|
DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS, OR LIPS
|
Facility
|
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$339.88 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$1,336.74
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$373.87
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$339.88
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET
|
Facility
|
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$323.19 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$1,478.33
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$355.51
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$323.19
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
DELIVERY OF PLACENTA (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,748.29
|
|
|
Service Code
|
CPT 59414
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$89.06 |
| Max. Negotiated Rate |
$8,748.29 |
| Rate for Payer: Aetna Medicare |
$2,890.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,473.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,473.69
|
| Rate for Payer: BCBS Complete |
$1,596.23
|
| Rate for Payer: BCBS MAPPO |
$2,778.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,583.45
|
| Rate for Payer: BCN Medicare Advantage |
$2,778.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,778.95
|
| Rate for Payer: Mclaren Medicaid |
$1,520.09
|
| Rate for Payer: Mclaren Medicare |
$2,778.95
|
| Rate for Payer: Meridian Medicaid |
$1,596.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,917.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,195.79
|
| Rate for Payer: PACE Medicare |
$2,640.00
|
| Rate for Payer: PACE SWMI |
$2,778.95
|
| Rate for Payer: PHP Medicare Advantage |
$2,778.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,520.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,748.29
|
| Rate for Payer: Priority Health Medicare |
$2,778.95
|
| Rate for Payer: Priority Health Narrow Network |
$6,998.63
|
| Rate for Payer: Railroad Medicare Medicare |
$2,778.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.97
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,778.95
|
| Rate for Payer: UHC Exchange |
$89.06
|
| Rate for Payer: UHC Medicare Advantage |
$2,862.32
|
| Rate for Payer: VA VA |
$2,778.95
|
|
|
DEMECLOCYCLINE 150 MG TABLET
|
Facility
|
IP
|
$939.43
|
|
|
Service Code
|
NDC 42806-143-01
|
| Hospital Charge Code |
9726
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$413.35 |
| Max. Negotiated Rate |
$845.49 |
| Rate for Payer: Aetna American Axle |
$610.63
|
| Rate for Payer: Aetna Commercial |
$798.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$610.63
|
| Rate for Payer: Cash Price |
$751.54
|
| Rate for Payer: Cofinity Commercial |
$657.60
|
| Rate for Payer: Cofinity Commercial |
$807.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$751.54
|
| Rate for Payer: Healthscope Commercial |
$845.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$657.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$704.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$798.52
|
| Rate for Payer: PHP Commercial |
$798.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.60
|
| Rate for Payer: Priority Health SBD |
$591.84
|
| Rate for Payer: UMR Bronson Commercial |
$413.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$704.57
|
|
|
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$7,723.36
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
106804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$6,951.02 |
| Rate for Payer: Aetna American Axle |
$5,020.18
|
| Rate for Payer: Aetna Commercial |
$6,564.86
|
| Rate for Payer: Aetna Medicare |
$26.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,020.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.50
|
| Rate for Payer: BCBS Complete |
$14.47
|
| Rate for Payer: BCBS MAPPO |
$25.20
|
| Rate for Payer: BCBS Trust/PPO |
$81.42
|
| Rate for Payer: BCN Medicare Advantage |
$25.20
|
| Rate for Payer: Cash Price |
$6,178.69
|
| Rate for Payer: Cash Price |
$6,178.69
|
| Rate for Payer: Cofinity Commercial |
$5,406.35
|
| Rate for Payer: Cofinity Commercial |
$6,642.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,178.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$6,951.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,406.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,792.52
|
| Rate for Payer: Mclaren Medicaid |
$13.78
|
| Rate for Payer: Mclaren Medicare |
$25.20
|
| Rate for Payer: Meridian Medicaid |
