|
PR XEOMIN
|
Professional
|
Both
|
$10.00
|
|
|
Service Code
|
HCPCS 00085
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Aetna Medicare |
$5.00
|
| Rate for Payer: BCBS Complete |
$4.00
|
| Rate for Payer: Cash Price |
$8.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.50
|
| Rate for Payer: UMR Bronson Commercial |
$4.60
|
|
|
PR XERS TST BRNCSPSM PRE&POST SPMTRY&PLS OX W/ECG
|
Professional
|
Both
|
$80.00
|
|
|
Service Code
|
HCPCS 94617
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$108.98
|
| Rate for Payer: Aetna Medicare |
$84.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.98
|
| Rate for Payer: BCBS Complete |
$32.00
|
| Rate for Payer: BCBS MAPPO |
$81.33
|
| Rate for Payer: BCN Medicare Advantage |
$81.33
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cofinity Commercial |
$117.12
|
| Rate for Payer: Cofinity Commercial |
$108.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$81.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$85.40
|
| Rate for Payer: Nomi Health Commercial |
$97.60
|
| Rate for Payer: PACE SWMI |
$81.33
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: PHP Medicare Advantage |
$81.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.00
|
| Rate for Payer: Priority Health Medicare |
$81.33
|
| Rate for Payer: UHC Dual Complete DSNP |
$81.33
|
| Rate for Payer: UHC Medicare Advantage |
$81.33
|
| Rate for Payer: UMR Bronson Commercial |
$36.80
|
|
|
PR XERS TST BRNCSPSM PRE&POST SPMTRY&PLS OX WO /ECG
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 94619
|
| Min. Negotiated Rate |
$59.42 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$79.62
|
| Rate for Payer: Aetna Medicare |
$61.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.62
|
| Rate for Payer: BCBS Complete |
$64.00
|
| Rate for Payer: BCBS MAPPO |
$59.42
|
| Rate for Payer: BCN Medicare Advantage |
$59.42
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cofinity Commercial |
$85.56
|
| Rate for Payer: Cofinity Commercial |
$79.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.39
|
| Rate for Payer: Nomi Health Commercial |
$71.30
|
| Rate for Payer: PACE SWMI |
$59.42
|
| Rate for Payer: PHP Commercial |
$83.19
|
| Rate for Payer: PHP Medicare Advantage |
$59.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.00
|
| Rate for Payer: Priority Health Medicare |
$59.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$59.42
|
| Rate for Payer: UHC Medicare Advantage |
$59.42
|
| Rate for Payer: UMR Bronson Commercial |
$73.60
|
|
|
PR XTRNL ECG REC>48HR<7D RECORDING SCAN A/R R&I
|
Professional
|
Both
|
$312.00
|
|
|
Service Code
|
HCPCS 93241
|
| Min. Negotiated Rate |
$124.80 |
| Max. Negotiated Rate |
$343.30 |
| Rate for Payer: Aetna Commercial |
$319.46
|
| Rate for Payer: Aetna Medicare |
$247.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$343.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$319.46
|
| Rate for Payer: BCBS Complete |
$124.80
|
| Rate for Payer: BCBS MAPPO |
$238.40
|
| Rate for Payer: BCN Medicare Advantage |
$238.40
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cofinity Commercial |
$343.30
|
| Rate for Payer: Cofinity Commercial |
$319.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$238.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$286.08
|
| Rate for Payer: PACE SWMI |
$238.40
|
| Rate for Payer: PHP Commercial |
$333.76
|
| Rate for Payer: PHP Medicare Advantage |
$238.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.80
|
| Rate for Payer: Priority Health Medicare |
$238.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$238.40
|
| Rate for Payer: UHC Medicare Advantage |
$238.40
|
| Rate for Payer: UMR Bronson Commercial |
$143.52
|
|
|
PR XTRNL ECG REC<48 HRS RECORDING
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 93225
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna Commercial |
$21.44
|
| Rate for Payer: Aetna Medicare |
$16.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.44
|
| Rate for Payer: BCBS Complete |
$48.00
|
| Rate for Payer: BCBS MAPPO |
$16.00
|
| Rate for Payer: BCN Medicare Advantage |
