|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
|
IP
|
$24.97
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.99 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna American Axle |
$16.23
|
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.23
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Commercial |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.23
|
| Rate for Payer: Priority Health SBD |
$15.73
|
| Rate for Payer: UMR Bronson Commercial |
$10.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.73
|
|
|
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 Commercial |
$1,185.40
|
| Rate for Payer: Cofinity Commercial |
$964.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$964.86
|
| 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: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$895.94
|
| 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 Commercial |
$1,185.40
|
| Rate for Payer: Cofinity Commercial |
$964.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$964.86
|
| 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: PHP Commercial |
$1,171.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$895.94
|
| Rate for Payer: Priority Health SBD |
$868.37
|
| Rate for Payer: UMR Bronson Commercial |
$510.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,033.78
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 69367016004
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.71
|
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.71
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.71
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$169.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.27
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
OP
|
$265.05
|
|
|
Service Code
|
NDC 65162051210
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.07 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna American Axle |
$172.28
|
| Rate for Payer: Aetna Commercial |
$225.29
|
| Rate for Payer: Aetna Medicare |
$132.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.28
|
| Rate for Payer: BCBS Complete |
$106.02
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cofinity Commercial |
$185.53
|
| Rate for Payer: Cofinity Commercial |
$227.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$185.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.04
|
| Rate for Payer: Healthscope Commercial |
$238.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.29
|
| Rate for Payer: PHP Commercial |
$225.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.28
|
| Rate for Payer: Priority Health SBD |
$166.98
|
| Rate for Payer: UMR Bronson Commercial |
$98.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.79
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
OP
|
$385.70
|
|
|
Service Code
|
NDC 69367016004
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.71
|
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: Aetna Medicare |
$192.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.71
|
| Rate for Payer: BCBS Complete |
$154.28
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.71
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$142.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.27
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
OP
|
$444.60
|
|
|
Service Code
|
NDC 13273020903
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.50 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna American Axle |
$288.99
|
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna Medicare |
$222.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: BCBS Complete |
$177.84
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$311.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.99
|
| Rate for Payer: Priority Health SBD |
$280.10
|
| Rate for Payer: UMR Bronson Commercial |
$164.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.45
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$444.60
|
|
|
Service Code
|
NDC 13273020903
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.62 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna American Axle |
$288.99
|
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$311.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.99
|
| Rate for Payer: Priority Health SBD |
$280.10
|
| Rate for Payer: UMR Bronson Commercial |
$195.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.45
|
|
|
SALSALATE 500 MG TABLET
|
Facility
|
IP
|
$265.05
|
|
|
Service Code
|
NDC 65162051210
|
| Hospital Charge Code |
7034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna American Axle |
$172.28
|
| Rate for Payer: Aetna Commercial |
$225.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.28
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cofinity Commercial |
$185.53
|
| Rate for Payer: Cofinity Commercial |
$227.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$185.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.04
|
| Rate for Payer: Healthscope Commercial |
$238.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.29
|
| Rate for Payer: PHP Commercial |
$225.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.28
|
| Rate for Payer: Priority Health SBD |
$166.98
|
| Rate for Payer: UMR Bronson Commercial |
$116.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.79
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
IP
|
$291.84
|
|
|
Service Code
|
NDC 13273021003
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.41 |
| Max. Negotiated Rate |
$262.66 |
| Rate for Payer: Aetna American Axle |
$189.70
|
| Rate for Payer: Aetna Commercial |
$248.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: Cash Price |
$233.47
|
| Rate for Payer: Cofinity Commercial |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$250.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.47
|
