|
SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$1,378.37
|
|
|
Service Code
|
NDC 00173052100
|
| Hospital Charge Code |
28246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$606.48 |
| Max. Negotiated Rate |
$1,240.53 |
| Rate for Payer: Aetna American Axle |
$895.94
|
| Rate for Payer: Aetna Commercial |
$1,171.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$895.94
|
| Rate for Payer: Cash Price |
$1,102.70
|
| Rate for Payer: Cofinity Advantage |
$964.86
|
| Rate for Payer: Cofinity Commercial |
$1,185.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,102.70
|
| Rate for Payer: Healthscope Commercial |
$1,240.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$964.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,033.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,171.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,033.78
|
| Rate for Payer: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health SBD |
$868.37
|
| Rate for Payer: UMR Bronson Commercial |
$606.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,033.78
|
|
|
SALMETEROL 50 MCG/DOSE BLISTER POWDER FOR INHALATION
|
Facility
|
OP
|
$1,378.37
|
|
|
Service Code
|
NDC 00173052100
|
| Hospital Charge Code |
28246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$1,240.53 |
| Rate for Payer: Aetna American Axle |
$895.94
|
| Rate for Payer: Aetna Commercial |
$1,171.61
|
| Rate for Payer: Aetna Medicare |
$689.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$895.94
|
| Rate for Payer: BCBS Complete |
$551.35
|
| Rate for Payer: Cash Price |
$1,102.70
|
| Rate for Payer: Cofinity Advantage |
$964.86
|
| Rate for Payer: Cofinity Commercial |
$1,185.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,102.70
|
| Rate for Payer: Healthscope Commercial |
$1,240.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$964.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,033.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,102.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,171.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,033.78
|
| Rate for Payer: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health SBD |
$868.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$895.94
|
| Rate for Payer: UHC Core |
$718.13
|
| Rate for Payer: UHC Exchange |
$541.70
|
| Rate for Payer: UMR Bronson Commercial |
$510.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,033.78
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$986.67
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
11338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.13 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna American Axle |
$641.34
|
| Rate for Payer: Aetna Commercial |
$838.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$641.34
|
| Rate for Payer: Cash Price |
$789.34
|
| Rate for Payer: Cofinity Advantage |
$690.67
|
| Rate for Payer: Cofinity Commercial |
$848.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$789.34
|
| Rate for Payer: Healthscope Commercial |
$888.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$690.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$740.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$838.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$740.00
|
| Rate for Payer: PHP Commercial |
$838.67
|
| Rate for Payer: Priority Health SBD |
$621.60
|
| Rate for Payer: UMR Bronson Commercial |
$434.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$740.00
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$986.67
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
11338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.37 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna American Axle |
$641.34
|
| Rate for Payer: Aetna Commercial |
$838.67
|
| Rate for Payer: Aetna Medicare |
$64.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$641.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$77.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$77.36
|
| Rate for Payer: BCBS Complete |
$33.99
|
| Rate for Payer: BCBS MAPPO |
$61.89
|
| Rate for Payer: BCBS Trust/PPO |
$196.49
|
| Rate for Payer: BCN Commercial |
$196.49
|
| Rate for Payer: BCN Medicare Advantage |
$61.89
|
| Rate for Payer: Cash Price |
$789.34
|
| Rate for Payer: Cash Price |
$789.34
|
| Rate for Payer: Cofinity Advantage |
$690.67
|
| Rate for Payer: Cofinity Commercial |
$848.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$789.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$61.89
|
| Rate for Payer: Healthscope Commercial |
$888.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$690.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$740.00
|
| Rate for Payer: Mclaren Medicaid |
$61.89
|
| Rate for Payer: Mclaren Medicare |
$61.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$64.98