$16.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cofinity Commercial |
$23.04
|
| Rate for Payer: Cofinity Commercial |
$21.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.80
|
| Rate for Payer: Nomi Health Commercial |
$19.20
|
| Rate for Payer: PACE SWMI |
$16.00
|
| Rate for Payer: PHP Commercial |
$22.40
|
| Rate for Payer: PHP Medicare Advantage |
$16.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.00
|
| Rate for Payer: Priority Health Medicare |
$16.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.00
|
| Rate for Payer: UHC Medicare Advantage |
$16.00
|
| Rate for Payer: UMR Bronson Commercial |
$55.20
|
|
|
PR XTRNL ECG REC<48 HRS RECORDING SCAN A/R R&I
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 93224
|
| Min. Negotiated Rate |
$63.55 |
| Max. Negotiated Rate |
$152.75 |
| Rate for Payer: Aetna Commercial |
$85.16
|
| Rate for Payer: Aetna Medicare |
$66.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.16
|
| Rate for Payer: BCBS Complete |
$94.00
|
| Rate for Payer: BCBS MAPPO |
$63.55
|
| Rate for Payer: BCN Medicare Advantage |
$63.55
|
| Rate for Payer: Cash Price |
$188.00
|
| Rate for Payer: Cash Price |
$188.00
|
| Rate for Payer: Cofinity Commercial |
$91.51
|
| Rate for Payer: Cofinity Commercial |
$85.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$63.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$66.73
|
| Rate for Payer: Nomi Health Commercial |
$76.26
|
| Rate for Payer: PACE SWMI |
$63.55
|
| Rate for Payer: PHP Commercial |
$88.97
|
| Rate for Payer: PHP Medicare Advantage |
$63.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.75
|
| Rate for Payer: Priority Health Medicare |
$63.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$63.55
|
| Rate for Payer: UHC Medicare Advantage |
$63.55
|
| Rate for Payer: UMR Bronson Commercial |
$108.10
|
|
|
PR XTRNL ECG REC<48 HRS RVW&INTERPJ PHYS/QHP
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 93227
|
| Min. Negotiated Rate |
$17.12 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna Commercial |
$22.94
|
| Rate for Payer: Aetna Medicare |
$17.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.94
|
| Rate for Payer: BCBS Complete |
$80.00
|
| Rate for Payer: BCBS MAPPO |
$17.12
|
| Rate for Payer: BCN Medicare Advantage |
$17.12
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$24.65
|
| Rate for Payer: Cofinity Commercial |
$22.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.98
|
| Rate for Payer: Nomi Health Commercial |
$20.54
|
| Rate for Payer: PACE SWMI |
$17.12
|
| Rate for Payer: PHP Commercial |
$23.97
|
| Rate for Payer: PHP Medicare Advantage |
$17.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.00
|
| Rate for Payer: Priority Health Medicare |
$17.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.12
|
| Rate for Payer: UHC Medicare Advantage |
$17.12
|
| Rate for Payer: UMR Bronson Commercial |
$92.00
|
|
|
PR XTRNL MOBILE CV TELEMETRY W/I&REPORT 30 DAYS
|
Professional
|
Both
|
$58.00
|
|
|
Service Code
|
HCPCS 93228
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna Commercial |
$31.81
|
| Rate for Payer: Aetna Medicare |
$24.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.81
|
| Rate for Payer: BCBS Complete |
$23.20
|
| Rate for Payer: BCBS MAPPO |
$23.74
|
| Rate for Payer: BCN Medicare Advantage |
$23.74
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cofinity Commercial |
$34.19
|
| Rate for Payer: Cofinity Commercial |
$31.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.93
|
| Rate for Payer: Nomi Health Commercial |
$28.49
|
| Rate for Payer: PACE SWMI |
$23.74
|
| Rate for Payer: PHP Commercial |
$33.24
|
| Rate for Payer: PHP Medicare Advantage |
$23.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.70
|
| Rate for Payer: Priority Health Medicare |
$23.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.74
|
| Rate for Payer: UHC Medicare Advantage |
$23.74
|
| Rate for Payer: UMR Bronson Commercial |
$26.68
|
|
|
PR XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS
|
Professional
|
Both
|
$654.00
|
|
|
Service Code
|
HCPCS 93271
|
| Min. Negotiated Rate |