| Rate for Payer: Healthscope Commercial |
$262.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: PHP Commercial |
$248.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.70
|
| Rate for Payer: Priority Health SBD |
$183.86
|
| Rate for Payer: UMR Bronson Commercial |
$128.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.88
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
OP
|
$291.84
|
|
|
Service Code
|
NDC 13273021003
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.98 |
| Max. Negotiated Rate |
$262.66 |
| Rate for Payer: Aetna American Axle |
$189.70
|
| Rate for Payer: Aetna Commercial |
$248.06
|
| Rate for Payer: Aetna Medicare |
$145.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.70
|
| Rate for Payer: BCBS Complete |
$116.74
|
| Rate for Payer: Cash Price |
$233.47
|
| Rate for Payer: Cofinity Commercial |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$250.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.47
|
| Rate for Payer: Healthscope Commercial |
$262.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: PHP Commercial |
$248.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.70
|
| Rate for Payer: Priority Health SBD |
$183.86
|
| Rate for Payer: UMR Bronson Commercial |
$107.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.88
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
IP
|
$379.05
|
|
|
Service Code
|
NDC 69367016104
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.78 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$265.33
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$265.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.19
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.38
|
| Rate for Payer: Priority Health SBD |
$238.80
|
| Rate for Payer: UMR Bronson Commercial |
$166.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
SALSALATE 750 MG TABLET
|
Facility
|
OP
|
$379.05
|
|
|
Service Code
|
NDC 69367016104
|
| Hospital Charge Code |
7035
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.25 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna Medicare |
$189.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: BCBS Complete |
$151.62
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$265.33
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$265.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.19
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.38
|
| Rate for Payer: Priority Health SBD |
$238.80
|
| Rate for Payer: UMR Bronson Commercial |
$140.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$967.33
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
11338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$870.60 |
| Rate for Payer: Aetna American Axle |
$628.76
|
| Rate for Payer: Aetna Commercial |
$822.23
|
| Rate for Payer: Aetna Medicare |
$52.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$628.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.96
|
| Rate for Payer: BCBS Complete |
$28.35
|
| Rate for Payer: BCBS MAPPO |
$50.37
|
| Rate for Payer: BCN Medicare Advantage |
$50.37
|
| Rate for Payer: Cash Price |
$773.86
|
| Rate for Payer: Cash Price |
$773.86
|
| Rate for Payer: Cofinity Commercial |
$831.90
|
| Rate for Payer: Cofinity Commercial |
$677.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$677.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$773.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$50.37
|
| Rate for Payer: Healthscope Commercial |
$870.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$677.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$725.50
|
| Rate for Payer: Mclaren Medicaid |
$27.00
|
| Rate for Payer: Mclaren Medicare |
$50.37
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.89
|
| Rate for Payer: Meridian Medicaid |
$28.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$822.23
|
| Rate for Payer: PACE Medicare |
$47.85
|
| Rate for Payer: PACE SWMI |
$50.37
|
| Rate for Payer: PHP Commercial |
$822.23
|
| Rate for Payer: PHP Medicare Advantage |
$50.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$27.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$628.76
|
| Rate for Payer: Priority Health Medicare |
$50.37
|
| Rate for Payer: Priority Health SBD |
$609.42
|
| Rate for Payer: Railroad Medicare Medicare |
$50.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$141.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$50.37
|
| Rate for Payer: UHC Exchange |
$96.26
|
| Rate for Payer: UHC Medicare Advantage |
$50.37
|
| Rate for Payer: UHCCP Medicaid |
$27.00
|
| Rate for Payer: UMR Bronson Commercial |
$357.91
|
| Rate for Payer: VA VA |
$50.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$725.50
|
|
|
SARGRAMOSTIM 250 MCG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$967.33
|
|
|
Service Code
|
HCPCS J2820
|
| Hospital Charge Code |
11338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$425.63 |
| Max. Negotiated Rate |
$870.60 |
| Rate for Payer: Aetna American Axle |
$628.76
|
| Rate for Payer: Aetna Commercial |
$822.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$628.76
|
| Rate for Payer: Cash Price |
$773.86
|
| Rate for Payer: Cofinity Commercial |
$677.13
|
| Rate for Payer: Cofinity Commercial |
$831.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$677.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$773.86
|
| Rate for Payer: Healthscope Commercial |
$870.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$677.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$725.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$822.23
|
| Rate for Payer: PHP Commercial |
$822.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$628.76
|
| Rate for Payer: Priority Health SBD |
$609.42
|
| Rate for Payer: UMR Bronson Commercial |
$425.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$725.50
