|
SPIRONOLACTONE 25 MG TABLET
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
7437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.08 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna American Axle |
$183.30
|
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.30
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.70
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.30
|
| Rate for Payer: Priority Health SBD |
$177.66
|
| Rate for Payer: UMR Bronson Commercial |
$124.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
|
SPIRONOLACTONE 25 MG TABLET
|
Facility
|
IP
|
$387.75
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
7437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.61 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna American Axle |
$252.04
|
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.04
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Commercial |
$271.42
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$271.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.20
|
| Rate for Payer: Healthscope Commercial |
$348.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$271.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.59
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.04
|
| Rate for Payer: Priority Health SBD |
$244.28
|
| Rate for Payer: UMR Bronson Commercial |
$170.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
SPIRONOLACTONE 25 MG TABLET
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
7437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.34 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna American Axle |
$183.30
|
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: Aetna Medicare |
$141.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.30
|
| Rate for Payer: BCBS Complete |
$112.80
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.70
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.30
|
| Rate for Payer: Priority Health SBD |
$177.66
|
| Rate for Payer: UMR Bronson Commercial |
$104.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$1,242.87
|
|
|
Service Code
|
CPT 15121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$126.19 |
| Max. Negotiated Rate |
$1,242.87 |
| Rate for Payer: BCBS Trust/PPO |
$1,242.87
|
| Rate for Payer: BCN Commercial |
$1,242.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.81
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$126.19
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$662.28 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$4,798.54
|
| Rate for Payer: BCN Commercial |
$4,798.54
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$728.51
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$662.28
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$1,426.72
|
|
|
Service Code
|
CPT 15101
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$106.71 |
| Max. Negotiated Rate |
$1,426.72 |
| Rate for Payer: BCBS Trust/PPO |
$1,426.72
|
| Rate for Payer: BCN Commercial |
$1,426.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$117.38
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$106.71
|
|
|
SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$687.05 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$3,939.90
|
| Rate for Payer: BCN Commercial |
$3,939.90
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$755.76
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$687.05
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS
|
Facility
|
OP
|
$9,692.51
|
|
|
Service Code
|
CPT 37765
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,652.95 |
| Max. Negotiated Rate |
$9,692.51 |
| Rate for Payer: Aetna Medicare |
$3,207.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,854.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,854.82
|
| Rate for Payer: BCBS Complete |
$1,735.60
|
| Rate for Payer: BCBS MAPPO |
$3,083.86
|
| Rate for Payer: BCBS Trust/PPO |
$3,341.21
|
| Rate for Payer: BCN Commercial |
$3,341.21
|
| Rate for Payer: BCN Medicare Advantage |
$3,083.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,083.86
|
| Rate for Payer: Mclaren Medicaid |
$1,652.95
|
| Rate for Payer: Mclaren Medicare |
$3,083.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,238.05
|
| Rate for Payer: Meridian Medicaid |
$1,735.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,546.44
|
| Rate for Payer: Nomi Health Commercial |
$6,476.11
|
| Rate for Payer: PACE Medicare |
$2,929.67
|
| Rate for Payer: PACE SWMI |
$3,083.86
|
| Rate for Payer: PHP Medicare Advantage |
$3,083.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,652.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,692.51
|
| Rate for Payer: Priority Health Medicare |
$3,083.86
|
| Rate for Payer: Priority Health Narrow Network |
$7,754.01
|
| Rate for Payer: Railroad Medicare Medicare |
$3,083.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,680.76
