|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$205.20
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.92 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna American Axle |
$133.38
|
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.38
|
| Rate for Payer: BCBS Complete |
$82.08
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Commercial |
$143.64
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.38
|
| Rate for Payer: Priority Health SBD |
$129.28
|
| Rate for Payer: UMR Bronson Commercial |
$75.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$595.65
|
|
|
Service Code
|
NDC 59762010406
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.39 |
| Max. Negotiated Rate |
$536.09 |
| Rate for Payer: Aetna American Axle |
$387.17
|
| Rate for Payer: Aetna Commercial |
$506.30
|
| Rate for Payer: Aetna Medicare |
$297.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.17
|
| Rate for Payer: BCBS Complete |
$238.26
|
| Rate for Payer: Cash Price |
$476.52
|
| Rate for Payer: Cofinity Commercial |
$416.95
|
| Rate for Payer: Cofinity Commercial |
$512.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.52
|
| Rate for Payer: Healthscope Commercial |
$536.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.30
|
| Rate for Payer: PHP Commercial |
$506.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$387.17
|
| Rate for Payer: Priority Health SBD |
$375.26
|
| Rate for Payer: UMR Bronson Commercial |
$220.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.74
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$595.65
|
|
|
Service Code
|
NDC 59762010406
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.09 |
| Max. Negotiated Rate |
$536.09 |
| Rate for Payer: Aetna American Axle |
$387.17
|
| Rate for Payer: Aetna Commercial |
$506.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.17
|
| Rate for Payer: Cash Price |
$476.52
|
| Rate for Payer: Cofinity Commercial |
$416.95
|
| Rate for Payer: Cofinity Commercial |
$512.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.52
|
| Rate for Payer: Healthscope Commercial |
$536.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.30
|
| Rate for Payer: PHP Commercial |
$506.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$387.17
|
| Rate for Payer: Priority Health SBD |
$375.26
|
| Rate for Payer: UMR Bronson Commercial |
$262.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.74
|
|
|
SULINDAC 200 MG TABLET
|
Facility
|
IP
|
$269.80
|
|
|
Service Code
|
NDC 42806001101
|
| Hospital Charge Code |
7579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.71 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$188.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.33
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.37
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$118.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
SULINDAC 200 MG TABLET
|
Facility
|
OP
|
$269.80
|
|
|
Service Code
|
NDC 42806001101
|
| Hospital Charge Code |
7579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.83 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna Medicare |
$134.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: BCBS Complete |
$107.92
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$188.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.33
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.37
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$99.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$318.64
|
|
|
Service Code
|
NDC 00173052300
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.20 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.12
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$140.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
OP
|
$318.64
|
|
|
Service Code
|
NDC 00173052300
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.90 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna Medicare |
$159.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.12
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$117.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
OP
|
$95.17
|
|
|
Service Code
|
NDC 09900000878
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.21 |
| Max. Negotiated Rate |
$85.65 |
| Rate for Payer: Aetna American Axle |
$61.86
|
| Rate for Payer: Aetna Commercial |
$80.89
|
| Rate for Payer: Aetna Medicare |
$47.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.86
|
| Rate for Payer: BCBS Complete |
$38.07
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$66.62
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$85.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.89
|
| Rate for Payer: PHP Commercial |
$80.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.86
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UMR Bronson Commercial |
$35.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.38
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
IP
|
$1,065.01
|
|
|
Service Code
|
NDC 00173073500
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$468.60 |
| Max. Negotiated Rate |
$958.51 |
| Rate for Payer: Aetna American Axle |
$692.26
|
| Rate for Payer: Aetna Commercial |
$905.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$692.26
|
| Rate for Payer: Cash Price |
$852.01
|
| Rate for Payer: Cofinity Commercial |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$745.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$852.01
|
| Rate for Payer: Healthscope Commercial |
$958.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$745.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$798.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$905.26
|
| Rate for Payer: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$692.26
|
| Rate for Payer: Priority Health SBD |
$670.96
|
| Rate for Payer: UMR Bronson Commercial |
$468.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$798.76
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
IP
|
$95.17
|
|
|
Service Code
|
NDC 09900000878
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.87 |
| Max. Negotiated Rate |
$85.65 |
| Rate for Payer: Aetna American Axle |
$61.86
|
| Rate for Payer: Aetna Commercial |
$80.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.86
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$66.62
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$85.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.89
|
| Rate for Payer: PHP Commercial |
$80.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.86
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UMR Bronson Commercial |