|
| Rate for Payer: Meridian Medicaid |
$64.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.17
|
| Rate for Payer: Molina Medicare/Medicaid |
$68.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$838.67
|
| Rate for Payer: Nomi Health Commercial |
$185.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$740.00
|
| Rate for Payer: PACE Medicare |
$58.80
|
| Rate for Payer: PACE SWMI |
$61.89
|
| Rate for Payer: PHP Commercial |
$838.67
|
| Rate for Payer: PHP Medicare Advantage |
$61.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$32.37
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$158.84
|
| Rate for Payer: Priority Health Medicare |
$61.89
|
| Rate for Payer: Priority Health SBD |
$621.60
|
| Rate for Payer: Priority Health Tiered Network |
$127.07
|
| Rate for Payer: Railroad Medicare Medicare |
$61.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.89
|
| Rate for Payer: UHC Core |
$101.89
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$61.89
|
| Rate for Payer: UHC Exchange |
$101.89
|
| Rate for Payer: UHC Medicaid |
$32.37
|
| Rate for Payer: UHCCP Medicaid |
$32.37
|
| Rate for Payer: UMR Bronson Commercial |
$365.07
|
| Rate for Payer: VA VA |
$61.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$740.00
|
|
|
SCHIZOAFFECTIVE DISORDERS
|
Facility
|
IP
|
$7,823.22
|
|
|
Service Code
|
APR-DRG 7613
|
| Min. Negotiated Rate |
$7,450.69 |
| Max. Negotiated Rate |
$7,823.22 |
| Rate for Payer: BCBS Complete |
$7,823.22
|
| Rate for Payer: Mclaren Medicaid |
$7,450.69
|
| Rate for Payer: Meridian Medicaid |
$7,823.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$7,450.69
|
| Rate for Payer: UHC Medicaid |
$7,450.69
|
| Rate for Payer: UHCCP Medicaid |
$7,450.69
|
|
|
SCHIZOAFFECTIVE DISORDERS
|
Facility
|
IP
|
$13,418.24
|
|
|
Service Code
|
APR-DRG 7614
|
| Min. Negotiated Rate |
$12,779.28 |
| Max. Negotiated Rate |
$13,418.24 |
| Rate for Payer: BCBS Complete |
$13,418.24
|
| Rate for Payer: Mclaren Medicaid |
$12,779.28
|
| Rate for Payer: Meridian Medicaid |
$13,418.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$12,779.28
|
| Rate for Payer: UHC Medicaid |
$12,779.28
|
| Rate for Payer: UHCCP Medicaid |
$12,779.28
|
|
|
SCHIZOAFFECTIVE DISORDERS
|
Facility
|
IP
|
$3,955.80
|
|
|
Service Code
|
APR-DRG 7611
|
| Min. Negotiated Rate |
$3,767.43 |
| Max. Negotiated Rate |
$3,955.80 |
| Rate for Payer: BCBS Complete |
$3,955.80
|
| Rate for Payer: Mclaren Medicaid |
$3,767.43
|
| Rate for Payer: Meridian Medicaid |
$3,955.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,767.43
|
| Rate for Payer: UHC Medicaid |
$3,767.43
|
| Rate for Payer: UHCCP Medicaid |
$3,767.43
|
|
|
SCHIZOAFFECTIVE DISORDERS
|
Facility
|
IP
|
$4,302.04
|
|
|
Service Code
|
APR-DRG 7612
|
| Min. Negotiated Rate |
$4,097.19 |
| Max. Negotiated Rate |
$4,302.04 |
| Rate for Payer: BCBS Complete |
$4,302.04
|
| Rate for Payer: Mclaren Medicaid |
$4,097.19
|
| Rate for Payer: Meridian Medicaid |
$4,302.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,097.19
|
| Rate for Payer: UHC Medicaid |
$4,097.19
|
| Rate for Payer: UHCCP Medicaid |
$4,097.19
|
|
|
SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS
|
Facility
|
IP
|
$13,903.71
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$13,241.63 |
| Max. Negotiated Rate |
$13,903.71 |
| Rate for Payer: BCBS Complete |
$13,903.71
|
| Rate for Payer: Mclaren Medicaid |
$13,241.63
|
| Rate for Payer: Meridian Medicaid |
$13,903.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,241.63
|
| Rate for Payer: UHC Medicaid |
$13,241.63
|
| Rate for Payer: UHCCP Medicaid |
$13,241.63
|
|
|
SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS
|
Facility
|
IP
|
$6,972.13
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$6,640.13 |
| Max. Negotiated Rate |
$6,972.13 |
| Rate for Payer: BCBS Complete |
$6,972.13
|
| Rate for Payer: Mclaren Medicaid |
$6,640.13
|
| Rate for Payer: Meridian Medicaid |
$6,972.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,640.13
|
| Rate for Payer: UHC Medicaid |
$6,640.13
|
| Rate for Payer: UHCCP Medicaid |
$6,640.13
|
|
|
SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS
|
Facility
|
IP
|
$5,510.88
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$5,248.46 |
| Max. Negotiated Rate |
$5,510.88 |
| Rate for Payer: BCBS Complete |
$5,510.88
|
| Rate for Payer: Mclaren Medicaid |
$5,248.46
|
| Rate for Payer: Meridian Medicaid |
$5,510.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,248.46
|
| Rate for Payer: UHC Medicaid |
$5,248.46
|
| Rate for Payer: UHCCP Medicaid |
$5,248.46
|
|
|
SCHIZOPHRENIA AND OTHER SEVERE PSYCHOTIC DISORDERS
|
Facility
|
IP
|
$4,343.81
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$4,136.96 |
| Max. Negotiated Rate |
$4,343.81 |
