|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$14.94
|
|
|
Service Code
|
NDC 52380190508
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna American Axle |
$9.71
|
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Aetna Medicare |
$7.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.71
|
| Rate for Payer: BCBS Complete |
$5.98
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: Cofinity Commercial |
$10.46
|
| Rate for Payer: Cofinity Commercial |
$12.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.95
|
| Rate for Payer: Healthscope Commercial |
$13.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.70
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.71
|
| Rate for Payer: Priority Health SBD |
$9.41
|
| Rate for Payer: UMR Bronson Commercial |
$5.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.21
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$21.29
|
|
|
Service Code
|
NDC 00395232516
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna American Axle |
$13.84
|
| Rate for Payer: Aetna Commercial |
$18.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.84
|
| Rate for Payer: Cash Price |
$17.03
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$18.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.03
|
| Rate for Payer: Healthscope Commercial |
$19.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.10
|
| Rate for Payer: PHP Commercial |
$18.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.84
|
| Rate for Payer: Priority Health SBD |
$13.41
|
| Rate for Payer: UMR Bronson Commercial |
$9.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.97
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$13.81
|
|
|
Service Code
|
NDC 00904110309
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna American Axle |
$8.98
|
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: Aetna Medicare |
$6.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.98
|
| Rate for Payer: BCBS Complete |
$5.52
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cofinity Commercial |
$11.88
|
| Rate for Payer: Cofinity Commercial |
$9.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.05
|
| Rate for Payer: Healthscope Commercial |
$12.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.74
|
| Rate for Payer: PHP Commercial |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.98
|
| Rate for Payer: Priority Health SBD |
$8.70
|
| Rate for Payer: UMR Bronson Commercial |
$5.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.36
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$13.81
|
|
|
Service Code
|
NDC 00904110309
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna American Axle |
$8.98
|
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.98
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cofinity Commercial |
$11.88
|
| Rate for Payer: Cofinity Commercial |
$9.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.05
|
| Rate for Payer: Healthscope Commercial |
$12.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.74
|
| Rate for Payer: PHP Commercial |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.98
|
| Rate for Payer: Priority Health SBD |
$8.70
|
| Rate for Payer: UMR Bronson Commercial |
$6.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.36
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$14.94
|
|
|
Service Code
|
NDC 52380190508
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.57 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna American Axle |
$9.71
|
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.71
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: Cofinity Commercial |
$10.46
|
| Rate for Payer: Cofinity Commercial |
$12.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.95
|
| Rate for Payer: Healthscope Commercial |
$13.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.70
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.71
|
| Rate for Payer: Priority Health SBD |
$9.41
|
| Rate for Payer: UMR Bronson Commercial |
$6.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.21
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
IP
|
$33.39
|
|
|
Service Code
|
NDC 00065041130
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$30.05 |
| Rate for Payer: Aetna American Axle |
$21.70
|
| Rate for Payer: Aetna Commercial |
$28.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.70
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cofinity Commercial |
$23.37
|
| Rate for Payer: Cofinity Commercial |
$28.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.71
|
| Rate for Payer: Healthscope Commercial |
$30.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.38
