|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$1,051.31
|
|
|
Service Code
|
NDC 10019-553-04
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$462.58 |
| Max. Negotiated Rate |
$946.18 |
| Rate for Payer: Aetna American Axle |
$683.35
|
| Rate for Payer: Aetna Commercial |
$893.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$683.35
|
| Rate for Payer: Cash Price |
$841.05
|
| Rate for Payer: Cofinity Commercial |
$735.92
|
| Rate for Payer: Cofinity Commercial |
$904.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$841.05
|
| Rate for Payer: Healthscope Commercial |
$946.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$735.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$788.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$893.61
|
| Rate for Payer: PHP Commercial |
$893.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$735.92
|
| Rate for Payer: Priority Health SBD |
$662.33
|
| Rate for Payer: UMR Bronson Commercial |
$462.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$788.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$438.05
|
|
|
Service Code
|
NDC 10019-553-03
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.74 |
| Max. Negotiated Rate |
$394.24 |
| Rate for Payer: Aetna American Axle |
$284.73
|
| Rate for Payer: Aetna Commercial |
$372.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.73
|
| Rate for Payer: Cash Price |
$350.44
|
| Rate for Payer: Cofinity Commercial |
$306.64
|
| Rate for Payer: Cofinity Commercial |
$376.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.44
|
| Rate for Payer: Healthscope Commercial |
$394.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$306.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$372.34
|
| Rate for Payer: PHP Commercial |
$372.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.64
|
| Rate for Payer: Priority Health SBD |
$275.97
|
| Rate for Payer: UMR Bronson Commercial |
$192.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$257.75
|
|
|
Service Code
|
NDC 66758-208-54
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.41 |
| Max. Negotiated Rate |
$231.98 |
| Rate for Payer: Aetna American Axle |
$167.54
|
| Rate for Payer: Aetna Commercial |
$219.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.54
|
| Rate for Payer: Cash Price |
$206.20
|
| Rate for Payer: Cofinity Commercial |
$180.42
|
| Rate for Payer: Cofinity Commercial |
$221.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.20
|
| Rate for Payer: Healthscope Commercial |
$231.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$219.09
|
| Rate for Payer: PHP Commercial |
$219.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.42
|
| Rate for Payer: Priority Health SBD |
$162.38
|
| Rate for Payer: UMR Bronson Commercial |
$113.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.31
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$43.81
|
|
|
Service Code
|
NDC 10019-553-90
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$39.43 |
| Rate for Payer: Aetna American Axle |
$28.48
|
| Rate for Payer: Aetna Commercial |
$37.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.48
|
| Rate for Payer: Cash Price |
$35.05
|
| Rate for Payer: Cofinity Commercial |
$30.67
|
| Rate for Payer: Cofinity Commercial |
$37.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.05
|
| Rate for Payer: Healthscope Commercial |
$39.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.24
|
| Rate for Payer: PHP Commercial |
$37.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.67
|
| Rate for Payer: Priority Health SBD |
$27.60
|
| Rate for Payer: UMR Bronson Commercial |
$19.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.86
|
|
|
SCREENING OF A PATIENT
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS D0190
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$20.16 |
| Rate for Payer: Aetna Commercial |
$13.35
|
| Rate for Payer: BCBS Complete |
$20.16
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Meridian Medicaid |
$20.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
| Rate for Payer: UMR Bronson Commercial |
$6.90
|
|
|
SCROTAL EXPLORATION
|
Facility
|
OP
|
$9,755.07
|
|
|
Service Code
|
CPT 55110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$382.78 |
| Max. Negotiated Rate |
$9,755.07 |
| Rate for Payer: Aetna Medicare |
$3,222.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,873.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,873.46
|
| Rate for Payer: BCBS Complete |
$1,779.93
|
| Rate for Payer: BCBS MAPPO |
$3,098.77
|
| Rate for Payer: BCBS Trust/PPO |
$1,519.83
|
| Rate for Payer: BCN Medicare Advantage |
$3,098.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,098.77
|
| Rate for Payer: Mclaren Medicaid |
$1,695.03
|
| Rate for Payer: Mclaren Medicare |
$3,098.77
|
| Rate for Payer: Meridian Medicaid |
$1,779.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,253.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,563.59
|
| Rate for Payer: PACE Medicare |
$2,943.83
|
| Rate for Payer: PACE SWMI |
$3,098.77
|
| Rate for Payer: PHP Medicare Advantage |
$3,098.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,755.07
|
| Rate for Payer: Priority Health Medicare |
$3,098.77
|
| Rate for Payer: Priority Health Narrow Network |
$7,804.06
|
| Rate for Payer: Railroad Medicare Medicare |
$3,098.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$421.06