$14.47
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$26.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,564.86
|
| Rate for Payer: PACE Medicare |
$23.94
|
| Rate for Payer: PACE SWMI |
$25.20
|
| Rate for Payer: PHP Commercial |
$6,564.86
|
| Rate for Payer: PHP Medicare Advantage |
$25.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,406.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.11
|
| Rate for Payer: Priority Health Medicare |
$25.20
|
| Rate for Payer: Priority Health Narrow Network |
$56.89
|
| Rate for Payer: Priority Health SBD |
$4,865.72
|
| Rate for Payer: Railroad Medicare Medicare |
$25.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$25.20
|
| Rate for Payer: UHC Medicare Advantage |
$25.95
|
| Rate for Payer: UMR Bronson Commercial |
$2,857.64
|
| Rate for Payer: VA VA |
$25.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,792.52
|
|
|
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$7,723.36
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
106804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,398.28 |
| Max. Negotiated Rate |
$6,951.02 |
| Rate for Payer: Aetna American Axle |
$5,020.18
|
| Rate for Payer: Aetna Commercial |
$6,564.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,020.18
|
| Rate for Payer: Cash Price |
$6,178.69
|
| Rate for Payer: Cofinity Commercial |
$5,406.35
|
| Rate for Payer: Cofinity Commercial |
$6,642.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,178.69
|
| Rate for Payer: Healthscope Commercial |
$6,951.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,406.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,792.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,564.86
|
| Rate for Payer: PHP Commercial |
$6,564.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,406.35
|
| Rate for Payer: Priority Health SBD |
$4,865.72
|
| Rate for Payer: UMR Bronson Commercial |
$3,398.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,792.52
|
|
|
DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$5,168.23
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
105502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$4,651.41 |
| Rate for Payer: Aetna American Axle |
$3,359.35
|
| Rate for Payer: Aetna Commercial |
$4,393.00
|
| Rate for Payer: Aetna Medicare |
$26.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,359.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.50
|
| Rate for Payer: BCBS Complete |
$14.47
|
| Rate for Payer: BCBS MAPPO |
$25.20
|
| Rate for Payer: BCBS Trust/PPO |
$81.42
|
| Rate for Payer: BCN Medicare Advantage |
$25.20
|
| Rate for Payer: Cash Price |
$4,134.58
|
| Rate for Payer: Cash Price |
$4,134.58
|
| Rate for Payer: Cofinity Commercial |
$4,444.68
|
| Rate for Payer: Cofinity Commercial |
$3,617.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,134.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$4,651.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,617.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,876.17
|
| Rate for Payer: Mclaren Medicaid |
$13.78
|
| Rate for Payer: Mclaren Medicare |
$25.20
|
| Rate for Payer: Meridian Medicaid |
$14.47
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$26.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,393.00
|
| Rate for Payer: PACE Medicare |
$23.94
|
| Rate for Payer: PACE SWMI |
$25.20
|
| Rate for Payer: PHP Commercial |
$4,393.00
|
| Rate for Payer: PHP Medicare Advantage |
$25.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,617.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.11
|
| Rate for Payer: Priority Health Medicare |
$25.20
|
| Rate for Payer: Priority Health Narrow Network |
$56.89
|
| Rate for Payer: Priority Health SBD |
$3,255.98
|
| Rate for Payer: Railroad Medicare Medicare |
$25.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$25.20
|
| Rate for Payer: UHC Medicare Advantage |
$25.95
|
| Rate for Payer: UMR Bronson Commercial |
$1,912.25
|
| Rate for Payer: VA VA |
$25.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,876.17
|
|
|
DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$5,168.23
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
105502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,274.02 |
| Max. Negotiated Rate |
$4,651.41 |
| Rate for Payer: Aetna American Axle |
$3,359.35
|
| Rate for Payer: Aetna Commercial |
$4,393.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,359.35
|
| Rate for Payer: Cash Price |
$4,134.58
|
| Rate for Payer: Cofinity Commercial |