| Rate for Payer: BCBS Complete |
$4,343.81
|
| Rate for Payer: Mclaren Medicaid |
$4,136.96
|
| Rate for Payer: Meridian Medicaid |
$4,343.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,136.96
|
| Rate for Payer: UHC Medicaid |
$4,136.96
|
| Rate for Payer: UHCCP Medicaid |
$4,136.96
|
|
|
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT
|
Facility
|
OP
|
$13,319.06
|
|
|
Service Code
|
CPT 67255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,146.17 |
| Max. Negotiated Rate |
$13,319.06 |
| Rate for Payer: Aetna Medicare |
$4,283.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,148.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,148.20
|
| Rate for Payer: BCBS Complete |
$2,261.91
|
| Rate for Payer: BCBS MAPPO |
$4,118.56
|
| Rate for Payer: BCBS Trust/PPO |
$2,146.17
|
| Rate for Payer: BCN Commercial |
$2,146.17
|
| Rate for Payer: BCN Medicare Advantage |
$4,118.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,118.56
|
| Rate for Payer: Mclaren Medicaid |
$4,118.56
|
| Rate for Payer: Mclaren Medicare |
$4,118.56
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4,324.49
|
| Rate for Payer: Meridian Medicaid |
$4,324.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,736.34
|
| Rate for Payer: Molina Medicare/Medicaid |
$4,530.42
|
| Rate for Payer: Nomi Health Commercial |
$12,355.68
|
| Rate for Payer: PACE Medicare |
$3,912.63
|
| Rate for Payer: PACE SWMI |
$4,118.56
|
| Rate for Payer: PHP Medicare Advantage |
$4,118.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,154.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$13,319.06
|
| Rate for Payer: Priority Health Medicare |
$4,118.56
|
| Rate for Payer: Priority Health Tiered Network |
$10,655.25
|
| Rate for Payer: Railroad Medicare Medicare |
$4,118.56
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$4,118.56
|
| Rate for Payer: UHC Medicaid |
$2,154.01
|
| Rate for Payer: UHCCP Medicaid |
$2,154.01
|
| Rate for Payer: VA VA |
$4,118.56
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$438.05
|
|
|
Service Code
|
NDC 10019055303
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.74 |
| Max. Negotiated Rate |
$394.25 |
| Rate for Payer: Aetna American Axle |
$284.73
|
| Rate for Payer: Aetna Commercial |
$372.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.73
|
| Rate for Payer: Cash Price |
$350.44
|
| Rate for Payer: Cofinity Advantage |
$306.63
|
| Rate for Payer: Cofinity Commercial |
$376.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.44
|
| Rate for Payer: Healthscope Commercial |
$394.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$306.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$372.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$328.54
|
| Rate for Payer: PHP Commercial |
$372.34
|
| Rate for Payer: Priority Health SBD |
$275.97
|
| Rate for Payer: UMR Bronson Commercial |
$192.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$24.68
|
|
|
Service Code
|
NDC 50742050501
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$22.21 |
| Rate for Payer: Aetna American Axle |
$16.04
|
| Rate for Payer: Aetna Commercial |
$20.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.04
|
| Rate for Payer: Cash Price |
$19.74
|
| Rate for Payer: Cofinity Advantage |
$17.28
|
| Rate for Payer: Cofinity Commercial |
$21.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.74
|
| Rate for Payer: Healthscope Commercial |
$22.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.51
|
| Rate for Payer: PHP Commercial |
$20.98
|
| Rate for Payer: Priority Health SBD |
$15.55
|
| Rate for Payer: UMR Bronson Commercial |
$10.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.51
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
OP
|
$438.05
|
|
|
Service Code
|
NDC 10019055303
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.08 |
| Max. Negotiated Rate |
$394.25 |
| Rate for Payer: Aetna American Axle |
$284.73
|
| Rate for Payer: Aetna Commercial |
$372.34
|
| Rate for Payer: Aetna Medicare |
$219.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.73
|
| Rate for Payer: BCBS Complete |
$175.22
|
| Rate for Payer: Cash Price |
$350.44
|
| Rate for Payer: Cofinity Advantage |
$306.63
|
| Rate for Payer: Cofinity Commercial |
$376.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.44
|
| Rate for Payer: Healthscope Commercial |
$394.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$306.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$350.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$372.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$328.54
|
| Rate for Payer: PHP Commercial |
$372.34
|
| Rate for Payer: Priority Health SBD |
$275.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$284.73
|
| Rate for Payer: UHC Core |
$228.22
|
| Rate for Payer: UHC Exchange |
