|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$276.24
|
|
|
Service Code
|
NDC 67405-550-55
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.55 |
| Max. Negotiated Rate |
$248.62 |
| Rate for Payer: Aetna American Axle |
$179.56
|
| Rate for Payer: Aetna Commercial |
$234.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.56
|
| Rate for Payer: Cash Price |
$220.99
|
| Rate for Payer: Cofinity Commercial |
$193.37
|
| Rate for Payer: Cofinity Commercial |
$237.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.99
|
| Rate for Payer: Healthscope Commercial |
$248.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.80
|
| Rate for Payer: PHP Commercial |
$234.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.37
|
| Rate for Payer: Priority Health SBD |
$174.03
|
| Rate for Payer: UMR Bronson Commercial |
$121.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.18
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
|
Service Code
|
NDC 42806-312-50
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.16 |
| Max. Negotiated Rate |
$196.70 |
| Rate for Payer: Aetna American Axle |
$142.06
|
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$152.98
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
| Rate for Payer: Priority Health SBD |
$137.69
|
| Rate for Payer: UMR Bronson Commercial |
$96.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$132.53
|
|
|
Service Code
|
NDC 72578-001-18
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.65
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.77
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UMR Bronson Commercial |
$58.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$470.64
|
|
|
Service Code
|
NDC 0591-5553-50
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.08 |
| Max. Negotiated Rate |
$423.58 |
| Rate for Payer: Aetna American Axle |
$305.92
|
| Rate for Payer: Aetna Commercial |
$400.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.92
|
| Rate for Payer: Cash Price |
$376.51
|
| Rate for Payer: Cofinity Commercial |
$329.45
|
| Rate for Payer: Cofinity Commercial |
$404.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.51
|
| Rate for Payer: Healthscope Commercial |
$423.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$400.04
|
| Rate for Payer: PHP Commercial |
$400.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.45
|
| Rate for Payer: Priority Health SBD |
$296.50
|
| Rate for Payer: UMR Bronson Commercial |
$207.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.98
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$132.53
|
|
|
Service Code
|
NDC 53489-120-02
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.65
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.77
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UMR Bronson Commercial |
$58.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
DOXYCYCLINE HYCLATE 50 MG CAPSULE
|
Facility
|
IP
|
$185.04
|
|
|
Service Code
|
NDC 53489-118-02
|
| Hospital Charge Code |
2624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.42 |
| Max. Negotiated Rate |
$166.54 |
| Rate for Payer: Aetna American Axle |
$120.28
|
| Rate for Payer: Aetna Commercial |
$157.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.28
|
| Rate for Payer: Cash Price |
$148.03
|
| Rate for Payer: Cofinity Commercial |
$129.53
|
| Rate for Payer: Cofinity Commercial |
$159.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.03
|
| Rate for Payer: Healthscope Commercial |
$166.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.28
|
| Rate for Payer: PHP Commercial |
$157.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.53
|
| Rate for Payer: Priority Health SBD |
$116.58
|
| Rate for Payer: UMR Bronson Commercial |
$81.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.78
|
|
|
DOXYCYCLINE HYCLATE 50 MG CAPSULE
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 0143-3141-50
|
| Hospital Charge Code |
2624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.33 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.70
|
| Rate for Payer: Aetna Commercial |
$195.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.70
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$195.76
|
| Rate for Payer: PHP Commercial |
$195.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.21
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$101.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$203.04
|
|
|
Service Code
|
NDC 62135-417-46
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.34 |
| Max. Negotiated Rate |
$182.74 |
| Rate for Payer: Aetna American Axle |