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,083.86
|
| Rate for Payer: UHC Exchange |
$5,893.56
|
| Rate for Payer: UHC Medicare Advantage |
$3,083.86
|
| Rate for Payer: UHCCP Medicaid |
$1,652.95
|
| Rate for Payer: VA VA |
$3,083.86
|
|
|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS
|
Facility
|
OP
|
$9,692.51
|
|
|
Service Code
|
CPT 37766
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$320.80 |
| Max. Negotiated Rate |
$9,692.51 |
| Rate for Payer: Aetna Medicare |
$3,207.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,854.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,854.82
|
| Rate for Payer: BCBS Complete |
$1,735.60
|
| Rate for Payer: BCBS MAPPO |
$3,083.86
|
| Rate for Payer: BCBS Trust/PPO |
$500.97
|
| Rate for Payer: BCN Commercial |
$500.97
|
| Rate for Payer: BCN Medicare Advantage |
$3,083.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,083.86
|
| Rate for Payer: Mclaren Medicaid |
$1,652.95
|
| Rate for Payer: Mclaren Medicare |
$3,083.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,238.05
|
| Rate for Payer: Meridian Medicaid |
$1,735.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,546.44
|
| Rate for Payer: Nomi Health Commercial |
$6,476.11
|
| Rate for Payer: PACE Medicare |
$2,929.67
|
| Rate for Payer: PACE SWMI |
$3,083.86
|
| Rate for Payer: PHP Medicare Advantage |
$3,083.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,652.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,692.51
|
| Rate for Payer: Priority Health Medicare |
$3,083.86
|
| Rate for Payer: Priority Health Narrow Network |
$7,754.01
|
| Rate for Payer: Railroad Medicare Medicare |
$3,083.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.88
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,083.86
|
| Rate for Payer: UHC Exchange |
$320.80
|
| Rate for Payer: UHC Medicare Advantage |
$3,083.86
|
| Rate for Payer: UHCCP Medicaid |
$1,652.95
|
| Rate for Payer: VA VA |
$3,083.86
|
|
|
STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL;
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 69660
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$881.82 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$6,030.15
|
| Rate for Payer: BCN Commercial |
$6,030.15
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$970.00
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$881.82
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,106.68
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
STAVUDINE 30 MG CAPSULE
|
Facility
|
OP
|
$458.50
|
|
|
Service Code
|
NDC 65862004660
|
| Hospital Charge Code |
13310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.64 |
| Max. Negotiated Rate |
$412.65 |
| Rate for Payer: Aetna American Axle |
$298.02
|
| Rate for Payer: Aetna Commercial |
$389.72
|
| Rate for Payer: Aetna Medicare |
$229.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.02
|
| Rate for Payer: BCBS Complete |
$183.40
|
| Rate for Payer: Cash Price |
$366.80
|
| Rate for Payer: Cofinity Commercial |
$320.95
|
| Rate for Payer: Cofinity Commercial |
$394.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$320.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.80
|
| Rate for Payer: Healthscope Commercial |
$412.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$320.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$343.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.72
|
| Rate for Payer: PHP Commercial |
$389.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.02
|
| Rate for Payer: Priority Health SBD |
$288.86
|
| Rate for Payer: UMR Bronson Commercial |
$169.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$343.88
|
|
|
STAVUDINE 30 MG CAPSULE
|
Facility
|
IP
|
$458.50
|
|
|
Service Code
|
NDC 65862004660
|
| Hospital Charge Code |
13310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.74 |
| Max. Negotiated Rate |
$412.65 |
| Rate for Payer: Aetna American Axle |
$298.02
|
| Rate for Payer: Aetna Commercial |
$389.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.02
|
| Rate for Payer: Cash Price |
$366.80
|
| Rate for Payer: Cofinity Commercial |
$320.95
|
| Rate for Payer: Cofinity Commercial |
$394.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$320.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.80
|
| Rate for Payer: Healthscope Commercial |
$412.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$320.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$343.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.72
|
| Rate for Payer: PHP Commercial |
$389.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.02
|
| Rate for Payer: Priority Health SBD |
$288.86
|
| Rate for Payer: UMR Bronson Commercial |
$201.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$343.88
|
|
|
STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING BURR HOLE(S), FOR INTRACRANIAL LESION;