$3,617.76
|
| Rate for Payer: Cofinity Commercial |
$4,444.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,134.58
|
| Rate for Payer: Healthscope Commercial |
$4,651.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,617.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,876.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,393.00
|
| Rate for Payer: PHP Commercial |
$4,393.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,617.76
|
| Rate for Payer: Priority Health SBD |
$3,255.98
|
| Rate for Payer: UMR Bronson Commercial |
$2,274.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,876.17
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$18,876.90
|
|
|
Service Code
|
MS-DRG 158
|
| Min. Negotiated Rate |
$7,357.24 |
| Max. Negotiated Rate |
$18,876.90 |
| Rate for Payer: Aetna Medicare |
$8,054.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,680.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,680.58
|
| Rate for Payer: BCBS MAPPO |
$7,744.46
|
| Rate for Payer: BCBS Trust/PPO |
$18,876.90
|
| Rate for Payer: BCN Medicare Advantage |
$7,744.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,744.46
|
| Rate for Payer: Mclaren Medicare |
$7,744.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,131.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,906.13
|
| Rate for Payer: PACE Medicare |
$7,357.24
|
| Rate for Payer: PACE SWMI |
$7,744.46
|
| Rate for Payer: PHP Medicare Advantage |
$7,744.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,467.40
|
| Rate for Payer: Priority Health Medicare |
$7,744.46
|
| Rate for Payer: Priority Health Narrow Network |
$10,773.92
|
| Rate for Payer: Railroad Medicare Medicare |
$7,744.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,315.88
|
| Rate for Payer: UHC Core |
$11,738.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,744.46
|
| Rate for Payer: UHC Exchange |
$9,332.44
|
| Rate for Payer: UHC Medicare Advantage |
$7,976.79
|
| Rate for Payer: VA VA |
$7,744.46
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$51,680.30
|
|
|
Service Code
|
MS-DRG 157
|
| Min. Negotiated Rate |
$12,983.22 |
| Max. Negotiated Rate |
$51,680.30 |
| Rate for Payer: Aetna Medicare |
$14,213.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,083.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,083.19
|
| Rate for Payer: BCBS MAPPO |
$13,666.55
|
| Rate for Payer: BCBS Trust/PPO |
$51,680.30
|
| Rate for Payer: BCN Medicare Advantage |
$13,666.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,666.55
|
| Rate for Payer: Mclaren Medicare |
$13,666.55
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,349.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,716.53
|
| Rate for Payer: PACE Medicare |
$12,983.22
|
| Rate for Payer: PACE SWMI |
$13,666.55
|
| Rate for Payer: PHP Medicare Advantage |
$13,666.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24,495.31
|
| Rate for Payer: Priority Health Medicare |
$13,666.55
|
| Rate for Payer: Priority Health Narrow Network |
$19,596.25
|
| Rate for Payer: Railroad Medicare Medicare |
$13,666.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26,038.58
|
| Rate for Payer: UHC Core |
$21,351.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$13,666.55
|
| Rate for Payer: UHC Exchange |
$16,974.41
|
| Rate for Payer: UHC Medicare Advantage |
$14,076.55
|
| Rate for Payer: VA VA |
$13,666.55
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$13,810.90
|
|
|
Service Code
|
MS-DRG 159
|
| Min. Negotiated Rate |
$5,429.70 |
| Max. Negotiated Rate |
$13,810.90 |
| Rate for Payer: Aetna Medicare |
$5,944.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,144.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,144.34
|
| Rate for Payer: BCBS MAPPO |
$5,715.47
|
| Rate for Payer: BCBS Trust/PPO |
$13,810.90
|
| Rate for Payer: BCN Medicare Advantage |
$5,715.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,715.47
|
| Rate for Payer: Mclaren Medicare |
$5,715.47
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,001.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,572.79
|
| Rate for Payer: PACE Medicare |
$5,429.70
|
| Rate for Payer: PACE SWMI |
$5,715.47
|
| Rate for Payer: PHP Medicare Advantage |
$5,715.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,689.07
|
| Rate for Payer: Priority Health Medicare |
$5,715.47
|
| Rate for Payer: Priority Health Narrow Network |
$7,751.26
|
| Rate for Payer: Railroad Medicare Medicare |
$5,715.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,299.50
