|
ULIPRISTAL 30 MG TABLET
|
Facility
|
IP
|
$139.79
|
|
|
Service Code
|
NDC 73302045601
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.86 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$118.82
|
| Rate for Payer: BCBS Trust/PPO |
$114.11
|
| Rate for Payer: BCN Commercial |
$108.03
|
| Rate for Payer: Cash Price |
$111.83
|
| Rate for Payer: Cofinity Commercial |
$120.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.83
|
| Rate for Payer: Healthscope Commercial |
$125.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.82
|
| Rate for Payer: Nomi Health Commercial |
$114.63
|
| Rate for Payer: PHP Commercial |
$118.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.86
|
| Rate for Payer: Priority Health HMO/PPO |
$121.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.02
|
| Rate for Payer: UHC Core |
$116.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.84
|
|
|
ULIPRISTAL 30 MG TABLET
|
Facility
|
OP
|
$139.79
|
|
|
Service Code
|
NDC 73302045601
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$118.82
|
| Rate for Payer: Aetna Medicare |
$36.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$43.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$43.68
|
| Rate for Payer: BCBS Complete |
$55.92
|
| Rate for Payer: BCBS MAPPO |
$34.95
|
| Rate for Payer: BCBS Trust/PPO |
$114.92
|
| Rate for Payer: BCN Commercial |
$108.69
|
| Rate for Payer: BCN Medicare Advantage |
$34.95
|
| Rate for Payer: Cash Price |
$111.83
|
| Rate for Payer: Cofinity Commercial |
$120.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.95
|
| Rate for Payer: Healthscope Commercial |
$125.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$36.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.82
|
| Rate for Payer: Nomi Health Commercial |
$114.63
|
| Rate for Payer: PACE Senior Care Partners |
$33.20
|
| Rate for Payer: PACE SWMI |
$34.95
|
| Rate for Payer: PHP Commercial |
$118.82
|
| Rate for Payer: PHP Medicare Advantage |
$34.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.86
|
| Rate for Payer: Priority Health HMO/PPO |
$121.62
|
| Rate for Payer: Priority Health Medicare |
$35.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.66
|
| Rate for Payer: Railroad Medicare Medicare |
$34.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.02
|
| Rate for Payer: UHC Core |
$116.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.95
|
| Rate for Payer: UHC Exchange |
$34.95
|
| Rate for Payer: UHC Medicare Advantage |
$34.95
|
| Rate for Payer: VA VA |
$34.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.84
|
|
|
ULIPRISTAL 30 MG TABLET
|
Facility
|
IP
|
$123.70
|
|
|
Service Code
|
NDC 50102091101
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.41 |
| Max. Negotiated Rate |
$111.33 |
| Rate for Payer: Aetna Commercial |
$105.14
|
| Rate for Payer: BCBS Trust/PPO |
$100.98
|
| Rate for Payer: BCN Commercial |
$95.60
|
| Rate for Payer: Cash Price |
$98.96
|
| Rate for Payer: Cofinity Commercial |
$106.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.96
|
| Rate for Payer: Healthscope Commercial |
$111.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.14
|
| Rate for Payer: Nomi Health Commercial |
$101.43
|
| Rate for Payer: PHP Commercial |
$105.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.41
|
| Rate for Payer: Priority Health HMO/PPO |
$107.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.86
|
| Rate for Payer: UHC Core |
$103.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.78
|
|
|
ULIPRISTAL 30 MG TABLET
|
Facility
|
OP
|
$123.70
|
|
|
Service Code
|
NDC 50102091101
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$111.33 |
| Rate for Payer: Aetna Commercial |
$105.14
|
| Rate for Payer: Aetna Medicare |
$32.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$38.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$38.66
|
| Rate for Payer: BCBS Complete |
$49.48
|
| Rate for Payer: BCBS MAPPO |
$30.93
|
| Rate for Payer: BCBS Trust/PPO |
$101.69
|
| Rate for Payer: BCN Commercial |
$96.18
|
| Rate for Payer: BCN Medicare Advantage |
$30.93
|
| Rate for Payer: Cash Price |
$98.96
|
| Rate for Payer: Cofinity Commercial |
$106.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$30.93
|
| Rate for Payer: Healthscope Commercial |
$111.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$32.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.14
|
| Rate for Payer: Nomi Health Commercial |
$101.43
|
| Rate for Payer: PACE Senior Care Partners |
$29.38
|
| Rate for Payer: PACE SWMI |
$30.93
|
| Rate for Payer: PHP Commercial |
$105.14
|
| Rate for Payer: PHP Medicare Advantage |
$30.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.41
|
| Rate for Payer: Priority Health HMO/PPO |
$107.62