|
Facility
|
OP
|
$5,220.68
|
|
|
Service Code
|
CPT 61750
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,409.55 |
| Max. Negotiated Rate |
$5,220.68 |
| Rate for Payer: BCBS Trust/PPO |
$5,220.68
|
| Rate for Payer: BCN Commercial |
$5,220.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,550.50
|
| Rate for Payer: UHC Core |
$1,879.00
|
| Rate for Payer: UHC Exchange |
$1,409.55
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 61782
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$166.33 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$640.60
|
| Rate for Payer: BCN Commercial |
$640.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$182.96
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$166.33
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, INTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$879.39
|
|
|
Service Code
|
CPT 61781
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$235.34 |
| Max. Negotiated Rate |
$879.39 |
| Rate for Payer: BCBS Trust/PPO |
$879.39
|
| Rate for Payer: BCN Commercial |
$879.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$258.87
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$235.34
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$862.96
|
|
|
Service Code
|
CPT 61783
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$229.23 |
| Max. Negotiated Rate |
$862.96 |
| Rate for Payer: BCBS Trust/PPO |
$862.96
|
| Rate for Payer: BCN Commercial |
$862.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.15
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$229.23
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
OP
|
$443.75
|
|
|
Service Code
|
NDC 62327033303
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.19 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna American Axle |
$288.44
|
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna Medicare |
$221.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: BCBS Complete |
$177.50
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
| Rate for Payer: UMR Bronson Commercial |
$164.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.81
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
OP
|
$443.75
|
|
|
Service Code
|
NDC 62327033343
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.19 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna American Axle |
$288.44
|
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna Medicare |
$221.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: BCBS Complete |
$177.50
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
| Rate for Payer: UMR Bronson Commercial |
$164.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.81
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
IP
|
$443.75
|
|
|
Service Code
|
NDC 62327033303
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$195.25 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna American Axle |
$288.44
|
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
| Rate for Payer: UMR Bronson Commercial |
$195.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.81
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
IP
|
$443.75
|
|
|
Service Code
|
NDC 62327033343
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$195.25 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna American Axle |
$288.44
|
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
| Rate for Payer: UMR Bronson Commercial |
$195.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.81
|
|
|
STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$182.42
|
|
|
Service Code
|
HCPCS J3000
|
| Hospital Charge Code |
7508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.26 |
| Max. Negotiated Rate |
$164.18 |
| Rate for Payer: Aetna American Axle |
$118.57
|
| Rate for Payer: Aetna Commercial |
$155.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.57
|
| Rate for Payer: Cash Price |
$145.94
|
| Rate for Payer: Cofinity Commercial |
$127.69
|
| Rate for Payer: Cofinity Commercial |
$156.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.94
|
| Rate for Payer: Healthscope Commercial |
$164.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.06
|
| Rate for Payer: PHP Commercial |
$155.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.57
|
| Rate for Payer: Priority Health SBD |
$114.92
|
| Rate for Payer: UMR Bronson Commercial |
$80.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.82
|
|
|
STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$182.42
|
|
|
Service Code
|
HCPCS J3000
|
| Hospital Charge Code |
7508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$164.18 |
| Rate for Payer: Aetna American Axle |
$118.57
|
| Rate for Payer: Aetna Commercial |
$155.06
|
| Rate for Payer: Aetna Medicare |
$91.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.57
|
| Rate for Payer: BCBS Complete |
$72.97
|