|
| Rate for Payer: PHP Commercial |
$28.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.70
|
| Rate for Payer: Priority Health SBD |
$21.04
|
| Rate for Payer: UMR Bronson Commercial |
$14.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.04
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
OP
|
$3.54
|
|
|
Service Code
|
NDC 09900000395
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna American Axle |
$2.30
|
| Rate for Payer: Aetna Commercial |
$3.01
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.30
|
| Rate for Payer: BCBS Complete |
$1.42
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cofinity Commercial |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$3.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.83
|
| Rate for Payer: Healthscope Commercial |
$3.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.01
|
| Rate for Payer: PHP Commercial |
$3.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.30
|
| Rate for Payer: Priority Health SBD |
$2.23
|
| Rate for Payer: UMR Bronson Commercial |
$1.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.65
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
OP
|
$33.39
|
|
|
Service Code
|
NDC 00065041130
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$30.05 |
| Rate for Payer: Aetna American Axle |
$21.70
|
| Rate for Payer: Aetna Commercial |
$28.38
|
| Rate for Payer: Aetna Medicare |
$16.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.70
|
| Rate for Payer: BCBS Complete |
$13.36
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cofinity Commercial |
$23.37
|
| Rate for Payer: Cofinity Commercial |
$28.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.71
|
| Rate for Payer: Healthscope Commercial |
$30.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.38
|
| Rate for Payer: PHP Commercial |
$28.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.70
|
| Rate for Payer: Priority Health SBD |
$21.04
|
| Rate for Payer: UMR Bronson Commercial |
$12.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.04
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION
|
Facility
|
IP
|
$3.54
|
|
|
Service Code
|
NDC 09900000395
|
| Hospital Charge Code |
19791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna American Axle |
$2.30
|
| Rate for Payer: Aetna Commercial |
$3.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.30
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cofinity Commercial |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$3.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.83
|
| Rate for Payer: Healthscope Commercial |
$3.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.01
|
| Rate for Payer: PHP Commercial |
$3.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.30
|
| Rate for Payer: Priority Health SBD |
$2.23
|
| Rate for Payer: UMR Bronson Commercial |
$1.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.65
|
|
|
PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR
|
Professional
|
Both
|
$2,098.00
|
|
|
Service Code
|
HCPCS 54332
|
| Min. Negotiated Rate |
$839.20 |
| Max. Negotiated Rate |
$1,389.10 |
| Rate for Payer: Aetna Commercial |
$1,292.63
|
| Rate for Payer: Aetna Medicare |
$1,003.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,389.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,292.63
|
| Rate for Payer: BCBS Complete |
$839.20
|
| Rate for Payer: BCBS MAPPO |
$964.65
|
| Rate for Payer: BCN Medicare Advantage |
$964.65
|
| Rate for Payer: Cash Price |
$1,678.40
|
| Rate for Payer: Cash Price |
$1,678.40
|
| Rate for Payer: Cofinity Commercial |
$1,389.10
|
| Rate for Payer: Cofinity Commercial |
$1,292.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$964.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,012.88
|
| Rate for Payer: Nomi Health Commercial |
$1,157.58
|
| Rate for Payer: PACE SWMI |
$964.65
|
| Rate for Payer: PHP Commercial |
$1,350.51
|
| Rate for Payer: PHP Medicare Advantage |
$964.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,363.70
|
| Rate for Payer: Priority Health Medicare |
$964.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$964.65
|
| Rate for Payer: UHC Medicare Advantage |
$964.65
|
| Rate for Payer: UMR Bronson Commercial |
$965.08
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS
|
Professional
|
Both
|
$1,774.00
|
|
|
Service Code
|
HCPCS 54326
|
| Min. Negotiated Rate |
$709.60 |
| Max. Negotiated Rate |
$1,295.71 |
| Rate for Payer: Aetna Commercial |
$1,205.73
|
| Rate for Payer: Aetna Medicare |
$935.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,295.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,205.73