|
| Rate for Payer: Priority Health Medicare |
$31.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.88
|
| Rate for Payer: Railroad Medicare Medicare |
$30.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.86
|
| Rate for Payer: UHC Core |
$103.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$30.93
|
| Rate for Payer: UHC Exchange |
$30.93
|
| Rate for Payer: UHC Medicare Advantage |
$30.93
|
| Rate for Payer: VA VA |
$30.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.78
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
OP
|
$108.71
|
|
|
Service Code
|
NDC 00173087306
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.82 |
| Max. Negotiated Rate |
$97.84 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Aetna Medicare |
$28.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33.97
|
| Rate for Payer: BCBS Complete |
$43.48
|
| Rate for Payer: BCBS MAPPO |
$27.18
|
| Rate for Payer: BCBS Trust/PPO |
$89.37
|
| Rate for Payer: BCN Commercial |
$84.52
|
| Rate for Payer: BCN Medicare Advantage |
$27.18
|
| Rate for Payer: Cash Price |
$86.97
|
| Rate for Payer: Cofinity Commercial |
$93.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.18
|
| Rate for Payer: Healthscope Commercial |
$97.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.40
|
| Rate for Payer: Nomi Health Commercial |
$89.14
|
| Rate for Payer: PACE Senior Care Partners |
$25.82
|
| Rate for Payer: PACE SWMI |
$27.18
|
| Rate for Payer: PHP Commercial |
$92.40
|
| Rate for Payer: PHP Medicare Advantage |
$27.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.66
|
| Rate for Payer: Priority Health HMO/PPO |
$94.58
|
| Rate for Payer: Priority Health Medicare |
$27.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$72.84
|
| Rate for Payer: Railroad Medicare Medicare |
$27.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.66
|
| Rate for Payer: UHC Core |
$90.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$27.18
|
| Rate for Payer: UHC Exchange |
$27.18
|
| Rate for Payer: UHC Medicare Advantage |
$27.18
|
| Rate for Payer: VA VA |
$27.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.53
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$108.71
|
|
|
Service Code
|
NDC 00173087306
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.66 |
| Max. Negotiated Rate |
$97.84 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: BCBS Trust/PPO |
$88.74
|
| Rate for Payer: BCN Commercial |
$84.01
|
| Rate for Payer: Cash Price |
$86.97
|
| Rate for Payer: Cofinity Commercial |
$93.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.97
|
| Rate for Payer: Healthscope Commercial |
$97.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.40
|
| Rate for Payer: Nomi Health Commercial |
$89.14
|
| Rate for Payer: PHP Commercial |
$92.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.66
|
| Rate for Payer: Priority Health HMO/PPO |
$94.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$72.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.66
|
| Rate for Payer: UHC Core |
$90.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.53
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$1,152.59
|
|
|
Service Code
|
NDC 00173087310
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$749.18 |
| Max. Negotiated Rate |
$1,037.33 |
| Rate for Payer: Aetna Commercial |
$979.70
|
| Rate for Payer: BCBS Trust/PPO |
$940.86
|
| Rate for Payer: BCN Commercial |
$890.72
|
| Rate for Payer: Cash Price |
$922.07
|
| Rate for Payer: Cofinity Commercial |
$991.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$922.07
|
| Rate for Payer: Healthscope Commercial |
$1,037.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$864.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$979.70
|
| Rate for Payer: Nomi Health Commercial |
$945.12
|
| Rate for Payer: PHP Commercial |
$979.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$749.18
|
| Rate for Payer: Priority Health HMO/PPO |
$1,002.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$772.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,014.28
|
| Rate for Payer: UHC Core |
$962.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$864.44
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
OP
|
$1,152.59
|
|
|
Service Code
|
NDC 00173087310
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.74 |
| Max. Negotiated Rate |
$1,037.33 |
| Rate for Payer: Aetna Commercial |
$979.70
|
| Rate for Payer: Aetna Medicare |
$299.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$360.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$360.18
|
| Rate for Payer: BCBS Complete |
$461.04
|
| Rate for Payer: BCBS MAPPO |
$288.15
|
| Rate for Payer: BCBS Trust/PPO |
$947.54
|
| Rate for Payer: BCN Commercial |