$41.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.38
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
OP
|
$1,065.01
|
|
|
Service Code
|
NDC 00173073500
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$394.05 |
| Max. Negotiated Rate |
$958.51 |
| Rate for Payer: Aetna American Axle |
$692.26
|
| Rate for Payer: Aetna Commercial |
$905.26
|
| Rate for Payer: Aetna Medicare |
$532.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$692.26
|
| Rate for Payer: BCBS Complete |
$426.00
|
| Rate for Payer: Cash Price |
$852.01
|
| Rate for Payer: Cofinity Commercial |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$745.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$852.01
|
| Rate for Payer: Healthscope Commercial |
$958.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$745.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$798.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$905.26
|
| Rate for Payer: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$692.26
|
| Rate for Payer: Priority Health SBD |
$670.96
|
| Rate for Payer: UMR Bronson Commercial |
$394.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$798.76
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$2,321.48
|
|
|
Service Code
|
NDC 00173073601
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$858.95 |
| Max. Negotiated Rate |
$2,089.33 |
| Rate for Payer: Aetna American Axle |
$1,508.96
|
| Rate for Payer: Aetna Commercial |
$1,973.26
|
| Rate for Payer: Aetna Medicare |
$1,160.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,508.96
|
| Rate for Payer: BCBS Complete |
$928.59
|
| Rate for Payer: Cash Price |
$1,857.18
|
| Rate for Payer: Cofinity Commercial |
$1,625.04
|
| Rate for Payer: Cofinity Commercial |
$1,996.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,625.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,857.18
|
| Rate for Payer: Healthscope Commercial |
$2,089.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,625.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,741.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,973.26
|
| Rate for Payer: PHP Commercial |
$1,973.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,508.96
|
| Rate for Payer: Priority Health SBD |
$1,462.53
|
| Rate for Payer: UMR Bronson Commercial |
$858.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,741.11
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$2,321.48
|
|
|
Service Code
|
NDC 00173073601
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,021.45 |
| Max. Negotiated Rate |
$2,089.33 |
| Rate for Payer: Aetna American Axle |
$1,508.96
|
| Rate for Payer: Aetna Commercial |
$1,973.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,508.96
|
| Rate for Payer: Cash Price |
$1,857.18
|
| Rate for Payer: Cofinity Commercial |
$1,625.04
|
| Rate for Payer: Cofinity Commercial |
$1,996.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,625.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,857.18
|
| Rate for Payer: Healthscope Commercial |
$2,089.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,625.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,741.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,973.26
|
| Rate for Payer: PHP Commercial |
$1,973.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,508.96
|
| Rate for Payer: Priority Health SBD |
$1,462.53
|
| Rate for Payer: UMR Bronson Commercial |
$1,021.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,741.11
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 09900000877
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$284.78
|
|
|
Service Code
|
NDC 55111029236
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$256.30 |
| Rate for Payer: Aetna American Axle |
$185.11
|
| Rate for Payer: Aetna Commercial |
$242.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.11
|
| Rate for Payer: Cash Price |
$227.82
|
| Rate for Payer: Cofinity Commercial |
$199.35
|
| Rate for Payer: Cofinity Commercial |
$244.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.82
|
| Rate for Payer: Healthscope Commercial |
$256.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.06
|
| Rate for Payer: PHP Commercial |
$242.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.11
|
| Rate for Payer: Priority Health SBD |
$179.41
|
| Rate for Payer: UMR Bronson Commercial |
$125.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.59
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 09900000877
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.17
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$0.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$284.78
|
|
|
Service Code
|
NDC 55111029236
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.37 |
| Max. Negotiated Rate |
$256.30 |
| Rate for Payer: Aetna American Axle |
$185.11
|
| Rate for Payer: Aetna Commercial |
$242.06
|
| Rate for Payer: Aetna Medicare |
$142.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.11
|
| Rate for Payer: BCBS Complete |
$113.91
|
| Rate for Payer: Cash Price |
$227.82
|
| Rate for Payer: Cofinity Commercial |
$199.35
|
| Rate for Payer: Cofinity Commercial |
$244.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.82
|
| Rate for Payer: Healthscope Commercial |
$256.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.06
|
| Rate for Payer: PHP Commercial |
$242.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.11
|
| Rate for Payer: Priority Health SBD |
$179.41
|
| Rate for Payer: UMR Bronson Commercial |
$105.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.59
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
OP
|
$95.05
|
|
|
Service Code
|
NDC 66993008169
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.17 |
| Max. Negotiated Rate |
$85.55 |
| Rate for Payer: Aetna American Axle |
$61.78
|
| Rate for Payer: Aetna Commercial |
$80.79
|
| Rate for Payer: Aetna Medicare |
$47.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.78
|
| Rate for Payer: BCBS Complete |
$38.02
|
| Rate for Payer: Cash Price |
$76.04
|
| Rate for Payer: Cofinity Commercial |
$66.53
|
| Rate for Payer: Cofinity Commercial |
$81.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.04
|
| Rate for Payer: Healthscope Commercial |
$85.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.79
|
| Rate for Payer: PHP Commercial |
$80.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.78
|
| Rate for Payer: Priority Health SBD |
$59.88
|
| Rate for Payer: UMR Bronson Commercial |
$35.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.29