|
| Rate for Payer: BCBS Complete |
$709.60
|
| Rate for Payer: BCBS MAPPO |
$899.80
|
| Rate for Payer: BCN Medicare Advantage |
$899.80
|
| Rate for Payer: Cash Price |
$1,419.20
|
| Rate for Payer: Cash Price |
$1,419.20
|
| Rate for Payer: Cofinity Commercial |
$1,295.71
|
| Rate for Payer: Cofinity Commercial |
$1,205.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$899.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$944.79
|
| Rate for Payer: Nomi Health Commercial |
$1,079.76
|
| Rate for Payer: PACE SWMI |
$899.80
|
| Rate for Payer: PHP Commercial |
$1,259.72
|
| Rate for Payer: PHP Medicare Advantage |
$899.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,153.10
|
| Rate for Payer: Priority Health Medicare |
$899.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$899.80
|
| Rate for Payer: UHC Medicare Advantage |
$899.80
|
| Rate for Payer: UMR Bronson Commercial |
$816.04
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT
|
Professional
|
Both
|
$5,000.00
|
|
|
Service Code
|
HCPCS 54322
|
| Min. Negotiated Rate |
$746.55 |
| Max. Negotiated Rate |
$3,250.00 |
| Rate for Payer: Aetna Commercial |
$1,000.38
|
| Rate for Payer: Aetna Medicare |
$776.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,075.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,000.38
|
| Rate for Payer: BCBS Complete |
$2,000.00
|
| Rate for Payer: BCBS MAPPO |
$746.55
|
| Rate for Payer: BCN Medicare Advantage |
$746.55
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cofinity Commercial |
$1,075.03
|
| Rate for Payer: Cofinity Commercial |
$1,000.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$746.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$783.88
|
| Rate for Payer: Nomi Health Commercial |
$895.86
|
| Rate for Payer: PACE SWMI |
$746.55
|
| Rate for Payer: PHP Commercial |
$1,045.17
|
| Rate for Payer: PHP Medicare Advantage |
$746.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,250.00
|
| Rate for Payer: Priority Health Medicare |
$746.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$746.55
|
| Rate for Payer: UHC Medicare Advantage |
$746.55
|
| Rate for Payer: UMR Bronson Commercial |
$2,300.00
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS
|
Professional
|
Both
|
$2,012.00
|
|
|
Service Code
|
HCPCS 54324
|
| Min. Negotiated Rate |
$804.80 |
| Max. Negotiated Rate |
$1,331.44 |
| Rate for Payer: Aetna Commercial |
$1,238.98
|
| Rate for Payer: Aetna Medicare |
$961.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,331.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,238.98
|
| Rate for Payer: BCBS Complete |
$804.80
|
| Rate for Payer: BCBS MAPPO |
$924.61
|
| Rate for Payer: BCN Medicare Advantage |
$924.61
|
| Rate for Payer: Cash Price |
$1,609.60
|
| Rate for Payer: Cash Price |
$1,609.60
|
| Rate for Payer: Cofinity Commercial |
$1,331.44
|
| Rate for Payer: Cofinity Commercial |
$1,238.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$924.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$970.84
|
| Rate for Payer: Nomi Health Commercial |
$1,109.53
|
| Rate for Payer: PACE SWMI |
$924.61
|
| Rate for Payer: PHP Commercial |
$1,294.45
|
| Rate for Payer: PHP Medicare Advantage |
$924.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,307.80
|
| Rate for Payer: Priority Health Medicare |
$924.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$924.61
|
| Rate for Payer: UHC Medicare Advantage |
$924.61
|
| Rate for Payer: UMR Bronson Commercial |
$925.52
|
|
|
PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 99460
|
| Min. Negotiated Rate |
$63.20 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$117.08
|
| Rate for Payer: Aetna Medicare |
$90.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.08
|
| Rate for Payer: BCBS Complete |
$63.20
|
| Rate for Payer: BCBS MAPPO |
$87.37
|
| Rate for Payer: BCN Medicare Advantage |
$87.37
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cofinity Commercial |
$125.81
|
| Rate for Payer: Cofinity Commercial |
$117.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$87.37
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$91.74
|
| Rate for Payer: Nomi Health Commercial |
$104.84
|
| Rate for Payer: PACE SWMI |
$87.37
|
| Rate for Payer: PHP Commercial |
$122.32
|
| Rate for Payer: PHP Medicare Advantage |
$87.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.70
|
| Rate for Payer: Priority Health Medicare |
$87.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$87.37
|
| Rate for Payer: UHC Medicare Advantage |
$87.37
|
| Rate for Payer: UMR Bronson Commercial |
$72.68
|
|
|
PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS 99463
|
| Min. Negotiated Rate |
$68.80 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$136.79
|
| Rate for Payer: Aetna Medicare |
$106.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.79
|
| Rate for Payer: BCBS Complete |
$68.80
|
| Rate for Payer: BCBS MAPPO |
$102.08
|
| Rate for Payer: BCN Medicare Advantage |
$102.08
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cofinity Commercial |
$147.00
|
| Rate for Payer: Cofinity Commercial |
$136.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$102.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$107.18
|
| Rate for Payer: Nomi Health Commercial |
$122.50
|
| Rate for Payer: PACE SWMI |
$102.08
|
| Rate for Payer: PHP Commercial |
$142.91
|
| Rate for Payer: PHP Medicare Advantage |
$102.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.80
|
| Rate for Payer: Priority Health Medicare |
$102.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$102.08
|
| Rate for Payer: UHC Medicare Advantage |
$102.08
|
| Rate for Payer: UMR Bronson Commercial |
$79.12
|
|
|
PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES
|
Professional
|
Both
|
$353.00
|
|
|
Service Code
|
HCPCS 99223
|
| Min. Negotiated Rate |
$141.20 |
| Max. Negotiated Rate |
$237.31 |
| Rate for Payer: Aetna Commercial |
$220.83
|
| Rate for Payer: Aetna Medicare |
$171.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.83
|
| Rate for Payer: BCBS Complete |
$141.20
|
| Rate for Payer: BCBS MAPPO |
$164.80
|
| Rate for Payer: BCN Medicare Advantage |
$164.80
|
| Rate for Payer: Cash Price |
$282.40
|
| Rate for Payer: Cash Price |
$282.40
|
| Rate for Payer: Cofinity Commercial |
$237.31
|
| Rate for Payer: Cofinity Commercial |
$220.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$164.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$173.04
|
| Rate for Payer: Nomi Health Commercial |
$197.76
|
| Rate for Payer: PACE SWMI |
$164.80
|
| Rate for Payer: PHP Commercial |
$230.72
|
| Rate for Payer: PHP Medicare Advantage |
$164.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.45
|
| Rate for Payer: Priority Health Medicare |
$164.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$164.80
|
| Rate for Payer: UHC Medicare Advantage |
$164.80
|
| Rate for Payer: UMR Bronson Commercial |
$162.38
|
|
|
PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS 99222
|
| Min. Negotiated Rate |
$96.40 |
| Max. Negotiated Rate |
$178.10 |
| Rate for Payer: Aetna Commercial |
$165.73
|
| Rate for Payer: Aetna Medicare |
$128.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.73
|
| Rate for Payer: BCBS Complete |
$96.40
|
| Rate for Payer: BCBS MAPPO |
$123.68
|
| Rate for Payer: BCN Medicare Advantage |
$123.68
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cofinity Commercial |
$178.10
|
| Rate for Payer: Cofinity Commercial |
$165.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$123.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$129.86
|
| Rate for Payer: Nomi Health Commercial |
$148.42
|
| Rate for Payer: PACE SWMI |
$123.68
|
| Rate for Payer: PHP Commercial |
$173.15
|
| Rate for Payer: PHP Medicare Advantage |
$123.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.65
|
| Rate for Payer: Priority Health Medicare |
$123.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$123.68
|
| Rate for Payer: UHC Medicare Advantage |
$123.68
|
| Rate for Payer: UMR Bronson Commercial |
$110.86
|
|
|
PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
HCPCS 99221
|
| Min. Negotiated Rate |
$70.80 |
| Max. Negotiated Rate |
$115.05 |
| Rate for Payer: Aetna Commercial |
$105.35
|
| Rate for Payer: Aetna Medicare |
$81.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.35
|
| Rate for Payer: BCBS Complete |
$70.80
|
| Rate for Payer: BCBS MAPPO |
$78.62
|
| Rate for Payer: BCN Medicare Advantage |
$78.62
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cofinity Commercial |
$113.21
|
| Rate for Payer: Cofinity Commercial |
$105.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.55
|
| Rate for Payer: Nomi Health Commercial |
$94.34
|
| Rate for Payer: PACE SWMI |
$78.62
|
| Rate for Payer: PHP Commercial |
$110.07
|
| Rate for Payer: PHP Medicare Advantage |
$78.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.05
|
| Rate for Payer: Priority Health Medicare |
$78.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.62
|
| Rate for Payer: UHC Medicare Advantage |
$78.62
|
| Rate for Payer: UMR Bronson Commercial |
$81.42
|
|
|
PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<
|
Professional
|
Both
|
$1,675.00
|
|
|
Service Code
|
HCPCS 99468
|
| Min. Negotiated Rate |