$896.14
|
| Rate for Payer: BCN Medicare Advantage |
$288.15
|
| Rate for Payer: Cash Price |
$922.07
|
| Rate for Payer: Cofinity Commercial |
$991.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$922.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$288.15
|
| Rate for Payer: Healthscope Commercial |
$1,037.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$864.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$302.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$331.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$979.70
|
| Rate for Payer: Nomi Health Commercial |
$945.12
|
| Rate for Payer: PACE Senior Care Partners |
$273.74
|
| Rate for Payer: PACE SWMI |
$288.15
|
| Rate for Payer: PHP Commercial |
$979.70
|
| Rate for Payer: PHP Medicare Advantage |
$288.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$749.18
|
| Rate for Payer: Priority Health HMO/PPO |
$1,002.75
|
| Rate for Payer: Priority Health Medicare |
$291.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$772.24
|
| Rate for Payer: Railroad Medicare Medicare |
$288.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,014.28
|
| Rate for Payer: UHC Core |
$962.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$288.15
|
| Rate for Payer: UHC Exchange |
$288.15
|
| Rate for Payer: UHC Medicare Advantage |
$288.15
|
| Rate for Payer: VA VA |
$288.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$864.44
|
|
|
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION
|
Facility
|
OP
|
$217.63
|
|
|
Service Code
|
NDC 00173086906
|
| Hospital Charge Code |
169758
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.69 |
| Max. Negotiated Rate |
$195.87 |
| Rate for Payer: Aetna Commercial |
$184.99
|
| Rate for Payer: Aetna Medicare |
$56.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$68.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$68.01
|
| Rate for Payer: BCBS Complete |
$87.05
|
| Rate for Payer: BCBS MAPPO |
$54.41
|
| Rate for Payer: BCBS Trust/PPO |
$178.91
|
| Rate for Payer: BCN Commercial |
$169.21
|
| Rate for Payer: BCN Medicare Advantage |
$54.41
|
| Rate for Payer: Cash Price |
$174.10
|
| Rate for Payer: Cofinity Commercial |
$187.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.41
|
| Rate for Payer: Healthscope Commercial |
$195.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$57.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.99
|
| Rate for Payer: Nomi Health Commercial |
$178.46
|
| Rate for Payer: PACE Senior Care Partners |
$51.69
|
| Rate for Payer: PACE SWMI |
$54.41
|
| Rate for Payer: PHP Commercial |
$184.99
|
| Rate for Payer: PHP Medicare Advantage |
$54.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.46
|
| Rate for Payer: Priority Health HMO/PPO |
$189.34
|
| Rate for Payer: Priority Health Medicare |
$54.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$145.81
|
| Rate for Payer: Railroad Medicare Medicare |
$54.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.51
|
| Rate for Payer: UHC Core |
$181.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$54.41
|
| Rate for Payer: UHC Exchange |
$54.41
|
| Rate for Payer: UHC Medicare Advantage |
$54.41
|
| Rate for Payer: VA VA |
$54.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.22
|
|
|
UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION
|
Facility
|
IP
|
$217.63
|
|
|
Service Code
|
NDC 00173086906
|
| Hospital Charge Code |
169758
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.46 |
| Max. Negotiated Rate |
$195.87 |
| Rate for Payer: Aetna Commercial |
$184.99
|
| Rate for Payer: BCBS Trust/PPO |
$177.65
|
| Rate for Payer: BCN Commercial |
$168.18
|
| Rate for Payer: Cash Price |
$174.10
|
| Rate for Payer: Cofinity Commercial |
$187.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.10
|
| Rate for Payer: Healthscope Commercial |
$195.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.99
|
| Rate for Payer: Nomi Health Commercial |
$178.46
|
| Rate for Payer: PHP Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.46
|
| Rate for Payer: Priority Health HMO/PPO |
$189.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$145.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.51
|
| Rate for Payer: UHC Core |
$181.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.22
|
|
|
UNLISTED LAPAROSCOPIC PROCEDURE, LIVER
|
Facility
|
OP
|
$4,429.45
|
|
|
Service Code
|
CPT 47379
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,218.24 |
| Max. Negotiated Rate |
$4,429.45 |
| Rate for Payer: BCBS Complete |
$4,429.45
|
| Rate for Payer: Mclaren Medicaid |
$4,218.24
|
| Rate for Payer: Meridian Medicaid |
$4,429.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,218.24
|
| Rate for Payer: UHCCP Medicaid |