$120.90 |
| Max. Negotiated Rate |
$425.10 |
| Rate for Payer: Aetna Commercial |
$162.01
|
| Rate for Payer: Aetna Medicare |
$125.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.01
|
| Rate for Payer: BCBS Complete |
$261.60
|
| Rate for Payer: BCBS MAPPO |
$120.90
|
| Rate for Payer: BCN Medicare Advantage |
$120.90
|
| Rate for Payer: Cash Price |
$523.20
|
| Rate for Payer: Cash Price |
$523.20
|
| Rate for Payer: Cofinity Commercial |
$174.10
|
| Rate for Payer: Cofinity Commercial |
$162.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$120.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$126.94
|
| Rate for Payer: Nomi Health Commercial |
$145.08
|
| Rate for Payer: PACE SWMI |
$120.90
|
| Rate for Payer: PHP Commercial |
$169.26
|
| Rate for Payer: PHP Medicare Advantage |
$120.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.10
|
| Rate for Payer: Priority Health Medicare |
$120.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$120.90
|
| Rate for Payer: UHC Medicare Advantage |
$120.90
|
| Rate for Payer: UMR Bronson Commercial |
$300.84
|
|
|
PR XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS 93270
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: Aetna Commercial |
$9.59
|
| Rate for Payer: Aetna Medicare |
$7.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.31
|
| Rate for Payer: BCBS Complete |
$49.20
|
| Rate for Payer: BCBS MAPPO |
$7.16
|
| Rate for Payer: BCN Medicare Advantage |
$7.16
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cofinity Commercial |
$9.59
|
| Rate for Payer: Cofinity Commercial |
$10.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.52
|
| Rate for Payer: Nomi Health Commercial |
$8.59
|
| Rate for Payer: PACE SWMI |
$7.16
|
| Rate for Payer: PHP Commercial |
$10.02
|
| Rate for Payer: PHP Medicare Advantage |
$7.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.95
|
| Rate for Payer: Priority Health Medicare |
$7.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.16
|
| Rate for Payer: UHC Medicare Advantage |
$7.16
|
| Rate for Payer: UMR Bronson Commercial |
$56.58
|
|
|
PR XTRNL PT ACTIV ECG TRANSMIS W/R&I </30 DAYS
|
Professional
|
Both
|
$871.00
|
|
|
Service Code
|
HCPCS 93268
|
| Min. Negotiated Rate |
$150.65 |
| Max. Negotiated Rate |
$566.15 |
| Rate for Payer: Aetna Commercial |
$201.87
|
| Rate for Payer: Aetna Medicare |
$156.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.87
|
| Rate for Payer: BCBS Complete |
$348.40
|
| Rate for Payer: BCBS MAPPO |
$150.65
|
| Rate for Payer: BCN Medicare Advantage |
$150.65
|
| Rate for Payer: Cash Price |
$696.80
|
| Rate for Payer: Cash Price |
$696.80
|
| Rate for Payer: Cofinity Commercial |
$216.94
|
| Rate for Payer: Cofinity Commercial |
$201.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$150.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$158.18
|
| Rate for Payer: Nomi Health Commercial |
$180.78
|
| Rate for Payer: PACE SWMI |
$150.65
|
| Rate for Payer: PHP Commercial |
$210.91
|
| Rate for Payer: PHP Medicare Advantage |
$150.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$566.15
|
| Rate for Payer: Priority Health Medicare |
$150.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$150.65
|
| Rate for Payer: UHC Medicare Advantage |
$150.65
|
| Rate for Payer: UMR Bronson Commercial |
$400.66
|
|
|
PR XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
HCPCS 93272
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$113.10 |
| Rate for Payer: Aetna Commercial |
$30.27
|
| Rate for Payer: Aetna Medicare |
$23.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.27
|
| Rate for Payer: BCBS Complete |
$69.60
|
| Rate for Payer: BCBS MAPPO |
$22.59
|
| Rate for Payer: BCN Medicare Advantage |
$22.59
|
| Rate for Payer: Cash Price |
$139.20
|
| Rate for Payer: Cash Price |
$139.20
|
| Rate for Payer: Cofinity Commercial |
$32.53
|
| Rate for Payer: Cofinity Commercial |
$30.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.72
|
| Rate for Payer: Nomi Health Commercial |
$27.11
|
| Rate for Payer: PACE SWMI |
$22.59
|
| Rate for Payer: PHP Commercial |
$31.63
|