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,098.77
|
| Rate for Payer: UHC Exchange |
$382.78
|
| Rate for Payer: UHC Medicare Advantage |
$3,191.73
|
| Rate for Payer: VA VA |
$3,098.77
|
|
|
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED
|
Facility
|
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 13160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$782.26 |
| 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 |
$3,530.17
|
| 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) |
$860.49
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$782.26
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
SECONDARY PERCUTANEOUS TRANSLUMINAL THROMBECTOMY (EG, NONPRIMARY MECHANICAL, SNARE BASKET, SUCTION TECHNIQUE), NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS, PROVIDED IN CONJUNCTION WITH ANOTHER PERCUTANEOUS INTERVENTION OTHER THAN PRIMARY MECHANICAL THROMBECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,562.09
|
|
|
Service Code
|
CPT 37186
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$232.48 |
| Max. Negotiated Rate |
$4,562.09 |
| Rate for Payer: BCBS Trust/PPO |
$4,562.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$255.73
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$232.48
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,016.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.83 |
| Max. Negotiated Rate |
$1,814.40 |
| Rate for Payer: Aetna American Axle |
$1,310.40
|
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Medicare |
$43.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,310.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.17
|
| Rate for Payer: BCBS Complete |
$23.97
|
| Rate for Payer: BCBS MAPPO |
$41.74
|
| Rate for Payer: BCBS Trust/PPO |
$108.03
|
| Rate for Payer: BCN Medicare Advantage |
$41.74
|
| Rate for Payer: Cash Price |
$1,612.80
|
| Rate for Payer: Cash Price |
$1,612.80
|
| Rate for Payer: Cofinity Commercial |
$1,733.76
|
| Rate for Payer: Cofinity Commercial |
$1,411.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,612.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.74
|
| Rate for Payer: Healthscope Commercial |
$1,814.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,411.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,512.00
|
| Rate for Payer: Mclaren Medicaid |
$22.83
|
| Rate for Payer: Mclaren Medicare |
$41.74
|
| Rate for Payer: Meridian Medicaid |
$23.97
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$43.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,713.60
|
| Rate for Payer: PACE Medicare |
$39.65
|
| Rate for Payer: PACE SWMI |
$41.74
|
| Rate for Payer: PHP Commercial |
$1,713.60
|
| Rate for Payer: PHP Medicare Advantage |
$41.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$22.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,411.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$122.57
|
| Rate for Payer: Priority Health Medicare |
$41.74
|
| Rate for Payer: Priority Health Narrow Network |
$98.06
|
| Rate for Payer: Priority Health SBD |
$1,270.08
|
| Rate for Payer: Railroad Medicare Medicare |
$41.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.74
|
| Rate for Payer: UHC Medicare Advantage |
$42.99
|
| Rate for Payer: UMR Bronson Commercial |
$745.92
|
| Rate for Payer: VA VA |
$41.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,512.00
|
|
|
SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,016.00
|
|
|
Service Code
|
HCPCS J2850
|
| Hospital Charge Code |
91185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$887.04 |
| Max. Negotiated Rate |
$1,814.40 |
| Rate for Payer: Aetna American Axle |
$1,310.40
|
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,310.40
|
| Rate for Payer: Cash Price |
$1,612.80
|
| Rate for Payer: Cofinity Commercial |
$1,411.20
|
| Rate for Payer: Cofinity Commercial |
$1,733.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,612.80
|
| Rate for Payer: Healthscope Commercial |
$1,814.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,411.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,512.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,713.60
|
| Rate for Payer: PHP Commercial |
$1,713.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,411.20
|
| Rate for Payer: Priority Health SBD |
$1,270.08
|
| Rate for Payer: UMR Bronson Commercial |
$887.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,512.00
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$31,353.45
|
|
|
Service Code
|
MS-DRG 100
|
| Min. Negotiated Rate |
$15,000.09 |
| Max. Negotiated Rate |
$31,353.45 |
| Rate for Payer: Aetna Medicare |
$16,421.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19,736.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19,736.96
|
| Rate for Payer: BCBS MAPPO |
$15,789.57
|
| Rate for Payer: BCBS Trust/PPO |
$31,353.45
|
| Rate for Payer: BCN Medicare Advantage |
$15,789.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,789.57
|
| Rate for Payer: Mclaren Medicare |
$15,789.57
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16,579.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,158.01
|
| Rate for Payer: PACE Medicare |
$15,000.09
|
| Rate for Payer: PACE SWMI |
$15,789.57
|
| Rate for Payer: PHP Medicare Advantage |
$15,789.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28,448.72