|
|
|
SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT
|
Facility
|
OP
|
$11,044.01
|
|
|
Service Code
|
CPT 67255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,102.95 |
| Max. Negotiated Rate |
$11,044.01 |
| Rate for Payer: Aetna Medicare |
$4,080.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,904.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,904.26
|
| Rate for Payer: BCBS Complete |
$2,208.10
|
| Rate for Payer: BCBS MAPPO |
$3,923.41
|
| Rate for Payer: BCN Medicare Advantage |
$3,923.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,923.41
|
| Rate for Payer: Mclaren Medicaid |
$2,102.95
|
| Rate for Payer: Mclaren Medicare |
$3,923.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4,119.58
|
| Rate for Payer: Meridian Medicaid |
$2,208.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,511.92
|
| Rate for Payer: PACE Medicare |
$3,727.24
|
| Rate for Payer: PACE SWMI |
$3,923.41
|
| Rate for Payer: PHP Medicare Advantage |
$3,923.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,102.95
|
| Rate for Payer: Priority Health Medicare |
$3,923.41
|
| Rate for Payer: Railroad Medicare Medicare |
$3,923.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,044.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,923.41
|
| Rate for Payer: UHC Exchange |
$7,498.03
|
| Rate for Payer: UHC Medicare Advantage |
$3,923.41
|
| Rate for Payer: UHCCP Medicaid |
$2,102.95
|
| Rate for Payer: VA VA |
$3,923.41
|
|
|
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 Commercial |
$30.67
|
| Rate for Payer: Cofinity Commercial |
$37.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.67
|
| 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: PHP Commercial |
$37.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.48
|
| Rate for Payer: Priority Health SBD |
$27.60
|
| 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
|
$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 Commercial |
$30.67
|
| Rate for Payer: Cofinity Commercial |
$37.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.67
|
| 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: PHP Commercial |
$37.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.48
|
| 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
|
|
|
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 Commercial |
$306.63
|
| Rate for Payer: Cofinity Commercial |
$376.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$306.63
|
| 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: PHP Commercial |
$372.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.73
|
| Rate for Payer: Priority Health SBD |
$275.97
|
| 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
|
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 Commercial |
$306.63
|
| Rate for Payer: Cofinity Commercial |
$376.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$306.63
|
| 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: PHP Commercial |
$372.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.73
|
| 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
|
$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 Commercial |
$735.92
|
| Rate for Payer: Cofinity Commercial |
$904.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$735.92
|
| 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: PHP Commercial |
$893.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$683.35
|
| 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
|
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 Commercial |
$735.92
|
| Rate for Payer: Cofinity Commercial |
$904.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$735.92
|
| 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: PHP Commercial |
$893.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$683.35
|
| Rate for Payer: Priority Health SBD |
$662.33
|
| Rate for Payer: UMR Bronson Commercial |
$388.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$788.48
|
|
|
SCREENING OF A PATIENT
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS D0190
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Aetna Medicare |
$7.50
|
| Rate for Payer: BCBS Complete |
$6.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.75
|
| Rate for Payer: UMR Bronson Commercial |
$6.90
|
|
|
SCROTAL EXPLORATION
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 55110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.95 |
| Max. Negotiated Rate |
$9,468.51 |
| Rate for Payer: Aetna Medicare |
$3,498.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,204.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,204.64
|
| Rate for Payer: BCBS Complete |
$1,893.10
|
| Rate for Payer: BCBS MAPPO |
$3,363.71
|
| Rate for Payer: BCN Medicare Advantage |
$3,363.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,363.71
|
| Rate for Payer: Mclaren Medicaid |
$1,802.95
|
| Rate for Payer: Mclaren Medicare |
$3,363.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,531.90
|
| Rate for Payer: Meridian Medicaid |
$1,893.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,868.27
|
| Rate for Payer: PACE Medicare |
$3,195.52
|
| Rate for Payer: PACE SWMI |
$3,363.71
|
| Rate for Payer: PHP Medicare Advantage |
$3,363.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,802.95
|
| Rate for Payer: Priority Health Medicare |
$3,363.71
|
| Rate for Payer: Railroad Medicare Medicare |
$3,363.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,468.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,363.71
|
| Rate for Payer: UHC Exchange |
$6,428.39
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,802.95
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT 13160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Exchange |
$3,409.42
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$956.23
|
| Rate for Payer: VA VA |
$1,784.01
|
|