|
| Rate for Payer: UHC Core |
$8,445.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,715.47
|
| Rate for Payer: UHC Exchange |
$6,714.19
|
| Rate for Payer: UHC Medicare Advantage |
$5,886.93
|
| Rate for Payer: VA VA |
$5,715.47
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$13,827.75
|
|
|
Service Code
|
MS-DRG 881
|
| Min. Negotiated Rate |
$7,122.97 |
| Max. Negotiated Rate |
$13,827.75 |
| Rate for Payer: Aetna Medicare |
$7,797.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,372.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,372.32
|
| Rate for Payer: BCBS MAPPO |
$7,497.86
|
| Rate for Payer: BCBS Trust/PPO |
$10,498.90
|
| Rate for Payer: BCN Medicare Advantage |
$7,497.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,497.86
|
| Rate for Payer: Mclaren Medicare |
$7,497.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,872.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,622.54
|
| Rate for Payer: PACE Medicare |
$7,122.97
|
| Rate for Payer: PACE SWMI |
$7,497.86
|
| Rate for Payer: PHP Medicare Advantage |
$7,497.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,008.20
|
| Rate for Payer: Priority Health Medicare |
$7,497.86
|
| Rate for Payer: Priority Health Narrow Network |
$10,406.56
|
| Rate for Payer: Railroad Medicare Medicare |
$7,497.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,827.75
|
| Rate for Payer: UHC Core |
$11,338.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,497.86
|
| Rate for Payer: UHC Exchange |
$9,014.24
|
| Rate for Payer: UHC Medicare Advantage |
$7,722.80
|
| Rate for Payer: VA VA |
$7,497.86
|
|
|
DERMABOND SKIN ADHESIVE
|
Facility
|
IP
|
$86.16
|
|
|
Service Code
|
NDC 9900-0001-99
|
| Hospital Charge Code |
158456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.91 |
| Max. Negotiated Rate |
$77.54 |
| Rate for Payer: Aetna American Axle |
$56.00
|
| Rate for Payer: Aetna Commercial |
$73.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.00
|
| Rate for Payer: Cash Price |
$68.93
|
| Rate for Payer: Cofinity Commercial |
$60.31
|
| Rate for Payer: Cofinity Commercial |
$74.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.93
|
| Rate for Payer: Healthscope Commercial |
$77.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$64.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.24
|
| Rate for Payer: PHP Commercial |
$73.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.31
|
| Rate for Payer: Priority Health SBD |
$54.28
|
| Rate for Payer: UMR Bronson Commercial |
$37.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$64.62
|
|
|
DERMAPLANNING
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 00175
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: BCBS Complete |
$16.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.00
|
| Rate for Payer: UMR Bronson Commercial |
$18.40
|
|
|
DESFLURANE 100 % INHALATION LIQUID
|
Facility
|
IP
|
$1,137.72
|
|
|
Service Code
|
NDC 10019-644-34
|
| Hospital Charge Code |
9747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$500.60 |
| Max. Negotiated Rate |
$1,023.95 |
| Rate for Payer: Aetna American Axle |
$739.52
|
| Rate for Payer: Aetna Commercial |
$967.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$739.52
|
| Rate for Payer: Cash Price |
$910.18
|
| Rate for Payer: Cofinity Commercial |
$796.40
|
| Rate for Payer: Cofinity Commercial |
$978.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$910.18
|
| Rate for Payer: Healthscope Commercial |
$1,023.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$796.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$853.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$967.06
|
| Rate for Payer: PHP Commercial |
$967.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$796.40
|
| Rate for Payer: Priority Health SBD |
$716.76
|
| Rate for Payer: UMR Bronson Commercial |
$500.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$853.29
|
|
|
DESIPRAMINE 25 MG TABLET
|
Facility
|
IP
|
$352.50
|
|
|
Service Code
|
NDC 50742-113-01
|
| Hospital Charge Code |
2286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.10 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna American Axle |
$229.12
|
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.12
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$246.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$299.62
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.75
|
| Rate for Payer: Priority Health SBD |
$222.08
|
| Rate for Payer: UMR Bronson Commercial |