$4,218.24
|
|
|
UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM
|
Facility
|
OP
|
$182.12
|
|
|
Service Code
|
CPT 22999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$173.43 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: BCBS Complete |
$182.12
|
| Rate for Payer: Mclaren Medicaid |
$173.43
|
| Rate for Payer: Meridian Medicaid |
$182.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$173.43
|
| Rate for Payer: UHCCP Medicaid |
$173.43
|
|
|
UNLISTED PROCEDURE, ANUS
|
Facility
|
OP
|
$692.17
|
|
|
Service Code
|
CPT 46999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$659.17 |
| Max. Negotiated Rate |
$692.17 |
| Rate for Payer: BCBS Complete |
$692.17
|
| Rate for Payer: Mclaren Medicaid |
$659.17
|
| Rate for Payer: Meridian Medicaid |
$692.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$659.17
|
| Rate for Payer: UHCCP Medicaid |
$659.17
|
|
|
UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES
|
Facility
|
OP
|
$176.30
|
|
|
Service Code
|
CPT 41899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$167.90 |
| Max. Negotiated Rate |
$176.30 |
| Rate for Payer: BCBS Complete |
$176.30
|
| Rate for Payer: Mclaren Medicaid |
$167.90
|
| Rate for Payer: Meridian Medicaid |
$176.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$167.90
|
| Rate for Payer: UHCCP Medicaid |
$167.90
|
|
|
UNLISTED PROCEDURE, NERVOUS SYSTEM
|
Facility
|
OP
|
$224.11
|
|
|
Service Code
|
CPT 64999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$213.42 |
| Max. Negotiated Rate |
$224.11 |
| Rate for Payer: BCBS Complete |
$224.11
|
| Rate for Payer: Mclaren Medicaid |
$213.42
|
| Rate for Payer: Meridian Medicaid |
$224.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$213.42
|
| Rate for Payer: UHCCP Medicaid |
$213.42
|
|
|
UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE
|
Facility
|
OP
|
$150.85
|
|
|
Service Code
|
CPT 17999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$143.66 |
| Max. Negotiated Rate |
$150.85 |
| Rate for Payer: BCBS Complete |
$150.85
|
| Rate for Payer: Mclaren Medicaid |
$143.66
|
| Rate for Payer: Meridian Medicaid |
$150.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$143.66
|
| Rate for Payer: UHCCP Medicaid |
$143.66
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$366.24
|
|
|
Service Code
|
NDC 00904716806
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.06 |
| Max. Negotiated Rate |
$329.62 |
| Rate for Payer: Aetna Commercial |
$311.30
|
| Rate for Payer: BCBS Trust/PPO |
$298.96
|
| Rate for Payer: BCN Commercial |
$283.03
|
| Rate for Payer: Cash Price |
$292.99
|
| Rate for Payer: Cofinity Commercial |
$314.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.99
|
| Rate for Payer: Healthscope Commercial |
$329.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.30
|
| Rate for Payer: Nomi Health Commercial |
$300.32
|
| Rate for Payer: PHP Commercial |
$311.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.06
|
| Rate for Payer: Priority Health HMO/PPO |
$318.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$245.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.29
|
| Rate for Payer: UHC Core |
$305.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.68
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$366.24
|
|
|
Service Code
|
NDC 00904716806
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.98 |
| Max. Negotiated Rate |
$329.62 |
| Rate for Payer: Aetna Commercial |
$311.30
|
| Rate for Payer: Aetna Medicare |
$95.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.45
|
| Rate for Payer: BCBS Complete |
$146.50
|
| Rate for Payer: BCBS MAPPO |
$91.56
|
| Rate for Payer: BCBS Trust/PPO |
$301.09
|
| Rate for Payer: BCN Commercial |
$284.75
|
| Rate for Payer: BCN Medicare Advantage |
$91.56
|
| Rate for Payer: Cash Price |
$292.99
|
| Rate for Payer: Cofinity Commercial |
$314.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.56
|
| Rate for Payer: Healthscope Commercial |
$329.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.30
|
| Rate for Payer: Nomi Health Commercial |
$300.32
|
| Rate for Payer: PACE Senior Care Partners |
$86.98
|
| Rate for Payer: PACE SWMI |
$91.56
|
| Rate for Payer: PHP Commercial |
$311.30
|
| Rate for Payer: PHP Medicare Advantage |
$91.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.06
|
| Rate for Payer: Priority Health HMO/PPO |
$318.63
|
| Rate for Payer: Priority Health Medicare |
$92.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$245.38
|
| Rate for Payer: Railroad Medicare Medicare |
$91.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.29
|
| Rate for Payer: UHC Core |
$305.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.56
|
| Rate for Payer: UHC Exchange |
$91.56
|