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$318.64
|
|
|
Service Code
|
NDC 00173052400
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.20 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.12
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$140.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
OP
|
$318.64
|
|
|
Service Code
|
NDC 00173052400
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.90 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna Medicare |
$159.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.12
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$117.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$95.05
|
|
|
Service Code
|
NDC 66993008169
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.82 |
| Max. Negotiated Rate |
$85.55 |
| Rate for Payer: Aetna American Axle |
$61.78
|
| Rate for Payer: Aetna Commercial |
$80.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.78
|
| Rate for Payer: Cash Price |
$76.04
|
| Rate for Payer: Cofinity Commercial |
$66.53
|
| Rate for Payer: Cofinity Commercial |
$81.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.04
|
| Rate for Payer: Healthscope Commercial |
$85.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.79
|
| Rate for Payer: PHP Commercial |
$80.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.78
|
| Rate for Payer: Priority Health SBD |
$59.88
|
| Rate for Payer: UMR Bronson Commercial |
$41.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.29
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna American Axle |
$17.15
|
| Rate for Payer: Aetna American Axle |
$17.67
|
| Rate for Payer: Aetna American Axle |
$13.46
|
| Rate for Payer: Aetna American Axle |
$16.17
|
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$21.15
|
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$13.19
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna Medicare |
$13.60
|
| Rate for Payer: Aetna Medicare |
$12.44
|
| Rate for Payer: Aetna Medicare |
$10.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.15
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: BCBS Complete |
$10.55
|
| Rate for Payer: BCBS Complete |
$9.95
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$21.40
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$18.47
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$21.15
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: Priority Health SBD |
$16.62
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: UMR Bronson Commercial |
$10.06
|
| Rate for Payer: UMR Bronson Commercial |
$9.76
|
| Rate for Payer: UMR Bronson Commercial |
$9.19
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: UMR Bronson Commercial |
$9.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.66
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$26.38
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.61 |
| Max. Negotiated Rate |
$23.74 |
| Rate for Payer: Aetna American Axle |
$17.15
|
| Rate for Payer: Aetna American Axle |
$13.46
|
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna American Axle |
$17.67
|
| Rate for Payer: Aetna American Axle |
$16.17
|
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$21.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Cofinity Commercial |
$18.47
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$21.40
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$21.15
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$16.62
|
| Rate for Payer: UMR Bronson Commercial |
$9.11
|
| Rate for Payer: UMR Bronson Commercial |
$10.93
|
| Rate for Payer: UMR Bronson Commercial |
$11.61
|
| Rate for Payer: UMR Bronson Commercial |
$11.96
|
| Rate for Payer: UMR Bronson Commercial |
$10.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.79
|
|
|
SUPRAHYOID LYMPHADENECTOMY
|
Facility
|
OP
|
$17,903.47
|
|
|
Service Code
|
CPT 38700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,409.09 |
| Max. Negotiated Rate |
$17,903.47 |
| Rate for Payer: Aetna Medicare |
$6,614.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,950.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,950.31
|
| Rate for Payer: BCBS Complete |
$3,579.55
|
| Rate for Payer: BCBS MAPPO |
$6,360.25
|
| Rate for Payer: BCN Medicare Advantage |
$6,360.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,360.25
|
| Rate for Payer: Mclaren Medicaid |
$3,409.09
|
| Rate for Payer: Mclaren Medicare |
$6,360.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,678.26
|
| Rate for Payer: Meridian Medicaid |
$3,579.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,314.29
|
| Rate for Payer: PACE Medicare |
$6,042.24
|
| Rate for Payer: PACE SWMI |
$6,360.25
|
| Rate for Payer: PHP Medicare Advantage |
$6,360.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,409.09
|
| Rate for Payer: Priority Health Medicare |
$6,360.25
|
| Rate for Payer: Railroad Medicare Medicare |
$6,360.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,903.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,360.25
|
| Rate for Payer: UHC Exchange |
$12,155.07
|
| Rate for Payer: UHC Medicare Advantage |
$6,360.25
|
| Rate for Payer: UHCCP Medicaid |
$3,409.09
|
| Rate for Payer: VA VA |
$6,360.25
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$1,680.50
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$319.99 |
| Max. Negotiated Rate |
$1,680.50 |
| Rate for Payer: Aetna Medicare |
$620.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$746.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$746.25
|
| Rate for Payer: BCBS Complete |
$335.99
|
| Rate for Payer: BCBS MAPPO |
$597.00
|
| Rate for Payer: BCN Medicare Advantage |
$597.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$597.00
|
| Rate for Payer: Mclaren Medicaid |
$319.99
|
| Rate for Payer: Mclaren Medicare |
$597.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$626.85
|
| Rate for Payer: Meridian Medicaid |
$335.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$686.55
|
| Rate for Payer: PACE Medicare |
$567.15
|
| Rate for Payer: PACE SWMI |
$597.00
|
| Rate for Payer: PHP Medicare Advantage |
$597.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$319.99
|
| Rate for Payer: Priority Health Medicare |
$597.00
|
| Rate for Payer: Railroad Medicare Medicare |
$597.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,680.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$597.00
|
| Rate for Payer: UHC Exchange |
$1,140.93
|
| Rate for Payer: UHC Medicare Advantage |
$597.00
|
| Rate for Payer: UHCCP Medicaid |
$319.99
|
| Rate for Payer: VA VA |
$597.00
|
|