$131.98
|
| Rate for Payer: Aetna Commercial |
$172.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.98
|
| Rate for Payer: Cash Price |
$162.43
|
| Rate for Payer: Cofinity Commercial |
$142.13
|
| Rate for Payer: Cofinity Commercial |
$174.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$162.43
|
| Rate for Payer: Healthscope Commercial |
$182.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.58
|
| Rate for Payer: PHP Commercial |
$172.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.13
|
| Rate for Payer: Priority Health SBD |
$127.92
|
| Rate for Payer: UMR Bronson Commercial |
$89.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.28
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$135.36
|
|
|
Service Code
|
NDC 68180-657-01
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.56 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna American Axle |
$87.98
|
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.98
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.75
|
| Rate for Payer: Priority Health SBD |
$85.28
|
| Rate for Payer: UMR Bronson Commercial |
$59.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.52
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
IP
|
$78.74
|
|
|
Service Code
|
NDC 4116700609
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$70.87 |
| Rate for Payer: Aetna American Axle |
$51.18
|
| Rate for Payer: Aetna Commercial |
$66.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.18
|
| Rate for Payer: Cash Price |
$62.99
|
| Rate for Payer: Cofinity Commercial |
$55.12
|
| Rate for Payer: Cofinity Commercial |
$67.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.99
|
| Rate for Payer: Healthscope Commercial |
$70.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.93
|
| Rate for Payer: PHP Commercial |
$66.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.12
|
| Rate for Payer: Priority Health SBD |
$49.61
|
| Rate for Payer: UMR Bronson Commercial |
$34.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.06
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
IP
|
$106.25
|
|
|
Service Code
|
NDC 4116700623
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$95.62 |
| Rate for Payer: Aetna American Axle |
$69.06
|
| Rate for Payer: Aetna Commercial |
$90.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.06
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cofinity Commercial |
$74.38
|
| Rate for Payer: Cofinity Commercial |
$91.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.00
|
| Rate for Payer: Healthscope Commercial |
$95.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.31
|
| Rate for Payer: PHP Commercial |
$90.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.38
|
| Rate for Payer: Priority Health SBD |
$66.94
|
| Rate for Payer: UMR Bronson Commercial |
$46.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.69
|
|
|
DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; SIMPLE
|
Facility
|
OP
|
$1,968.76
|
|
|
Service Code
|
CPT 69000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$124.43 |
| Max. Negotiated Rate |
$1,968.76 |
| Rate for Payer: Aetna Medicare |
$650.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$781.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$781.74
|
| Rate for Payer: BCBS Complete |
$359.22
|
| Rate for Payer: BCBS MAPPO |
$625.39
|
| Rate for Payer: BCBS Trust/PPO |
$356.27
|
| Rate for Payer: BCN Medicare Advantage |
$625.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$625.39
|
| Rate for Payer: Mclaren Medicaid |
$342.09
|
| Rate for Payer: Mclaren Medicare |
$625.39
|
| Rate for Payer: Meridian Medicaid |
$359.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$656.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$719.20
|
| Rate for Payer: PACE Medicare |
$594.12
|
| Rate for Payer: PACE SWMI |
$625.39
|
| Rate for Payer: PHP Medicare Advantage |
$625.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$342.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,968.76
|
| Rate for Payer: Priority Health Medicare |
$625.39
|
| Rate for Payer: Priority Health Narrow Network |
$1,575.01
|
| Rate for Payer: Railroad Medicare Medicare |
$625.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.87
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$625.39
|
| Rate for Payer: UHC Exchange |
$124.43
|
| Rate for Payer: UHC Medicare Advantage |
$644.15
|
| Rate for Payer: VA VA |
$625.39
|
|
|
DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 41800