|
| Rate for Payer: Priority Health Medicare |
$15,789.57
|
| Rate for Payer: Priority Health Narrow Network |
$22,758.98
|
| Rate for Payer: Railroad Medicare Medicare |
$15,789.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30,241.06
|
| Rate for Payer: UHC Core |
$24,797.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$15,789.57
|
| Rate for Payer: UHC Exchange |
$19,713.98
|
| Rate for Payer: UHC Medicare Advantage |
$16,263.26
|
| Rate for Payer: VA VA |
$15,789.57
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$14,594.92
|
|
|
Service Code
|
MS-DRG 101
|
| Min. Negotiated Rate |
$7,145.66 |
| Max. Negotiated Rate |
$14,594.92 |
| Rate for Payer: Aetna Medicare |
$7,822.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,402.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,402.19
|
| Rate for Payer: BCBS MAPPO |
$7,521.75
|
| Rate for Payer: BCBS Trust/PPO |
$14,594.92
|
| Rate for Payer: BCN Medicare Advantage |
$7,521.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,521.75
|
| Rate for Payer: Mclaren Medicare |
$7,521.75
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,897.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,650.01
|
| Rate for Payer: PACE Medicare |
$7,145.66
|
| Rate for Payer: PACE SWMI |
$7,521.75
|
| Rate for Payer: PHP Medicare Advantage |
$7,521.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,052.69
|
| Rate for Payer: Priority Health Medicare |
$7,521.75
|
| Rate for Payer: Priority Health Narrow Network |
$10,442.15
|
| Rate for Payer: Railroad Medicare Medicare |
$7,521.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,875.04
|
| Rate for Payer: UHC Core |
$11,377.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,521.75
|
| Rate for Payer: UHC Exchange |
$9,045.06
|
| Rate for Payer: UHC Medicare Advantage |
$7,747.40
|
| Rate for Payer: VA VA |
$7,521.75
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 36248
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$45.84 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$521.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.42
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$45.84
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
|
Facility
|
OP
|
$4,445.25
|
|
|
Service Code
|
CPT 36245
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.28 |
| Max. Negotiated Rate |
$4,445.25 |
| Rate for Payer: BCBS Trust/PPO |
$4,445.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$247.81
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$225.28
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
|
Facility
|
OP
|
$3,835.69
|
|
|
Service Code
|
CPT 36215
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$203.34 |
| Max. Negotiated Rate |
$3,835.69 |
| Rate for Payer: BCBS Trust/PPO |
$3,835.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$223.67
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$203.34
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
|
Facility
|
OP
|
$3,309.20
|
|
|
Service Code
|
CPT 36246
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$241.65 |
| Max. Negotiated Rate |
$3,309.20 |
| Rate for Payer: BCBS Trust/PPO |
$3,309.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.82
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$241.65
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
|
Facility
|
OP
|
$3,965.76
|
|
|
Service Code
|
CPT 36216
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$260.97 |
| Max. Negotiated Rate |
$3,965.76 |
| Rate for Payer: BCBS Trust/PPO |
$3,965.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.07
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$260.97
|
|
|
SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
|
Facility
|
OP
|
$4,388.22
|
|
|
Service Code
|
CPT 36247
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$284.55 |
| Max. Negotiated Rate |
$4,388.22 |
| Rate for Payer: BCBS Trust/PPO |
$4,388.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$313.00
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$284.55
|
|
|
SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S), FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; BILATERAL
|
Facility
|
OP
|
$8,919.33
|
|
|
Service Code
|
CPT 36252
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$341.52 |
| Max. Negotiated Rate |
$8,919.33 |
| Rate for Payer: Aetna Medicare |
$2,946.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,541.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,541.61
|
| Rate for Payer: BCBS Complete |
$1,627.44
|
| Rate for Payer: BCBS MAPPO |
$2,833.29
|
| Rate for Payer: BCBS Trust/PPO |
$2,102.14
|
| Rate for Payer: BCN Medicare Advantage |
$2,833.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,833.29
|
| Rate for Payer: Mclaren Medicaid |
$1,549.81
|
| Rate for Payer: Mclaren Medicare |
$2,833.29
|
| Rate for Payer: Meridian Medicaid |
$1,627.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,974.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,258.28
|
| Rate for Payer: PACE Medicare |
$2,691.63
|
| Rate for Payer: PACE SWMI |
$2,833.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,833.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,549.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,919.33
|
| Rate for Payer: Priority Health Medicare |
$2,833.29
|
| Rate for Payer: Priority Health Narrow Network |
