|
PR EMERGENCY DEPARTMENT VISIT LOW MDM
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
HCPCS 99283
|
| Min. Negotiated Rate |
$68.14 |
| Max. Negotiated Rate |
$112.45 |
| Rate for Payer: Aetna Commercial |
$91.31
|
| Rate for Payer: Aetna Medicare |
$70.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.31
|
| Rate for Payer: BCBS Complete |
$69.20
|
| Rate for Payer: BCBS MAPPO |
$68.14
|
| Rate for Payer: BCN Medicare Advantage |
$68.14
|
| Rate for Payer: Cash Price |
$138.40
|
| Rate for Payer: Cash Price |
$138.40
|
| Rate for Payer: Cofinity Commercial |
$98.12
|
| Rate for Payer: Cofinity Commercial |
$91.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$68.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$71.55
|
| Rate for Payer: Nomi Health Commercial |
$81.77
|
| Rate for Payer: PACE SWMI |
$68.14
|
| Rate for Payer: PHP Commercial |
$95.40
|
| Rate for Payer: PHP Medicare Advantage |
$68.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.45
|
| Rate for Payer: Priority Health Medicare |
$68.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$68.14
|
| Rate for Payer: UHC Medicare Advantage |
$68.14
|
| Rate for Payer: UMR Bronson Commercial |
$79.58
|
|
|
PR EMERGENCY DEPARTMENT VISIT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$93.00
|
|
|
Service Code
|
HCPCS 99281
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$60.45 |
| Rate for Payer: Aetna Commercial |
$14.73
|
| Rate for Payer: Aetna Medicare |
$11.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.73
|
| Rate for Payer: BCBS Complete |
$37.20
|
| Rate for Payer: BCBS MAPPO |
$10.99
|
| Rate for Payer: BCN Medicare Advantage |
$10.99
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cofinity Commercial |
$15.83
|
| Rate for Payer: Cofinity Commercial |
$14.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.54
|
| Rate for Payer: Nomi Health Commercial |
$13.19
|
| Rate for Payer: PACE SWMI |
$10.99
|
| Rate for Payer: PHP Commercial |
$15.39
|
| Rate for Payer: PHP Medicare Advantage |
$10.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.45
|
| Rate for Payer: Priority Health Medicare |
$10.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.99
|
| Rate for Payer: UHC Medicare Advantage |
$10.99
|
| Rate for Payer: UMR Bronson Commercial |
$42.78
|
|
|
PR EMERGENCY DEPARTMENT VISIT MODERATE MDM
|
Professional
|
Both
|
$249.00
|
|
|
Service Code
|
HCPCS 99284
|
| Min. Negotiated Rate |
$99.60 |
| Max. Negotiated Rate |
$167.66 |
| Rate for Payer: Aetna Commercial |
$156.02
|
| Rate for Payer: Aetna Medicare |
$121.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.02
|
| Rate for Payer: BCBS Complete |
$99.60
|
| Rate for Payer: BCBS MAPPO |
$116.43
|
| Rate for Payer: BCN Medicare Advantage |
$116.43
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cofinity Commercial |
$167.66
|
| Rate for Payer: Cofinity Commercial |
$156.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$116.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$122.25
|
| Rate for Payer: Nomi Health Commercial |
$139.72
|
| Rate for Payer: PACE SWMI |
$116.43
|
| Rate for Payer: PHP Commercial |
$163.00
|
| Rate for Payer: PHP Medicare Advantage |
$116.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.85
|
| Rate for Payer: Priority Health Medicare |
$116.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$116.43
|
| Rate for Payer: UHC Medicare Advantage |
$116.43
|
| Rate for Payer: UMR Bronson Commercial |
$114.54
|
|
|
PR EMERGENCY DEPARTMENT VISIT STRAIGHTFORWARD MDM
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 99282
|
| Min. Negotiated Rate |
$40.36 |
| Max. Negotiated Rate |
$76.70 |
| Rate for Payer: Aetna Commercial |
$54.08
|
| Rate for Payer: Aetna Medicare |
$41.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.08
|
| Rate for Payer: BCBS Complete |
$47.20
|
| Rate for Payer: BCBS MAPPO |
$40.36
|
| Rate for Payer: BCN Medicare Advantage |
$40.36
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cofinity Commercial |
$58.12
|
| Rate for Payer: Cofinity Commercial |
$54.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$40.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$42.38
|
| Rate for Payer: Nomi Health Commercial |
$48.43
|
| Rate for Payer: PACE SWMI |
$40.36
|
| Rate for Payer: PHP Commercial |
$56.50
|
| Rate for Payer: PHP Medicare Advantage |
$40.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.70
|
| Rate for Payer: Priority Health Medicare |
$40.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$40.36
|
| Rate for Payer: UHC Medicare Advantage |
$40.36
|
| Rate for Payer: UMR Bronson Commercial |
$54.28
|
|
|
PR EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
HCPCS 51784
|
| Min. Negotiated Rate |
$59.33 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$79.50
|
| Rate for Payer: Aetna Medicare |