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$62.11 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$118.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$141.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$141.94
|
| Rate for Payer: BCBS Complete |
$65.22
|
| Rate for Payer: BCBS MAPPO |
$113.55
|
| Rate for Payer: BCBS Trust/PPO |
$124.17
|
| Rate for Payer: BCN Medicare Advantage |
$113.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$113.55
|
| Rate for Payer: Mclaren Medicaid |
$62.11
|
| Rate for Payer: Mclaren Medicare |
$113.55
|
| Rate for Payer: Meridian Medicaid |
$65.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$119.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$130.58
|
| Rate for Payer: PACE Medicare |
$107.87
|
| Rate for Payer: PACE SWMI |
$113.55
|
| Rate for Payer: PHP Medicare Advantage |
$113.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$62.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$357.43
|
| Rate for Payer: Priority Health Medicare |
$113.55
|
| Rate for Payer: Priority Health Narrow Network |
$285.94
|
| Rate for Payer: Railroad Medicare Medicare |
$113.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.85
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$113.55
|
| Rate for Payer: UHC Exchange |
$152.59
|
| Rate for Payer: UHC Medicare Advantage |
$116.96
|
| Rate for Payer: VA VA |
$113.55
|
|
|
DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; COMPLICATED
|
Facility
|
OP
|
$1,539.60
|
|
|
Service Code
|
CPT 40801
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$195.81 |
| Max. Negotiated Rate |
$1,539.60 |
| Rate for Payer: Aetna Medicare |
$508.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$611.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$611.32
|
| Rate for Payer: BCBS Complete |
$280.92
|
| Rate for Payer: BCBS MAPPO |
$489.06
|
| Rate for Payer: BCBS Trust/PPO |
$473.59
|
| Rate for Payer: BCN Medicare Advantage |
$489.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$489.06
|
| Rate for Payer: Mclaren Medicaid |
$267.52
|
| Rate for Payer: Mclaren Medicare |
$489.06
|
| Rate for Payer: Meridian Medicaid |
$280.92
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$513.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$562.42
|
| Rate for Payer: PACE Medicare |
$464.61
|
| Rate for Payer: PACE SWMI |
$489.06
|
| Rate for Payer: PHP Medicare Advantage |
$489.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$267.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,539.60
|
| Rate for Payer: Priority Health Medicare |
$489.06
|
| Rate for Payer: Priority Health Narrow Network |
$1,231.68
|
| Rate for Payer: Railroad Medicare Medicare |
$489.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$215.39
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$489.06
|
| Rate for Payer: UHC Exchange |
$195.81
|
| Rate for Payer: UHC Medicare Advantage |
$503.73
|
| Rate for Payer: VA VA |
$489.06
|
|
|
DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; SIMPLE
|
Facility
|
OP
|
$1,968.76
|
|
|
Service Code
|
CPT 40800
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$117.22 |
| Max. Negotiated Rate |
$1,968.76 |
| Rate for Payer: Aetna Medicare |
$650.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$781.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$781.74
|
| Rate for Payer: BCBS Complete |
$359.22
|
| Rate for Payer: BCBS MAPPO |
$625.39
|
| Rate for Payer: BCBS Trust/PPO |
$434.17
|
| Rate for Payer: BCN Medicare Advantage |
$625.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$625.39
|
| Rate for Payer: Mclaren Medicaid |
$342.09
|
| Rate for Payer: Mclaren Medicare |
$625.39
|
| Rate for Payer: Meridian Medicaid |
$359.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$656.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$719.20
|
| Rate for Payer: PACE Medicare |
$594.12
|
| Rate for Payer: PACE SWMI |
$625.39
|
| Rate for Payer: PHP Medicare Advantage |
$625.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$342.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,968.76
|
| Rate for Payer: Priority Health Medicare |
$625.39
|
| Rate for Payer: Priority Health Narrow Network |
$1,575.01
|
| Rate for Payer: Railroad Medicare Medicare |
$625.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.94
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$625.39
|
| Rate for Payer: UHC Exchange |
$117.22
|
| Rate for Payer: UHC Medicare Advantage |
$644.15
|
| Rate for Payer: VA VA |
$625.39
|
|
|
DRAINAGE OF ABSCESS; PAROTID, COMPLICATED
|
Facility
|
OP
|
$9,009.23
|
|
|
Service Code
|
CPT 42305
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$429.93 |
| Max. Negotiated Rate |