| Rate for Payer: UHC Medicare Advantage |
$91.56
|
| Rate for Payer: VA VA |
$91.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.68
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$1,209.16
|
|
|
Service Code
|
NDC 00904716861
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$785.95 |
| Max. Negotiated Rate |
$1,088.24 |
| Rate for Payer: Aetna Commercial |
$1,027.79
|
| Rate for Payer: BCBS Trust/PPO |
$987.04
|
| Rate for Payer: BCN Commercial |
$934.44
|
| Rate for Payer: Cash Price |
$967.33
|
| Rate for Payer: Cofinity Commercial |
$1,039.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$967.33
|
| Rate for Payer: Healthscope Commercial |
$1,088.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$906.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,027.79
|
| Rate for Payer: Nomi Health Commercial |
$991.51
|
| Rate for Payer: PHP Commercial |
$1,027.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$785.95
|
| Rate for Payer: Priority Health HMO/PPO |
$1,051.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$810.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,064.06
|
| Rate for Payer: UHC Core |
$1,009.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$906.87
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$1,209.16
|
|
|
Service Code
|
NDC 00904716861
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.18 |
| Max. Negotiated Rate |
$1,088.24 |
| Rate for Payer: Aetna Commercial |
$1,027.79
|
| Rate for Payer: Aetna Medicare |
$314.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$377.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$377.86
|
| Rate for Payer: BCBS Complete |
$483.66
|
| Rate for Payer: BCBS MAPPO |
$302.29
|
| Rate for Payer: BCBS Trust/PPO |
$994.05
|
| Rate for Payer: BCN Commercial |
$940.12
|
| Rate for Payer: BCN Medicare Advantage |
$302.29
|
| Rate for Payer: Cash Price |
$967.33
|
| Rate for Payer: Cofinity Commercial |
$1,039.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$967.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$302.29
|
| Rate for Payer: Healthscope Commercial |
$1,088.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$906.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$317.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$347.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,027.79
|
| Rate for Payer: Nomi Health Commercial |
$991.51
|
| Rate for Payer: PACE Senior Care Partners |
$287.18
|
| Rate for Payer: PACE SWMI |
$302.29
|
| Rate for Payer: PHP Commercial |
$1,027.79
|
| Rate for Payer: PHP Medicare Advantage |
$302.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$785.95
|
| Rate for Payer: Priority Health HMO/PPO |
$1,051.97
|
| Rate for Payer: Priority Health Medicare |
$305.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$810.14
|
| Rate for Payer: Railroad Medicare Medicare |
$302.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,064.06
|
| Rate for Payer: UHC Core |
$1,009.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$302.29
|
| Rate for Payer: UHC Exchange |
$302.29
|
| Rate for Payer: UHC Medicare Advantage |
$302.29
|
| Rate for Payer: VA VA |
$302.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$906.87
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
OP
|
$73.53
|
|
|
Service Code
|
NDC 00378427593
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$66.18 |
| Rate for Payer: Aetna Commercial |
$62.50
|
| Rate for Payer: Aetna Medicare |
$19.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.98
|
| Rate for Payer: BCBS Complete |
$29.41
|
| Rate for Payer: BCBS MAPPO |
$18.38
|
| Rate for Payer: BCBS Trust/PPO |
$60.45
|
| Rate for Payer: BCN Commercial |
$57.17
|
| Rate for Payer: BCN Medicare Advantage |
$18.38
|
| Rate for Payer: Cash Price |
$58.82
|
| Rate for Payer: Cofinity Commercial |
$63.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.38
|
| Rate for Payer: Healthscope Commercial |
$66.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.50
|
| Rate for Payer: Nomi Health Commercial |
$60.29
|
| Rate for Payer: PACE Senior Care Partners |
$17.46
|
| Rate for Payer: PACE SWMI |
$18.38
|
| Rate for Payer: PHP Commercial |
$62.50
|
| Rate for Payer: PHP Medicare Advantage |
$18.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.79
|
| Rate for Payer: Priority Health HMO/PPO |
$63.97
|
| Rate for Payer: Priority Health Medicare |
$18.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$49.27
|
| Rate for Payer: Railroad Medicare Medicare |
$18.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.71
|
| Rate for Payer: UHC Core |
$61.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.38
|
| Rate for Payer: UHC Exchange |
$18.38
|
| Rate for Payer: UHC Medicare Advantage |
$18.38
|