$61.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.50
|
| Rate for Payer: BCBS Complete |
$157.20
|
| Rate for Payer: BCBS MAPPO |
$59.33
|
| Rate for Payer: BCN Medicare Advantage |
$59.33
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cash Price |
$314.40
|
| Rate for Payer: Cofinity Commercial |
$85.44
|
| Rate for Payer: Cofinity Commercial |
$79.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.30
|
| Rate for Payer: Nomi Health Commercial |
$71.20
|
| Rate for Payer: PACE SWMI |
$59.33
|
| Rate for Payer: PHP Commercial |
$83.06
|
| Rate for Payer: PHP Medicare Advantage |
$59.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.45
|
| Rate for Payer: Priority Health Medicare |
$59.33
|
| Rate for Payer: UHC Dual Complete DSNP |
$59.33
|
| Rate for Payer: UHC Medicare Advantage |
$59.33
|
| Rate for Payer: UMR Bronson Commercial |
$180.78
|
|
|
PRENATAL VIT 14-FERROUS FUM 29 MG IRON-FOLIC ACID 1 MG CHEWABLE TABLET
|
Facility
|
IP
|
$222.05
|
|
|
Service Code
|
NDC 13811001490
|
| Hospital Charge Code |
115087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.70 |
| Max. Negotiated Rate |
$199.84 |
| Rate for Payer: Aetna American Axle |
$144.33
|
| Rate for Payer: Aetna Commercial |
$188.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.33
|
| Rate for Payer: Cash Price |
$177.64
|
| Rate for Payer: Cofinity Commercial |
$155.44
|
| Rate for Payer: Cofinity Commercial |
$190.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$155.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.64
|
| Rate for Payer: Healthscope Commercial |
$199.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$155.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.74
|
| Rate for Payer: PHP Commercial |
$188.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.33
|
| Rate for Payer: Priority Health SBD |
$139.89
|
| Rate for Payer: UMR Bronson Commercial |
$97.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.54
|
|
|
PRENATAL VIT 14-FERROUS FUM 29 MG IRON-FOLIC ACID 1 MG CHEWABLE TABLET
|
Facility
|
OP
|
$222.05
|
|
|
Service Code
|
NDC 13811001490
|
| Hospital Charge Code |
115087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.16 |
| Max. Negotiated Rate |
$199.84 |
| Rate for Payer: Aetna American Axle |
$144.33
|
| Rate for Payer: Aetna Commercial |
$188.74
|
| Rate for Payer: Aetna Medicare |
$111.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.33
|
| Rate for Payer: BCBS Complete |
$88.82
|
| Rate for Payer: Cash Price |
$177.64
|
| Rate for Payer: Cofinity Commercial |
$155.44
|
| Rate for Payer: Cofinity Commercial |
$190.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$155.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.64
|
| Rate for Payer: Healthscope Commercial |
$199.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$155.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.74
|
| Rate for Payer: PHP Commercial |
$188.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.33
|
| Rate for Payer: Priority Health SBD |
$139.89
|
| Rate for Payer: UMR Bronson Commercial |
$82.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.54
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
IP
|
$68.15
|
|
|
Service Code
|
NDC 00904531360
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$61.34 |
| Rate for Payer: Aetna American Axle |
$44.30
|
| Rate for Payer: Aetna Commercial |
$57.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.30
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Cofinity Commercial |
$58.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$61.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.93
|
| Rate for Payer: PHP Commercial |
$57.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.30
|
| Rate for Payer: Priority Health SBD |
$42.93
|
| Rate for Payer: UMR Bronson Commercial |
$29.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.11
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
OP
|
$96.35
|
|
|
Service Code
|
NDC 57896057501
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.65 |
| Max. Negotiated Rate |
$86.72 |
| Rate for Payer: Aetna American Axle |
$62.63
|
| Rate for Payer: Aetna Commercial |
$81.90
|
| Rate for Payer: Aetna Medicare |
$48.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.63
|
| Rate for Payer: BCBS Complete |
$38.54
|
| Rate for Payer: Cash Price |
$77.08
|
| Rate for Payer: Cofinity Commercial |
$67.44
|
| Rate for Payer: Cofinity Commercial |
$82.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.08
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.90
|
| Rate for Payer: PHP Commercial |
$81.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.63
|
| Rate for Payer: Priority Health SBD |
$60.70
|
| Rate for Payer: UMR Bronson Commercial |
$35.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.26