$670.00 |
| Max. Negotiated Rate |
$1,210.87 |
| Rate for Payer: Aetna Commercial |
$1,126.78
|
| Rate for Payer: Aetna Medicare |
$874.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,210.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,126.78
|
| Rate for Payer: BCBS Complete |
$670.00
|
| Rate for Payer: BCBS MAPPO |
$840.88
|
| Rate for Payer: BCN Medicare Advantage |
$840.88
|
| Rate for Payer: Cash Price |
$1,340.00
|
| Rate for Payer: Cash Price |
$1,340.00
|
| Rate for Payer: Cofinity Commercial |
$1,210.87
|
| Rate for Payer: Cofinity Commercial |
$1,126.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$840.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$882.92
|
| Rate for Payer: Nomi Health Commercial |
$1,009.06
|
| Rate for Payer: PACE SWMI |
$840.88
|
| Rate for Payer: PHP Commercial |
$1,177.23
|
| Rate for Payer: PHP Medicare Advantage |
$840.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,088.75
|
| Rate for Payer: Priority Health Medicare |
$840.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$840.88
|
| Rate for Payer: UHC Medicare Advantage |
$840.88
|
| Rate for Payer: UMR Bronson Commercial |
$770.50
|
|
|
PR 1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 99492
|
| Min. Negotiated Rate |
$89.32 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna Commercial |
$119.69
|
| Rate for Payer: Aetna Medicare |
$92.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.69
|
| Rate for Payer: BCBS Complete |
$126.00
|
| Rate for Payer: BCBS MAPPO |
$89.32
|
| Rate for Payer: BCN Medicare Advantage |
$89.32
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cofinity Commercial |
$128.62
|
| Rate for Payer: Cofinity Commercial |
$119.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$89.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$93.79
|
| Rate for Payer: Nomi Health Commercial |
$107.18
|
| Rate for Payer: PACE SWMI |
$89.32
|
| Rate for Payer: PHP Commercial |
$125.05
|
| Rate for Payer: PHP Medicare Advantage |
$89.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.75
|
| Rate for Payer: Priority Health Medicare |
$89.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$89.32
|
| Rate for Payer: UHC Medicare Advantage |
$89.32
|
| Rate for Payer: UMR Bronson Commercial |
$144.90
|
|
|
PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
HCPCS 99494
|
| Min. Negotiated Rate |
$38.06 |
| Max. Negotiated Rate |
$83.85 |
| Rate for Payer: Aetna Commercial |
$51.00
|
| Rate for Payer: Aetna Medicare |
$39.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.00
|
| Rate for Payer: BCBS Complete |
$51.60
|
| Rate for Payer: BCBS MAPPO |
$38.06
|
| Rate for Payer: BCN Medicare Advantage |
$38.06
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cofinity Commercial |
$54.81
|
| Rate for Payer: Cofinity Commercial |
$51.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.96
|
| Rate for Payer: Nomi Health Commercial |
$45.67
|
| Rate for Payer: PACE SWMI |
$38.06
|
| Rate for Payer: PHP Commercial |
$53.28
|
| Rate for Payer: PHP Medicare Advantage |
$38.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.85
|
| Rate for Payer: Priority Health Medicare |
$38.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.06
|
| Rate for Payer: UHC Medicare Advantage |
$38.06
|
| Rate for Payer: UMR Bronson Commercial |
$59.34
|
|
|
PR 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
Both
|
$279.00
|
|
|
Service Code
|
HCPCS 90650
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$181.35 |
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS Complete |
$111.60
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.35
|
| Rate for Payer: UMR Bronson Commercial |
$128.34
|
|
|
PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
HCPCS 90649
|
| Min. Negotiated Rate |
$105.20 |
| Max. Negotiated Rate |
$170.95 |
| Rate for Payer: Aetna Medicare |
$131.50
|
| Rate for Payer: BCBS Complete |
$105.20
|
| Rate for Payer: Cash Price |
$210.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.95
|
| Rate for Payer: UMR Bronson Commercial |
$120.98
|
|
|
PR 5% DEXTROSE IN LAC RINGERS
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J7121
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
| Rate for Payer: UMR Bronson Commercial |
$14.26
|
|
|
PR 9VHPV VACC 2/3 DOSE SCHED IM USE
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 90651
|
| Min. Negotiated Rate |
$118.40 |
| Max. Negotiated Rate |
$192.40 |
| Rate for Payer: Aetna Medicare |
$148.00
|
| Rate for Payer: BCBS Complete |
$118.40
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.40
|
| Rate for Payer: UMR Bronson Commercial |
$136.16
|
|