| Rate for Payer: VA VA |
$18.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.15
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
IP
|
$494.88
|
|
|
Service Code
|
NDC 00904656561
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.67 |
| Max. Negotiated Rate |
$445.39 |
| Rate for Payer: Aetna Commercial |
$420.65
|
| Rate for Payer: BCBS Trust/PPO |
$403.97
|
| Rate for Payer: BCN Commercial |
$382.44
|
| Rate for Payer: Cash Price |
$395.90
|
| Rate for Payer: Cofinity Commercial |
$425.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$395.90
|
| Rate for Payer: Healthscope Commercial |
$445.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$371.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$420.65
|
| Rate for Payer: Nomi Health Commercial |
$405.80
|
| Rate for Payer: PHP Commercial |
$420.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.67
|
| Rate for Payer: Priority Health HMO/PPO |
$430.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$331.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$435.49
|
| Rate for Payer: UHC Core |
$413.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$371.16
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
IP
|
$73.53
|
|
|
Service Code
|
NDC 00378427593
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.79 |
| Max. Negotiated Rate |
$66.18 |
| Rate for Payer: Aetna Commercial |
$62.50
|
| Rate for Payer: BCBS Trust/PPO |
$60.02
|
| Rate for Payer: BCN Commercial |
$56.82
|
| Rate for Payer: Cash Price |
$58.82
|
| Rate for Payer: Cofinity Commercial |
$63.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.82
|
| Rate for Payer: Healthscope Commercial |
$66.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.50
|
| Rate for Payer: Nomi Health Commercial |
$60.29
|
| Rate for Payer: PHP Commercial |
$62.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.79
|
| Rate for Payer: Priority Health HMO/PPO |
$63.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$49.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.71
|
| Rate for Payer: UHC Core |
$61.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.15
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
OP
|
$76.76
|
|
|
Service Code
|
NDC 59746032430
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.23 |
| Max. Negotiated Rate |
$69.08 |
| Rate for Payer: Aetna Commercial |
$65.25
|
| Rate for Payer: Aetna Medicare |
$19.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.99
|
| Rate for Payer: BCBS Complete |
$30.70
|
| Rate for Payer: BCBS MAPPO |
$19.19
|
| Rate for Payer: BCBS Trust/PPO |
$63.10
|
| Rate for Payer: BCN Commercial |
$59.68
|
| Rate for Payer: BCN Medicare Advantage |
$19.19
|
| Rate for Payer: Cash Price |
$61.41
|
| Rate for Payer: Cofinity Commercial |
$66.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.19
|
| Rate for Payer: Healthscope Commercial |
$69.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.25
|
| Rate for Payer: Nomi Health Commercial |
$62.94
|
| Rate for Payer: PACE Senior Care Partners |
$18.23
|
| Rate for Payer: PACE SWMI |
$19.19
|
| Rate for Payer: PHP Commercial |
$65.25
|
| Rate for Payer: PHP Medicare Advantage |
$19.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.89
|
| Rate for Payer: Priority Health HMO/PPO |
$66.78
|
| Rate for Payer: Priority Health Medicare |
$19.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$51.43
|
| Rate for Payer: Railroad Medicare Medicare |
$19.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.55
|
| Rate for Payer: UHC Core |
$64.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.19
|
| Rate for Payer: UHC Exchange |
$19.19
|
| Rate for Payer: UHC Medicare Advantage |
$19.19
|
| Rate for Payer: VA VA |
$19.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.57
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
IP
|
$274.62
|
|
|
Service Code
|
NDC 00904656507
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$247.16 |
| Rate for Payer: Aetna Commercial |
$233.43
|
| Rate for Payer: BCBS Trust/PPO |
$224.17
|
| Rate for Payer: BCN Commercial |
$212.23
|
| Rate for Payer: Cash Price |
$219.70
|
| Rate for Payer: Cofinity Commercial |
$236.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.70
|
| Rate for Payer: Healthscope Commercial |
$247.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.43
|
| Rate for Payer: Nomi Health Commercial |
$225.19
|
| Rate for Payer: PHP Commercial |
$233.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.50
|
| Rate for Payer: Priority Health HMO/PPO |
$238.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$184.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.67
|
| Rate for Payer: UHC Core |
$229.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.97
|
|