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
OP
|
$68.15
|
|
|
Service Code
|
NDC 00904531360
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.22 |
| Max. Negotiated Rate |
$61.34 |
| Rate for Payer: Aetna American Axle |
$44.30
|
| Rate for Payer: Aetna Commercial |
$57.93
|
| Rate for Payer: Aetna Medicare |
$34.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.30
|
| Rate for Payer: BCBS Complete |
$27.26
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Cofinity Commercial |
$58.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$61.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.93
|
| Rate for Payer: PHP Commercial |
$57.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.30
|
| Rate for Payer: Priority Health SBD |
$42.93
|
| Rate for Payer: UMR Bronson Commercial |
$25.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.11
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
IP
|
$324.30
|
|
|
Service Code
|
NDC 77333071510
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.69 |
| Max. Negotiated Rate |
$291.87 |
| Rate for Payer: Aetna American Axle |
$210.79
|
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.79
|
| Rate for Payer: Cash Price |
$259.44
|
| Rate for Payer: Cofinity Commercial |
$227.01
|
| Rate for Payer: Cofinity Commercial |
$278.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.44
|
| Rate for Payer: Healthscope Commercial |
$291.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.65
|
| Rate for Payer: PHP Commercial |
$275.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.79
|
| Rate for Payer: Priority Health SBD |
$204.31
|
| Rate for Payer: UMR Bronson Commercial |
$142.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.22
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
OP
|
$33.14
|
|
|
Service Code
|
NDC 00904531346
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$29.83 |
| Rate for Payer: Aetna American Axle |
$21.54
|
| Rate for Payer: Aetna Commercial |
$28.17
|
| Rate for Payer: Aetna Medicare |
$16.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.54
|
| Rate for Payer: BCBS Complete |
$13.26
|
| Rate for Payer: Cash Price |
$26.51
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Commercial |
$28.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.51
|
| Rate for Payer: Healthscope Commercial |
$29.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.17
|
| Rate for Payer: PHP Commercial |
$28.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.54
|
| Rate for Payer: Priority Health SBD |
$20.88
|
| Rate for Payer: UMR Bronson Commercial |
$12.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.86
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
IP
|
$33.14
|
|
|
Service Code
|
NDC 00904531346
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.58 |
| Max. Negotiated Rate |
$29.83 |
| Rate for Payer: Aetna American Axle |
$21.54
|
| Rate for Payer: Aetna Commercial |
$28.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.54
|
| Rate for Payer: Cash Price |
$26.51
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Commercial |
$28.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.51
|
| Rate for Payer: Healthscope Commercial |
$29.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.17
|
| Rate for Payer: PHP Commercial |
$28.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.54
|
| Rate for Payer: Priority Health SBD |
$20.88
|
| Rate for Payer: UMR Bronson Commercial |
$14.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.86
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
IP
|
$3.25
|
|
|
Service Code
|
NDC 77333071525
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna American Axle |
$2.11
|
| Rate for Payer: Aetna Commercial |
$2.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.11
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.60
|
| Rate for Payer: Healthscope Commercial |
$2.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.76
|
| Rate for Payer: PHP Commercial |
$2.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.11
|
| Rate for Payer: Priority Health SBD |
$2.05
|
| Rate for Payer: UMR Bronson Commercial |
$1.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.44
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
OP
|
$324.30
|
|
|
Service Code
|
NDC 77333071510
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.99 |
| Max. Negotiated Rate |
$291.87 |
| Rate for Payer: Aetna American Axle |
$210.79
|
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna Medicare |
$162.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.79
|
| Rate for Payer: BCBS Complete |
$129.72
|
| Rate for Payer: Cash Price |
$259.44
|
| Rate for Payer: Cofinity Commercial |
$227.01
|
| Rate for Payer: Cofinity Commercial |
$278.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.44
|
| Rate for Payer: Healthscope Commercial |