$7,135.46
|
| Rate for Payer: Railroad Medicare Medicare |
$2,833.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$375.67
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,833.29
|
| Rate for Payer: UHC Exchange |
$341.52
|
| Rate for Payer: UHC Medicare Advantage |
$2,918.29
|
| Rate for Payer: VA VA |
$2,833.29
|
|
|
SELECTIVE CATHETER PLACEMENT, INTERNAL CAROTID ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID AND CERVICOCEREBRAL ARCH, WHEN PERFORMED
|
Facility
|
OP
|
$15,377.24
|
|
|
Service Code
|
CPT 36224
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$357.89 |
| Max. Negotiated Rate |
$15,377.24 |
| Rate for Payer: Aetna Medicare |
$5,080.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,105.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,105.86
|
| Rate for Payer: BCBS Complete |
$2,805.77
|
| Rate for Payer: BCBS MAPPO |
$4,884.69
|
| Rate for Payer: BCBS Trust/PPO |
$6,602.60
|
| Rate for Payer: BCN Medicare Advantage |
$4,884.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,884.69
|
| Rate for Payer: Mclaren Medicaid |
$2,671.93
|
| Rate for Payer: Mclaren Medicare |
$4,884.69
|
| Rate for Payer: Meridian Medicaid |
$2,805.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,128.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,617.39
|
| Rate for Payer: PACE Medicare |
$4,640.46
|
| Rate for Payer: PACE SWMI |
$4,884.69
|
| Rate for Payer: PHP Medicare Advantage |
$4,884.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,671.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,377.24
|
| Rate for Payer: Priority Health Medicare |
$4,884.69
|
| Rate for Payer: Priority Health Narrow Network |
$12,301.79
|
| Rate for Payer: Railroad Medicare Medicare |
$4,884.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$393.68
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,884.69
|
| Rate for Payer: UHC Exchange |
$357.89
|
| Rate for Payer: UHC Medicare Advantage |
$5,031.23
|
| Rate for Payer: VA VA |
$4,884.69
|
|
|
SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN)
|
Facility
|
OP
|
$3,445.90
|
|
|
Service Code
|
CPT 36011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$148.99 |
| Max. Negotiated Rate |
$3,445.90 |
| Rate for Payer: BCBS Trust/PPO |
$3,445.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.89
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$148.99
|
|
|
SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS)
|
Facility
|
OP
|
$3,513.63
|
|
|
Service Code
|
CPT 36012
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$166.01 |
| Max. Negotiated Rate |
$3,513.63 |
| Rate for Payer: BCBS Trust/PPO |
$3,513.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$182.61
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$166.01
|
|
|
SELEGILINE 5 MG CAPSULE
|
Facility
|
IP
|
$150.63
|
|
|
Service Code
|
NDC 60505-0055-1
|
| Hospital Charge Code |
17280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.28 |
| Max. Negotiated Rate |
$135.57 |
| Rate for Payer: Aetna American Axle |
$97.91
|
| Rate for Payer: Aetna Commercial |
$128.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.91
|
| Rate for Payer: Cash Price |
$120.50
|
| Rate for Payer: Cofinity Commercial |
$105.44
|
| Rate for Payer: Cofinity Commercial |
$129.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.50
|
| Rate for Payer: Healthscope Commercial |
$135.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$128.04
|
| Rate for Payer: PHP Commercial |
$128.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.44
|
| Rate for Payer: Priority Health SBD |
$94.90
|
| Rate for Payer: UMR Bronson Commercial |
$66.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.97
|
|
|
SELEGILINE 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH
|
Facility
|
IP
|
$7,029.41
|
|
|
Service Code
|
NDC 49502-901-30
|
| Hospital Charge Code |
70782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,092.94 |
| Max. Negotiated Rate |
$6,326.47 |
| Rate for Payer: Aetna American Axle |
$4,569.12
|
| Rate for Payer: Aetna Commercial |
$5,975.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,569.12
|
| Rate for Payer: Cash Price |
$5,623.53
|
| Rate for Payer: Cofinity Commercial |
$4,920.59
|
| Rate for Payer: Cofinity Commercial |
$6,045.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,623.53
|
| Rate for Payer: Healthscope Commercial |
$6,326.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,920.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,272.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,975.00
|
| Rate for Payer: PHP Commercial |
$5,975.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,920.59
|
| Rate for Payer: Priority Health SBD |
$4,428.53
|
| Rate for Payer: UMR Bronson Commercial |
$3,092.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,272.06
|
|
|
SELENIUM 50 MCG TABLET
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 07610-021-20
|
| Hospital Charge Code |
7140
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.04
|
| Rate for Payer: Aetna Commercial |
$75.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.04
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.90
|
| Rate for Payer: PHP Commercial |
$75.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.51
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$39.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.98
|
|