$155.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
DESIPRAMINE 25 MG TABLET
|
Facility
|
IP
|
$253.65
|
|
|
Service Code
|
NDC 23155-579-01
|
| Hospital Charge Code |
2286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.61 |
| Max. Negotiated Rate |
$228.28 |
| Rate for Payer: Aetna American Axle |
$164.87
|
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.87
|
| Rate for Payer: Cash Price |
$202.92
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Commercial |
$218.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.92
|
| Rate for Payer: Healthscope Commercial |
$228.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$215.60
|
| Rate for Payer: PHP Commercial |
$215.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.56
|
| Rate for Payer: Priority Health SBD |
$159.80
|
| Rate for Payer: UMR Bronson Commercial |
$111.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.24
|
|
|
DESIPRAMINE 25 MG TABLET
|
Facility
|
IP
|
$453.55
|
|
|
Service Code
|
NDC 62332-316-31
|
| Hospital Charge Code |
2286
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.56 |
| Max. Negotiated Rate |
$408.20 |
| Rate for Payer: Aetna American Axle |
$294.81
|
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$294.81
|
| Rate for Payer: Cash Price |
$362.84
|
| Rate for Payer: Cofinity Commercial |
$317.48
|
| Rate for Payer: Cofinity Commercial |
$390.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$362.84
|
| Rate for Payer: Healthscope Commercial |
$408.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$317.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$340.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$385.52
|
| Rate for Payer: PHP Commercial |
$385.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.48
|
| Rate for Payer: Priority Health SBD |
$285.74
|
| Rate for Payer: UMR Bronson Commercial |
$199.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$340.16
|
|
|
DESMOPRESSIN 0.1 MG/ML (REFRIGERATE) NASAL SOLUTION
|
Facility
|
IP
|
$949.20
|
|
|
Service Code
|
NDC 55566-2400-0
|
| Hospital Charge Code |
70761
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$417.65 |
| Max. Negotiated Rate |
$854.28 |
| Rate for Payer: Aetna American Axle |
$616.98
|
| Rate for Payer: Aetna Commercial |
$806.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$616.98
|
| Rate for Payer: Cash Price |
$759.36
|
| Rate for Payer: Cofinity Commercial |
$664.44
|
| Rate for Payer: Cofinity Commercial |
$816.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$759.36
|
| Rate for Payer: Healthscope Commercial |
$854.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$664.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$711.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$806.82
|
| Rate for Payer: PHP Commercial |
$806.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$664.44
|
| Rate for Payer: Priority Health SBD |
$598.00
|
| Rate for Payer: UMR Bronson Commercial |
$417.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$711.90
|
|
|
DESMOPRESSIN 0.1 MG TABLET
|
Facility
|
IP
|
$327.84
|
|
|
Service Code
|
NDC 68462-275-01
|
| Hospital Charge Code |
16052
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.25 |
| Max. Negotiated Rate |
$295.06 |
| Rate for Payer: Aetna American Axle |
$213.10
|
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.10
|
| Rate for Payer: Cash Price |
$262.27
|
| Rate for Payer: Cofinity Commercial |
$229.49
|
| Rate for Payer: Cofinity Commercial |
$281.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.27
|
| Rate for Payer: Healthscope Commercial |
$295.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.66
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.49
|
| Rate for Payer: Priority Health SBD |
$206.54
|
| Rate for Payer: UMR Bronson Commercial |
$144.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.88
|
|
|
DESMOPRESSIN 0.1 MG TABLET
|
Facility
|
IP
|
$478.08
|
|
|
Service Code
|
NDC 69918-101-01
|
| Hospital Charge Code |
16052
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.36 |
| Max. Negotiated Rate |
$430.27 |
| Rate for Payer: Aetna American Axle |
$310.75
|
| Rate for Payer: Aetna Commercial |
$406.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$310.75
|
| Rate for Payer: Cash Price |
$382.46
|
| Rate for Payer: Cofinity Commercial |
$334.66
|
| Rate for Payer: Cofinity Commercial |
$411.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$382.46
|
| Rate for Payer: Healthscope Commercial |