$291.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.65
|
| Rate for Payer: PHP Commercial |
$275.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.79
|
| Rate for Payer: Priority Health SBD |
$204.31
|
| Rate for Payer: UMR Bronson Commercial |
$119.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.22
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
IP
|
$96.35
|
|
|
Service Code
|
NDC 57896057501
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.39 |
| Max. Negotiated Rate |
$86.72 |
| Rate for Payer: Aetna American Axle |
$62.63
|
| Rate for Payer: Aetna Commercial |
$81.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.63
|
| Rate for Payer: Cash Price |
$77.08
|
| Rate for Payer: Cofinity Commercial |
$67.44
|
| Rate for Payer: Cofinity Commercial |
$82.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.08
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.90
|
| Rate for Payer: PHP Commercial |
$81.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.63
|
| Rate for Payer: Priority Health SBD |
$60.70
|
| Rate for Payer: UMR Bronson Commercial |
$42.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.26
|
|
|
PRENATAL VITS-FERROUS FUMARATE-IRON-FOLIC ACID 800 MCG TABLET WRAPPER
|
Facility
|
OP
|
$3.25
|
|
|
Service Code
|
NDC 77333071525
|
| Hospital Charge Code |
300610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna American Axle |
$2.11
|
| Rate for Payer: Aetna Commercial |
$2.76
|
| Rate for Payer: Aetna Medicare |
$1.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.11
|
| Rate for Payer: BCBS Complete |
$1.30
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.60
|
| Rate for Payer: Healthscope Commercial |
$2.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.76
|
| Rate for Payer: PHP Commercial |
$2.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.11
|
| Rate for Payer: Priority Health SBD |
$2.05
|
| Rate for Payer: UMR Bronson Commercial |
$1.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.44
|
|
|
PRENATAL VITS NO.130-FERROUS FUM 27 MG IRON-FOLIC ACID 800 MCG TABLET
|
Facility
|
OP
|
$179.78
|
|
|
Service Code
|
NDC 07610010418
|
| Hospital Charge Code |
177116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.52 |
| Max. Negotiated Rate |
$161.80 |
| Rate for Payer: Aetna American Axle |
$116.86
|
| Rate for Payer: Aetna Commercial |
$152.81
|
| Rate for Payer: Aetna Medicare |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.86
|
| Rate for Payer: BCBS Complete |
$71.91
|
| Rate for Payer: Cash Price |
$143.82
|
| Rate for Payer: Cofinity Commercial |
$125.85
|
| Rate for Payer: Cofinity Commercial |
$154.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.82
|
| Rate for Payer: Healthscope Commercial |
$161.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$152.81
|
| Rate for Payer: PHP Commercial |
$152.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.86
|
| Rate for Payer: Priority Health SBD |
$113.26
|
| Rate for Payer: UMR Bronson Commercial |
$66.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.84
|
|
|
PRENATAL VITS NO.130-FERROUS FUM 27 MG IRON-FOLIC ACID 800 MCG TABLET
|
Facility
|
IP
|
$179.78
|
|
|
Service Code
|
NDC 07610010418
|
| Hospital Charge Code |
177116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$161.80 |
| Rate for Payer: Aetna American Axle |
$116.86
|
| Rate for Payer: Aetna Commercial |
$152.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.86
|
| Rate for Payer: Cash Price |
$143.82
|
| Rate for Payer: Cofinity Commercial |
$125.85
|
| Rate for Payer: Cofinity Commercial |
$154.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.82
|
| Rate for Payer: Healthscope Commercial |
$161.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$152.81
|
| Rate for Payer: PHP Commercial |
$152.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.86
|
| Rate for Payer: Priority Health SBD |
$113.26
|
| Rate for Payer: UMR Bronson Commercial |
$79.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.84
|
|
|
PRENATAL VITS NO.130-FERROUS FUM 27 MG IRON-FOLIC ACID 800 MCG TABLET
|
Facility
|
IP
|
$33.14
|
|
|
Service Code
|
NDC 00904531346
|
| Hospital Charge Code |
177116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.58 |
| Max. Negotiated Rate |
$29.83 |
| Rate for Payer: Aetna American Axle |
$21.54
|
| Rate for Payer: Aetna Commercial |
$28.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.54
|
| Rate for Payer: Cash Price |
$26.51
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Commercial |
$28.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.51
|
| Rate for Payer: Healthscope Commercial |
$29.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.17
|
| Rate for Payer: PHP Commercial |
$28.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.54
|
| Rate for Payer: Priority Health SBD |
$20.88
|