$172.15
|
| Rate for Payer: UMR Bronson Commercial |
$162.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
OP
|
$24.68
|
|
|
Service Code
|
NDC 50742050501
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$22.21 |
| Rate for Payer: Aetna American Axle |
$16.04
|
| Rate for Payer: Aetna Commercial |
$20.98
|
| Rate for Payer: Aetna Medicare |
$12.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.04
|
| Rate for Payer: BCBS Complete |
$9.87
|
| Rate for Payer: Cash Price |
$19.74
|
| Rate for Payer: Cofinity Advantage |
$17.28
|
| Rate for Payer: Cofinity Commercial |
$21.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.74
|
| Rate for Payer: Healthscope Commercial |
$22.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.51
|
| Rate for Payer: PHP Commercial |
$20.98
|
| Rate for Payer: Priority Health SBD |
$15.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.04
|
| Rate for Payer: UHC Core |
$12.86
|
| Rate for Payer: UHC Exchange |
$9.70
|
| Rate for Payer: UMR Bronson Commercial |
$9.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.51
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$245.68
|
|
|
Service Code
|
NDC 50742050510
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.10 |
| Max. Negotiated Rate |
$221.11 |
| Rate for Payer: Aetna American Axle |
$159.69
|
| Rate for Payer: Aetna Commercial |
$208.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.69
|
| Rate for Payer: Cash Price |
$196.54
|
| Rate for Payer: Cofinity Advantage |
$171.98
|
| Rate for Payer: Cofinity Commercial |
$211.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.54
|
| Rate for Payer: Healthscope Commercial |
$221.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$184.26
|
| Rate for Payer: PHP Commercial |
$208.83
|
| Rate for Payer: Priority Health SBD |
$154.78
|
| Rate for Payer: UMR Bronson Commercial |
$108.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.26
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
OP
|
$245.68
|
|
|
Service Code
|
NDC 50742050510
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.90 |
| Max. Negotiated Rate |
$221.11 |
| Rate for Payer: Aetna American Axle |
$159.69
|
| Rate for Payer: Aetna Commercial |
$208.83
|
| Rate for Payer: Aetna Medicare |
$122.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.69
|
| Rate for Payer: BCBS Complete |
$98.27
|
| Rate for Payer: Cash Price |
$196.54
|
| Rate for Payer: Cofinity Advantage |
$171.98
|
| Rate for Payer: Cofinity Commercial |
$211.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.54
|
| Rate for Payer: Healthscope Commercial |
$221.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$196.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$184.26
|
| Rate for Payer: PHP Commercial |
$208.83
|
| Rate for Payer: Priority Health SBD |
$154.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$159.69
|
| Rate for Payer: UHC Core |
$128.00
|
| Rate for Payer: UHC Exchange |
$96.55
|
| Rate for Payer: UMR Bronson Commercial |
$90.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.26
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
OP
|
$1,051.31
|
|
|
Service Code
|
NDC 10019055304
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$388.98 |
| Max. Negotiated Rate |
$946.18 |
| Rate for Payer: Aetna American Axle |
$683.35
|
| Rate for Payer: Aetna Commercial |
$893.61
|
| Rate for Payer: Aetna Medicare |
$525.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$683.35
|
| Rate for Payer: BCBS Complete |
$420.52
|
| Rate for Payer: Cash Price |
$841.05
|
| Rate for Payer: Cofinity Advantage |
$735.92
|
| Rate for Payer: Cofinity Commercial |
$904.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$841.05
|
| Rate for Payer: Healthscope Commercial |
$946.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$735.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$788.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$841.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$893.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$788.48
|
| Rate for Payer: PHP Commercial |
$893.61
|
| Rate for Payer: Priority Health SBD |
$662.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$683.35
|
| Rate for Payer: UHC Core |
$547.73
|
| Rate for Payer: UHC Exchange |
$413.16
|
| Rate for Payer: UMR Bronson Commercial |
$388.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$788.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
OP
|
$43.81
|
|
|
Service Code
|
NDC 10019055390
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$39.43 |
| Rate for Payer: Aetna American Axle |
$28.48
|
| Rate for Payer: Aetna Commercial |
$37.24
|
| Rate for Payer: Aetna Medicare |
$21.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.48
|
| Rate for Payer: BCBS Complete |
$17.52
|
| Rate for Payer: Cash Price |