$430.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$334.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$358.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$406.37
|
| Rate for Payer: PHP Commercial |
$406.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$334.66
|
| Rate for Payer: Priority Health SBD |
$301.19
|
| Rate for Payer: UMR Bronson Commercial |
$210.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$358.56
|
|
|
DESMOPRESSIN 0.1 MG TABLET
|
Facility
|
IP
|
$1,309.43
|
|
|
Service Code
|
NDC 0591-2464-01
|
| Hospital Charge Code |
16052
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$576.15 |
| Max. Negotiated Rate |
$1,178.49 |
| Rate for Payer: Aetna American Axle |
$851.13
|
| Rate for Payer: Aetna Commercial |
$1,113.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$851.13
|
| Rate for Payer: Cash Price |
$1,047.54
|
| Rate for Payer: Cofinity Commercial |
$1,126.11
|
| Rate for Payer: Cofinity Commercial |
$916.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,047.54
|
| Rate for Payer: Healthscope Commercial |
$1,178.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$916.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$982.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,113.02
|
| Rate for Payer: PHP Commercial |
$1,113.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$916.60
|
| Rate for Payer: Priority Health SBD |
$824.94
|
| Rate for Payer: UMR Bronson Commercial |
$576.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$982.07
|
|
|
DESMOPRESSIN 0.1 MG TABLET
|
Facility
|
IP
|
$392.45
|
|
|
Service Code
|
NDC 23155-489-01
|
| Hospital Charge Code |
16052
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.68 |
| Max. Negotiated Rate |
$353.20 |
| Rate for Payer: Aetna American Axle |
$255.09
|
| Rate for Payer: Aetna Commercial |
$333.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.09
|
| Rate for Payer: Cash Price |
$313.96
|
| Rate for Payer: Cofinity Commercial |
$274.72
|
| Rate for Payer: Cofinity Commercial |
$337.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.96
|
| Rate for Payer: Healthscope Commercial |
$353.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$274.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$294.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$333.58
|
| Rate for Payer: PHP Commercial |
$333.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.72
|
| Rate for Payer: Priority Health SBD |
$247.24
|
| Rate for Payer: UMR Bronson Commercial |
$172.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$294.34
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY
|
Facility
|
IP
|
$655.06
|
|
|
Service Code
|
NDC 24208-342-05
|
| Hospital Charge Code |
27770
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.23 |
| Max. Negotiated Rate |
$589.55 |
| Rate for Payer: Aetna American Axle |
$425.79
|
| Rate for Payer: Aetna Commercial |
$556.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.79
|
| Rate for Payer: Cash Price |
$524.05
|
| Rate for Payer: Cofinity Commercial |
$458.54
|
| Rate for Payer: Cofinity Commercial |
$563.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.05
|
| Rate for Payer: Healthscope Commercial |
$589.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$491.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$556.80
|
| Rate for Payer: PHP Commercial |
$556.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$458.54
|
| Rate for Payer: Priority Health SBD |
$412.69
|
| Rate for Payer: UMR Bronson Commercial |
$288.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$491.30
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)
|
Facility
|
IP
|
$208.02
|
|
|
Service Code
|
NDC 60505-0815-0
|
| Hospital Charge Code |
21135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.53 |
| Max. Negotiated Rate |
$187.22 |
| Rate for Payer: Aetna American Axle |
$135.21
|
| Rate for Payer: Aetna Commercial |
$176.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.21
|
| Rate for Payer: Cash Price |
$166.42
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Cofinity Commercial |
$178.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.42
|
| Rate for Payer: Healthscope Commercial |
$187.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.82
|
| Rate for Payer: PHP Commercial |
$176.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.61
|
| Rate for Payer: Priority Health SBD |
$131.05
|
| Rate for Payer: UMR Bronson Commercial |
$91.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.02
|
|