| Rate for Payer: UMR Bronson Commercial |
$14.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.86
|
|
|
PRENATAL VITS NO.130-FERROUS FUM 27 MG IRON-FOLIC ACID 800 MCG TABLET
|
Facility
|
OP
|
$33.14
|
|
|
Service Code
|
NDC 00904531346
|
| Hospital Charge Code |
177116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$29.83 |
| Rate for Payer: Aetna American Axle |
$21.54
|
| Rate for Payer: Aetna Commercial |
$28.17
|
| Rate for Payer: Aetna Medicare |
$16.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.54
|
| Rate for Payer: BCBS Complete |
$13.26
|
| Rate for Payer: Cash Price |
$26.51
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Commercial |
$28.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.51
|
| Rate for Payer: Healthscope Commercial |
$29.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.17
|
| Rate for Payer: PHP Commercial |
$28.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.54
|
| Rate for Payer: Priority Health SBD |
$20.88
|
| Rate for Payer: UMR Bronson Commercial |
$12.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.86
|
|
|
PR ENDOBRONCHIAL U/S ADD-ON
|
Professional
|
Both
|
$464.00
|
|
|
Service Code
|
HCPCS 31620
|
| Min. Negotiated Rate |
$185.60 |
| Max. Negotiated Rate |
$301.60 |
| Rate for Payer: Aetna Medicare |
$232.00
|
| Rate for Payer: BCBS Complete |
$185.60
|
| Rate for Payer: Cash Price |
$371.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.60
|
| Rate for Payer: UMR Bronson Commercial |
$213.44
|
|
|
PR ENDOCERVICAL CURETTAGE NOT DONE AS PART OF D&C
|
Professional
|
Both
|
$312.00
|
|
|
Service Code
|
HCPCS 57505
|
| Min. Negotiated Rate |
$102.36 |
| Max. Negotiated Rate |
$202.80 |
| Rate for Payer: Aetna Commercial |
$137.16
|
| Rate for Payer: Aetna Medicare |
$106.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.40
|
| Rate for Payer: BCBS Complete |
$124.80
|
| Rate for Payer: BCBS MAPPO |
$102.36
|
| Rate for Payer: BCN Medicare Advantage |
$102.36
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cofinity Commercial |
$137.16
|
| Rate for Payer: Cofinity Commercial |
$147.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$102.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$107.48
|
| Rate for Payer: Nomi Health Commercial |
$122.83
|
| Rate for Payer: PACE SWMI |
$102.36
|
| Rate for Payer: PHP Commercial |
$143.30
|
| Rate for Payer: PHP Medicare Advantage |
$102.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.80
|
| Rate for Payer: Priority Health Medicare |
$102.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$102.36
|
| Rate for Payer: UHC Medicare Advantage |
$102.36
|
| Rate for Payer: UMR Bronson Commercial |
$143.52
|
|
|
PR ENDOCERVICAL CURETTAGE NOT DONE AS PART OF D&C
|
Facility
|
IP
|
$312.00
|
|
|
Service Code
|
CPT 57505
|
| Hospital Charge Code |
57505
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$137.28 |
| Max. Negotiated Rate |
$280.80 |
| Rate for Payer: Aetna American Axle |
$202.80
|
| Rate for Payer: Aetna Commercial |
$265.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.80
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cofinity Commercial |
$218.40
|
| Rate for Payer: Cofinity Commercial |
$268.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.60
|
| Rate for Payer: Healthscope Commercial |
$280.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.20
|
| Rate for Payer: PHP Commercial |
$265.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.80
|
| Rate for Payer: Priority Health SBD |
$196.56
|
| Rate for Payer: UMR Bronson Commercial |
$137.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.00
|
|
|
PR ENDOCERVICAL CURETTAGE NOT DONE AS PART OF D&C
|
Professional
|
Both
|
$312.00
|
|
|
Service Code
|
HCPCS 57505
|
| Hospital Charge Code |
57505
|
| Min. Negotiated Rate |
$102.36 |
| Max. Negotiated Rate |
$202.80 |
| Rate for Payer: Aetna Commercial |
$137.16
|
| Rate for Payer: Aetna Medicare |
$106.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.40
|
| Rate for Payer: BCBS Complete |
$124.80
|
| Rate for Payer: BCBS MAPPO |
$102.36
|
| Rate for Payer: BCN Medicare Advantage |
$102.36
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cofinity Commercial |
$147.40
|
| Rate for Payer: Cofinity Commercial |
$137.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$102.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$107.48
|
| Rate for Payer: Nomi Health Commercial |
$122.83
|
| Rate for Payer: PACE SWMI |
$102.36
|
| Rate for Payer: PHP Commercial |
$143.30
|
| Rate for Payer: PHP Medicare Advantage |
$102.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.80
|
| Rate for Payer: Priority Health Medicare |
$102.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$102.36
|
| Rate for Payer: UHC Medicare Advantage |
$102.36
|
| Rate for Payer: UMR Bronson Commercial |
$143.52
|
|