| Rate for Payer: PHP Medicare Advantage |
$22.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.10
|
| Rate for Payer: Priority Health Medicare |
$22.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.59
|
| Rate for Payer: UHC Medicare Advantage |
$22.59
|
| Rate for Payer: UMR Bronson Commercial |
$80.04
|
|
|
PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL
|
Professional
|
Both
|
$608.00
|
|
|
Service Code
|
HCPCS 41015
|
| Min. Negotiated Rate |
$243.20 |
| Max. Negotiated Rate |
$409.94 |
| Rate for Payer: Aetna Commercial |
$381.47
|
| Rate for Payer: Aetna Medicare |
$296.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$381.47
|
| Rate for Payer: BCBS Complete |
$243.20
|
| Rate for Payer: BCBS MAPPO |
$284.68
|
| Rate for Payer: BCN Medicare Advantage |
$284.68
|
| Rate for Payer: Cash Price |
$486.40
|
| Rate for Payer: Cash Price |
$486.40
|
| Rate for Payer: Cofinity Commercial |
$409.94
|
| Rate for Payer: Cofinity Commercial |
$381.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$284.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$298.91
|
| Rate for Payer: Nomi Health Commercial |
$341.62
|
| Rate for Payer: PACE SWMI |
$284.68
|
| Rate for Payer: PHP Commercial |
$398.55
|
| Rate for Payer: PHP Medicare Advantage |
$284.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$395.20
|
| Rate for Payer: Priority Health Medicare |
$284.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$284.68
|
| Rate for Payer: UHC Medicare Advantage |
$284.68
|
| Rate for Payer: UMR Bronson Commercial |
$279.68
|
|
|
PR XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDB
|
Professional
|
Both
|
$902.00
|
|
|
Service Code
|
HCPCS 41017
|
| Min. Negotiated Rate |
$322.30 |
| Max. Negotiated Rate |
$586.30 |
| Rate for Payer: Aetna Commercial |
$431.88
|
| Rate for Payer: Aetna Medicare |
$335.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$431.88
|
| Rate for Payer: BCBS Complete |
$360.80
|
| Rate for Payer: BCBS MAPPO |
$322.30
|
| Rate for Payer: BCN Medicare Advantage |
$322.30
|
| Rate for Payer: Cash Price |
$721.60
|
| Rate for Payer: Cash Price |
$721.60
|
| Rate for Payer: Cofinity Commercial |
$464.11
|
| Rate for Payer: Cofinity Commercial |
$431.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$322.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$338.42
|
| Rate for Payer: Nomi Health Commercial |
$386.76
|
| Rate for Payer: PACE SWMI |
$322.30
|
| Rate for Payer: PHP Commercial |
$451.22
|
| Rate for Payer: PHP Medicare Advantage |
$322.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$586.30
|
| Rate for Payer: Priority Health Medicare |
$322.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$322.30
|
| Rate for Payer: UHC Medicare Advantage |
$322.30
|
| Rate for Payer: UMR Bronson Commercial |
$414.92
|
|
|
PR ZINC PASTE BAND W >=3""<5""/YD
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS A6456
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna Commercial |
$2.35
|
| Rate for Payer: Aetna Medicare |
$1.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: BCBS Complete |
$7.20
|
| Rate for Payer: BCBS MAPPO |
$1.75
|
| Rate for Payer: BCN Medicare Advantage |
$1.75
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$2.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.84
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| Rate for Payer: PACE SWMI |
$1.75
|
| Rate for Payer: PHP Commercial |
$2.45
|
| Rate for Payer: PHP Medicare Advantage |
$1.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.70
|
| Rate for Payer: Priority Health Medicare |
$1.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.75
|
| Rate for Payer: UHC Medicare Advantage |
$1.75
|
| Rate for Payer: UMR Bronson Commercial |
$8.28
|
|
|
PR ZOSTER VACCINE HZV LIVE FOR SUBCUTANEOUS USE
|
Professional
|
Both
|
$247.00
|
|
|
Service Code
|
HCPCS 90736
|
| Min. Negotiated Rate |
$98.80 |
| Max. Negotiated Rate |
$160.55 |
| Rate for Payer: Aetna Medicare |
$123.50
|
| Rate for Payer: BCBS Complete |
$98.80
|
| Rate for Payer: Cash Price |
$197.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.55