$9,009.23 |
| Rate for Payer: Aetna Medicare |
$2,976.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,577.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,577.30
|
| Rate for Payer: BCBS Complete |
$1,643.84
|
| Rate for Payer: BCBS MAPPO |
$2,861.84
|
| Rate for Payer: BCBS Trust/PPO |
$1,803.85
|
| Rate for Payer: BCN Medicare Advantage |
$2,861.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,861.84
|
| Rate for Payer: Mclaren Medicaid |
$1,565.43
|
| Rate for Payer: Mclaren Medicare |
$2,861.84
|
| Rate for Payer: Meridian Medicaid |
$1,643.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,004.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,291.12
|
| Rate for Payer: PACE Medicare |
$2,718.75
|
| Rate for Payer: PACE SWMI |
$2,861.84
|
| Rate for Payer: PHP Medicare Advantage |
$2,861.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,565.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,009.23
|
| Rate for Payer: Priority Health Medicare |
$2,861.84
|
| Rate for Payer: Priority Health Narrow Network |
$7,207.38
|
| Rate for Payer: Railroad Medicare Medicare |
$2,861.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$472.92
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,861.84
|
| Rate for Payer: UHC Exchange |
$429.93
|
| Rate for Payer: UHC Medicare Advantage |
$2,947.70
|
| Rate for Payer: VA VA |
$2,861.84
|
|
|
DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)
|
Facility
|
OP
|
$4,536.73
|
|
|
Service Code
|
CPT 26011
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$184.35 |
| Max. Negotiated Rate |
$4,536.73 |
| Rate for Payer: Aetna Medicare |
$1,498.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,801.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,801.41
|
| Rate for Payer: BCBS Complete |
$827.79
|
| Rate for Payer: BCBS MAPPO |
$1,441.13
|
| Rate for Payer: BCBS Trust/PPO |
$879.68
|
| Rate for Payer: BCN Medicare Advantage |
$1,441.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,441.13
|
| Rate for Payer: Mclaren Medicaid |
$788.30
|
| Rate for Payer: Mclaren Medicare |
$1,441.13
|
| Rate for Payer: Meridian Medicaid |
$827.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,513.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,657.30
|
| Rate for Payer: PACE Medicare |
$1,369.07
|
| Rate for Payer: PACE SWMI |
$1,441.13
|
| Rate for Payer: PHP Medicare Advantage |
$1,441.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$788.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,536.73
|
| Rate for Payer: Priority Health Medicare |
$1,441.13
|
| Rate for Payer: Priority Health Narrow Network |
$3,629.38
|
| Rate for Payer: Railroad Medicare Medicare |
$1,441.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$202.78
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,441.13
|
| Rate for Payer: UHC Exchange |
$184.35
|
| Rate for Payer: UHC Medicare Advantage |
$1,484.36
|
| Rate for Payer: VA VA |
$1,441.13
|
|
|
DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)
|
Facility
|
OP
|
$4,536.73
|
|
|
Service Code
|
CPT 26011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$184.35 |
| Max. Negotiated Rate |
$4,536.73 |
| Rate for Payer: Aetna Medicare |
$1,498.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,801.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,801.41
|
| Rate for Payer: BCBS Complete |
$827.79
|
| Rate for Payer: BCBS MAPPO |
$1,441.13
|
| Rate for Payer: BCBS Trust/PPO |
$879.68
|
| Rate for Payer: BCN Medicare Advantage |
$1,441.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,441.13
|
| Rate for Payer: Mclaren Medicaid |
$788.30
|
| Rate for Payer: Mclaren Medicare |
$1,441.13
|
| Rate for Payer: Meridian Medicaid |
$827.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,513.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,657.30
|
| Rate for Payer: PACE Medicare |
$1,369.07
|
| Rate for Payer: PACE SWMI |
$1,441.13
|
| Rate for Payer: PHP Medicare Advantage |
$1,441.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$788.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,536.73
|
| Rate for Payer: Priority Health Medicare |
$1,441.13
|
| Rate for Payer: Priority Health Narrow Network |
$3,629.38
|
| Rate for Payer: Railroad Medicare Medicare |
$1,441.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$202.78
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,441.13
|
| Rate for Payer: UHC Exchange |
$184.35
|
| Rate for Payer: UHC Medicare Advantage |
$1,484.36
|
| Rate for Payer: VA VA |
$1,441.13
|
|
|
DRAINAGE OF FINGER ABSCESS; SIMPLE
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 26010