| Rate for Payer: BCBS Trust/PPO |
$88.28
|
| Rate for Payer: BCN Commercial |
$88.28
|
| Rate for Payer: Cash Price |
$145.94
|
| Rate for Payer: Cash Price |
$145.94
|
| Rate for Payer: Cofinity Commercial |
$127.69
|
| Rate for Payer: Cofinity Commercial |
$156.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.94
|
| Rate for Payer: Healthscope Commercial |
$164.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.06
|
| Rate for Payer: PHP Commercial |
$155.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.57
|
| Rate for Payer: Priority Health SBD |
$114.92
|
| Rate for Payer: UMR Bronson Commercial |
$67.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.82
|
|
|
STREPTOZOCIN 1 GRAM INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,536.49
|
|
|
Service Code
|
HCPCS J9320
|
| Hospital Charge Code |
11436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$568.50 |
| Max. Negotiated Rate |
$1,382.84 |
| Rate for Payer: Aetna American Axle |
$998.72
|
| Rate for Payer: Aetna Commercial |
$1,306.02
|
| Rate for Payer: Aetna Medicare |
$768.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$998.72
|
| Rate for Payer: BCBS Complete |
$614.60
|
| Rate for Payer: BCBS Trust/PPO |
$912.74
|
| Rate for Payer: BCN Commercial |
$912.74
|
| Rate for Payer: Cash Price |
$1,229.19
|
| Rate for Payer: Cash Price |
$1,229.19
|
| Rate for Payer: Cofinity Commercial |
$1,075.54
|
| Rate for Payer: Cofinity Commercial |
$1,321.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,075.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,229.19
|
| Rate for Payer: Healthscope Commercial |
$1,382.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,075.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,152.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,306.02
|
| Rate for Payer: PHP Commercial |
$1,306.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$998.72
|
| Rate for Payer: Priority Health SBD |
$967.99
|
| Rate for Payer: UMR Bronson Commercial |
$568.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,152.37
|
|
|
STREPTOZOCIN 1 GRAM INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,536.49
|
|
|
Service Code
|
HCPCS J9320
|
| Hospital Charge Code |
11436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$676.06 |
| Max. Negotiated Rate |
$1,382.84 |
| Rate for Payer: Aetna American Axle |
$998.72
|
| Rate for Payer: Aetna Commercial |
$1,306.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$998.72
|
| Rate for Payer: Cash Price |
$1,229.19
|
| Rate for Payer: Cofinity Commercial |
$1,075.54
|
| Rate for Payer: Cofinity Commercial |
$1,321.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,075.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,229.19
|
| Rate for Payer: Healthscope Commercial |
$1,382.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,075.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,152.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,306.02
|
| Rate for Payer: PHP Commercial |
$1,306.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$998.72
|
| Rate for Payer: Priority Health SBD |
$967.99
|
| Rate for Payer: UMR Bronson Commercial |
$676.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,152.37
|
|
|
SUBCONJUNCTIVAL INJECTION
|
Facility
|
OP
|
$1,228.82
|
|
|
Service Code
|
CPT 68200
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31.90 |
| Max. Negotiated Rate |
$1,228.82 |
| Rate for Payer: Aetna Medicare |
$406.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$488.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$488.71
|
| Rate for Payer: BCBS Complete |
$220.04
|
| Rate for Payer: BCBS MAPPO |
$390.97
|
| Rate for Payer: BCBS Trust/PPO |
$246.22
|
| Rate for Payer: BCN Commercial |
$246.22
|
| Rate for Payer: BCN Medicare Advantage |
$390.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$390.97
|
| Rate for Payer: Mclaren Medicaid |
$209.56
|
| Rate for Payer: Mclaren Medicare |
$390.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$410.52
|
| Rate for Payer: Meridian Medicaid |
$220.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$449.62
|
| Rate for Payer: Nomi Health Commercial |
$1,172.91
|
| Rate for Payer: PACE Medicare |
$371.42
|
| Rate for Payer: PACE SWMI |
$390.97
|
| Rate for Payer: PHP Medicare Advantage |
$390.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$209.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,228.82
|
| Rate for Payer: Priority Health Medicare |
$390.97
|
| Rate for Payer: Priority Health Narrow Network |
$983.06
|
| Rate for Payer: Railroad Medicare Medicare |
$390.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.09
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$390.97
|
| Rate for Payer: UHC Exchange |
$31.90
|
| Rate for Payer: UHC Medicare Advantage |
$390.97
|
| Rate for Payer: UHCCP Medicaid |
$209.56
|
| Rate for Payer: VA VA |
$390.97
|
|