$35.05
|
| Rate for Payer: Cofinity Advantage |
$30.67
|
| Rate for Payer: Cofinity Commercial |
$37.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.05
|
| Rate for Payer: Healthscope Commercial |
$39.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.86
|
| Rate for Payer: PHP Commercial |
$37.24
|
| Rate for Payer: Priority Health SBD |
$27.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.48
|
| Rate for Payer: UHC Core |
$22.83
|
| Rate for Payer: UHC Exchange |
$17.22
|
| Rate for Payer: UMR Bronson Commercial |
$16.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.86
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$1,051.31
|
|
|
Service Code
|
NDC 10019055304
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$462.58 |
| Max. Negotiated Rate |
$946.18 |
| Rate for Payer: Aetna American Axle |
$683.35
|
| Rate for Payer: Aetna Commercial |
$893.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$683.35
|
| Rate for Payer: Cash Price |
$841.05
|
| Rate for Payer: Cofinity Advantage |
$735.92
|
| Rate for Payer: Cofinity Commercial |
$904.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$841.05
|
| Rate for Payer: Healthscope Commercial |
$946.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$735.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$788.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$893.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$788.48
|
| Rate for Payer: PHP Commercial |
$893.61
|
| Rate for Payer: Priority Health SBD |
$662.33
|
| Rate for Payer: UMR Bronson Commercial |
$462.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$788.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
|
IP
|
$43.81
|
|
|
Service Code
|
NDC 10019055390
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$39.43 |
| Rate for Payer: Aetna American Axle |
$28.48
|
| Rate for Payer: Aetna Commercial |
$37.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.48
|
| Rate for Payer: Cash Price |
$35.05
|
| Rate for Payer: Cofinity Advantage |
$30.67
|
| Rate for Payer: Cofinity Commercial |
$37.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.05
|
| Rate for Payer: Healthscope Commercial |
$39.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.86
|
| Rate for Payer: PHP Commercial |
$37.24
|
| Rate for Payer: Priority Health SBD |
$27.60
|
| Rate for Payer: UMR Bronson Commercial |
$19.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.86
|
|
|
SCREENING OF A PATIENT
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS D0190
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.02 |
| Rate for Payer: Aetna Commercial |
$13.35
|
| Rate for Payer: Aetna Medicare |
$7.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.35
|
| Rate for Payer: BCBS Complete |
$20.16
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Meridian Medicaid |
$20.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.02
|
| Rate for Payer: UHC Core |
$22.02
|
| Rate for Payer: UHC Exchange |
$22.02
|
| Rate for Payer: UHC Medicaid |
$19.20
|
| Rate for Payer: UHCCP Medicaid |
$19.20
|
| Rate for Payer: UMR Bronson Commercial |
$6.90
|
|
|
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED
|
Facility
|
OP
|
$11,418.88
|
|
|
Service Code
|
CPT 13160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,846.70 |
| Max. Negotiated Rate |
$11,418.88 |
| Rate for Payer: Aetna Medicare |
$3,672.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,413.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,413.73
|
| Rate for Payer: BCBS Complete |
$1,939.21
|
| Rate for Payer: BCBS MAPPO |
$3,530.98
|
| Rate for Payer: BCBS Trust/PPO |
$4,472.96
|
| Rate for Payer: BCN Commercial |
$4,472.96
|
| Rate for Payer: BCN Medicare Advantage |
$3,530.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,530.98
|
| Rate for Payer: Mclaren Medicaid |
$3,530.98
|
| Rate for Payer: Mclaren Medicare |
$3,530.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,707.53
|
| Rate for Payer: Meridian Medicaid |
$3,707.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,060.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,884.08
|
| Rate for Payer: Nomi Health Commercial |
$10,592.94
|
| Rate for Payer: PACE Medicare |
$3,354.43
|
| Rate for Payer: PACE SWMI |
$3,530.98
|
| Rate for Payer: PHP Medicare Advantage |
$3,530.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,846.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,418.88
|
| Rate for Payer: Priority Health Medicare |
$3,530.98
|
| Rate for Payer: Priority Health Tiered Network |
$9,135.10
|
| Rate for Payer: Railroad Medicare Medicare |
$3,530.98
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,530.98
|
| Rate for Payer: UHC Medicaid |
$1,846.70
|
| Rate for Payer: UHCCP Medicaid |
$1,846.70
|
| Rate for Payer: VA VA |
$3,530.98
|
|