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$97.34 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$185.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.44
|
| Rate for Payer: BCBS Complete |
$102.21
|
| Rate for Payer: BCBS MAPPO |
$177.95
|
| Rate for Payer: BCBS Trust/PPO |
$227.51
|
| Rate for Payer: BCN Medicare Advantage |
$177.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$177.95
|
| Rate for Payer: Mclaren Medicaid |
$97.34
|
| Rate for Payer: Mclaren Medicare |
$177.95
|
| Rate for Payer: Meridian Medicaid |
$102.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$186.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.64
|
| Rate for Payer: PACE Medicare |
$169.05
|
| Rate for Payer: PACE SWMI |
$177.95
|
| Rate for Payer: PHP Medicare Advantage |
$177.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$560.20
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$448.16
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.88
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$177.95
|
| Rate for Payer: UHC Exchange |
$140.80
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
|
DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; SIMPLE
|
Facility
|
OP
|
$7,951.14
|
|
|
Service Code
|
CPT 38300
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$208.25 |
| Max. Negotiated Rate |
$7,951.14 |
| Rate for Payer: Aetna Medicare |
$2,626.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,157.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,157.18
|
| Rate for Payer: BCBS Complete |
$1,450.79
|
| Rate for Payer: BCBS MAPPO |
$2,525.74
|
| Rate for Payer: BCBS Trust/PPO |
$967.77
|
| Rate for Payer: BCN Medicare Advantage |
$2,525.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,525.74
|
| Rate for Payer: Mclaren Medicaid |
$1,381.58
|
| Rate for Payer: Mclaren Medicare |
$2,525.74
|
| Rate for Payer: Meridian Medicaid |
$1,450.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,652.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,904.60
|
| Rate for Payer: PACE Medicare |
$2,399.45
|
| Rate for Payer: PACE SWMI |
$2,525.74
|
| Rate for Payer: PHP Medicare Advantage |
$2,525.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,381.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,951.14
|
| Rate for Payer: Priority Health Medicare |
$2,525.74
|
| Rate for Payer: Priority Health Narrow Network |
$6,360.91
|
| Rate for Payer: Railroad Medicare Medicare |
$2,525.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$229.08
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,525.74
|
| Rate for Payer: UHC Exchange |
$208.25
|
| Rate for Payer: UHC Medicare Advantage |
$2,601.51
|
| Rate for Payer: VA VA |
$2,525.74
|
|
|
DRAINAGE OF SCROTAL WALL ABSCESS
|
Facility
|
OP
|
$4,536.73
|
|
|
Service Code
|
CPT 55100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$166.01 |
| Max. Negotiated Rate |
$4,536.73 |
| Rate for Payer: Aetna Medicare |
$1,498.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,801.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,801.41
|
| Rate for Payer: BCBS Complete |
$827.79
|
| Rate for Payer: BCBS MAPPO |
$1,441.13
|
| Rate for Payer: BCBS Trust/PPO |
$774.22
|
| Rate for Payer: BCN Medicare Advantage |
$1,441.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,441.13
|
| Rate for Payer: Mclaren Medicaid |
$788.30
|
| Rate for Payer: Mclaren Medicare |
$1,441.13
|
| Rate for Payer: Meridian Medicaid |
$827.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,513.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,657.30
|
| Rate for Payer: PACE Medicare |
$1,369.07
|
| Rate for Payer: PACE SWMI |
$1,441.13
|
| Rate for Payer: PHP Medicare Advantage |
$1,441.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$788.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,536.73
|
| Rate for Payer: Priority Health Medicare |
$1,441.13
|
| Rate for Payer: Priority Health Narrow Network |
$3,629.38
|
| Rate for Payer: Railroad Medicare Medicare |
$1,441.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$182.61
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,441.13
|
| Rate for Payer: UHC Exchange |
$166.01
|
| Rate for Payer: UHC Medicare Advantage |
$1,484.36
|
| Rate for Payer: VA VA |
$1,441.13
|
|
|
DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH
|
Facility
|
OP
|
$9,057.42
|
|
|
Service Code
|
CPT 26020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$556.98 |
| Max. Negotiated Rate |
$9,057.42 |
| Rate for Payer: Aetna Medicare |