|
| Rate for Payer: UMR Bronson Commercial |
$113.62
|
|
|
PSEUDOEPHEDRINE 30 MG TABLET
|
Facility
|
OP
|
$44.65
|
|
|
Service Code
|
NDC 00904505359
|
| Hospital Charge Code |
6714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna American Axle |
$29.02
|
| Rate for Payer: Aetna Commercial |
$37.95
|
| Rate for Payer: Aetna Medicare |
$22.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.02
|
| Rate for Payer: BCBS Complete |
$17.86
|
| Rate for Payer: Cash Price |
$35.72
|
| Rate for Payer: Cofinity Commercial |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$38.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.72
|
| Rate for Payer: Healthscope Commercial |
$40.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.95
|
| Rate for Payer: PHP Commercial |
$37.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.02
|
| Rate for Payer: Priority Health SBD |
$28.13
|
| Rate for Payer: UMR Bronson Commercial |
$16.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.49
|
|
|
PSEUDOEPHEDRINE 30 MG TABLET
|
Facility
|
IP
|
$44.65
|
|
|
Service Code
|
NDC 00904505359
|
| Hospital Charge Code |
6714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.65 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna American Axle |
$29.02
|
| Rate for Payer: Aetna Commercial |
$37.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.02
|
| Rate for Payer: Cash Price |
$35.72
|
| Rate for Payer: Cofinity Commercial |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$38.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.72
|
| Rate for Payer: Healthscope Commercial |
$40.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.95
|
| Rate for Payer: PHP Commercial |
$37.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.02
|
| Rate for Payer: Priority Health SBD |
$28.13
|
| Rate for Payer: UMR Bronson Commercial |
$19.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.49
|
|
|
PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$27.74
|
|
|
Service Code
|
NDC 45802010752
|
| Hospital Charge Code |
6716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$24.97 |
| Rate for Payer: Aetna American Axle |
$18.03
|
| Rate for Payer: Aetna Commercial |
$23.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.03
|
| Rate for Payer: Cash Price |
$22.19
|
| Rate for Payer: Cofinity Commercial |
$19.42
|
| Rate for Payer: Cofinity Commercial |
$23.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.19
|
| Rate for Payer: Healthscope Commercial |
$24.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.58
|
| Rate for Payer: PHP Commercial |
$23.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.03
|
| Rate for Payer: Priority Health SBD |
$17.48
|
| Rate for Payer: UMR Bronson Commercial |
$12.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.80
|
|
|
PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$28.79
|
|
|
Service Code
|
NDC 00810067013
|
| Hospital Charge Code |
6716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$25.91 |
| Rate for Payer: Aetna American Axle |
$18.71
|
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Aetna Medicare |
$14.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.71
|
| Rate for Payer: BCBS Complete |
$11.52
|
| Rate for Payer: Cash Price |
$23.03
|
| Rate for Payer: Cofinity Commercial |
$20.15
|
| Rate for Payer: Cofinity Commercial |
$24.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.03
|
| Rate for Payer: Healthscope Commercial |
$25.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.47
|
| Rate for Payer: PHP Commercial |
$24.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.71
|
| Rate for Payer: Priority Health SBD |
$18.14
|
| Rate for Payer: UMR Bronson Commercial |
$10.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.59
|
|
|
PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$28.79
|
|
|
Service Code
|
NDC 00810067013
|
| Hospital Charge Code |
6716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.67 |
| Max. Negotiated Rate |
$25.91 |
| Rate for Payer: Aetna American Axle |
$18.71
|
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.71
|
