.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.06
|
| Rate for Payer: Meridian Medicaid |
$0.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.42
|
| Rate for Payer: Nomi Health Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PACE Senior Care Partners |
$0.95
|
| Rate for Payer: PACE SWMI |
$1.00
|
| Rate for Payer: PHP Commercial |
$3.42
|
| Rate for Payer: PHP Medicare Advantage |
$1.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.50
|
| Rate for Payer: Priority Health Medicare |
$1.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.54
|
| Rate for Payer: UHC Core |
$3.36
|
| Rate for Payer: UHC Exchange |
$1.00
|
| Rate for Payer: UHC Medicaid |
$0.71
|
| Rate for Payer: UHC Medicare Advantage |
$1.00
|
| Rate for Payer: UHCCP Medicaid |
$0.71
|
| Rate for Payer: VA VA |
$1.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.02
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$401.85
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna Medicare |
$104.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$125.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$125.58
|
| Rate for Payer: BCBS Complete |
$74.38
|
| Rate for Payer: BCBS MAPPO |
$100.46
|
| Rate for Payer: BCBS Trust/PPO |
$330.36
|
| Rate for Payer: BCN Commercial |
$330.36
|
| Rate for Payer: BCN Medicare Advantage |
$100.46
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$100.46
|
| Rate for Payer: Healthscope Commercial |
$361.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Mclaren Medicaid |
$70.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$105.49
|
| Rate for Payer: Meridian Medicaid |
$74.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$115.53
|
| Rate for Payer: Molina Medicare/Medicaid |
$110.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Nomi Health Commercial |
$329.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.39
|
| Rate for Payer: PACE Senior Care Partners |
$95.44
|
| Rate for Payer: PACE SWMI |
$100.46
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: PHP Medicare Advantage |
$100.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$70.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$349.61
|
| Rate for Payer: Priority Health Medicare |
$101.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$279.69
|
| Rate for Payer: Railroad Medicare Medicare |
$100.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.63
|
| Rate for Payer: UHC Core |
$335.54
|
| Rate for Payer: UHC Exchange |
$100.46
|
| Rate for Payer: UHC Medicaid |
$70.85
|
| Rate for Payer: UHC Medicare Advantage |
$100.46
|
| Rate for Payer: UHCCP Medicaid |
$70.85
|
| Rate for Payer: VA VA |
$100.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$401.85
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$279.69 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: BCBS Trust/PPO |
$331.89
|
| Rate for Payer: BCN Commercial |
$331.89
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Nomi Health Commercial |
$329.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.39
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$349.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$279.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.63
|
| Rate for Payer: UHC Core |
$335.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.39
|
|