$2,992.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,596.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,596.44
|
| Rate for Payer: BCBS Complete |
$1,652.63
|
| Rate for Payer: BCBS MAPPO |
$2,877.15
|
| Rate for Payer: BCBS Trust/PPO |
$1,810.03
|
| Rate for Payer: BCN Medicare Advantage |
$2,877.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,877.15
|
| Rate for Payer: Mclaren Medicaid |
$1,573.80
|
| Rate for Payer: Mclaren Medicare |
$2,877.15
|
| Rate for Payer: Meridian Medicaid |
$1,652.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,021.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,308.72
|
| Rate for Payer: PACE Medicare |
$2,733.29
|
| Rate for Payer: PACE SWMI |
$2,877.15
|
| Rate for Payer: PHP Medicare Advantage |
$2,877.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,573.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,057.42
|
| Rate for Payer: Priority Health Medicare |
$2,877.15
|
| Rate for Payer: Priority Health Narrow Network |
$7,245.94
|
| Rate for Payer: Railroad Medicare Medicare |
$2,877.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$612.68
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,877.15
|
| Rate for Payer: UHC Exchange |
$556.98
|
| Rate for Payer: UHC Medicare Advantage |
$2,963.46
|
| Rate for Payer: VA VA |
$2,877.15
|
|
|
DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 16020
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$55.01 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$185.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.44
|
| Rate for Payer: BCBS Complete |
$102.21
|
| Rate for Payer: BCBS MAPPO |
$177.95
|
| Rate for Payer: BCBS Trust/PPO |
$193.11
|
| Rate for Payer: BCN Medicare Advantage |
$177.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$177.95
|
| Rate for Payer: Mclaren Medicaid |
$97.34
|
| Rate for Payer: Mclaren Medicare |
$177.95
|
| Rate for Payer: Meridian Medicaid |
$102.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$186.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.64
|
| Rate for Payer: PACE Medicare |
$169.05
|
| Rate for Payer: PACE SWMI |
$177.95
|
| Rate for Payer: PHP Medicare Advantage |
$177.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$560.20
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$448.16
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.51
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$177.95
|
| Rate for Payer: UHC Exchange |
$55.01
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
|
DRONABINOL 2.5 MG CAPSULE
|
Facility
|
IP
|
$540.54
|
|
|
Service Code
|
NDC 42858-867-06
|
| Hospital Charge Code |
9904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.84 |
| Max. Negotiated Rate |
$486.49 |
| Rate for Payer: Aetna American Axle |
$351.35
|
| Rate for Payer: Aetna Commercial |
$459.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$351.35
|
| Rate for Payer: Cash Price |
$432.43
|
| Rate for Payer: Cofinity Commercial |
$464.86
|
| Rate for Payer: Cofinity Commercial |
$378.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$432.43
|
| Rate for Payer: Healthscope Commercial |
$486.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$378.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$405.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$459.46
|
| Rate for Payer: PHP Commercial |
$459.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$378.38
|
| Rate for Payer: Priority Health SBD |
$340.54
|
| Rate for Payer: UMR Bronson Commercial |
$237.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$405.40
|
|
|
DRONABINOL 2.5 MG CAPSULE
|
Facility
|
IP
|
$1,219.92
|
|
|
Service Code
|
NDC 0904-6745-61
|
| Hospital Charge Code |
9904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$536.76 |
| Max. Negotiated Rate |
$1,097.93 |
| Rate for Payer: Aetna American Axle |
$792.95
|
| Rate for Payer: Aetna Commercial |
$1,036.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$792.95
|
| Rate for Payer: Cash Price |
$975.94
|
| Rate for Payer: Cofinity Commercial |
$1,049.13
|
| Rate for Payer: Cofinity Commercial |
$853.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$975.94
|
| Rate for Payer: Healthscope Commercial |
$1,097.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$853.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$914.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,036.93
|
| Rate for Payer: PHP Commercial |
$1,036.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$853.94
|
| Rate for Payer: Priority Health SBD |
$768.55
|
| Rate for Payer: UMR Bronson Commercial |
$536.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$914.94
|
|