| Rate for Payer: Cash Price |
$23.03
|
| Rate for Payer: Cofinity Commercial |
$20.15
|
| Rate for Payer: Cofinity Commercial |
$24.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.03
|
| Rate for Payer: Healthscope Commercial |
$25.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.47
|
| Rate for Payer: PHP Commercial |
$24.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.71
|
| Rate for Payer: Priority Health SBD |
$18.14
|
| Rate for Payer: UMR Bronson Commercial |
$12.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.59
|
|
|
PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$27.74
|
|
|
Service Code
|
NDC 45802010752
|
| Hospital Charge Code |
6716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$24.97 |
| Rate for Payer: Aetna American Axle |
$18.03
|
| Rate for Payer: Aetna Commercial |
$23.58
|
| Rate for Payer: Aetna Medicare |
$13.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.03
|
| Rate for Payer: BCBS Complete |
$11.10
|
| Rate for Payer: Cash Price |
$22.19
|
| Rate for Payer: Cofinity Commercial |
$19.42
|
| Rate for Payer: Cofinity Commercial |
$23.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.19
|
| Rate for Payer: Healthscope Commercial |
$24.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.58
|
| Rate for Payer: PHP Commercial |
$23.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.03
|
| Rate for Payer: Priority Health SBD |
$17.48
|
| Rate for Payer: UMR Bronson Commercial |
$10.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.80
|
|
|
PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$2.89
|
|
|
Service Code
|
NDC 09900000882
|
| Hospital Charge Code |
6716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna American Axle |
$1.88
|
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.88
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cofinity Commercial |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$2.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.31
|
| Rate for Payer: Healthscope Commercial |
$2.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.46
|
| Rate for Payer: PHP Commercial |
$2.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.88
|
| Rate for Payer: Priority Health SBD |
$1.82
|
| Rate for Payer: UMR Bronson Commercial |
$1.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.17
|
|
|
PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$2.89
|
|
|
Service Code
|
NDC 09900000882
|
| Hospital Charge Code |
6716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna American Axle |
$1.88
|
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna Medicare |
$1.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.88
|
| Rate for Payer: BCBS Complete |
$1.16
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cofinity Commercial |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$2.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.31
|
| Rate for Payer: Healthscope Commercial |
$2.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.46
|
| Rate for Payer: PHP Commercial |
$2.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.88
|
| Rate for Payer: Priority Health SBD |
$1.82
|
| Rate for Payer: UMR Bronson Commercial |
$1.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.17
|
|
|
PSYLLIUM ORAL PACKET
|
Facility
|
IP
|
$8.85
|
|
|
Service Code
|
NDC 37000002410
|
| Hospital Charge Code |
11218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$7.96 |
| Rate for Payer: Aetna American Axle |
$5.75
|
| Rate for Payer: Aetna Commercial |
$7.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.75
|
| Rate for Payer: Cash Price |
$7.08
|
| Rate for Payer: Cofinity Commercial |
$6.20
|
| Rate for Payer: Cofinity Commercial |
$7.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.08
|
| Rate for Payer: Healthscope Commercial |
$7.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.52
|
| Rate for Payer: PHP Commercial |
$7.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.75
|
| Rate for Payer: Priority Health SBD |
$5.58
|
| Rate for Payer: UMR Bronson Commercial |
$3.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.64
|
|
