|
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 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 |
$85.54 |
| 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 |
$66.54
|
| Rate for Payer: Cofinity Commercial |
$81.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.04
|
| Rate for Payer: Healthscope Commercial |
$85.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.54
|
| 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
|
$95.05
|
|
|
Service Code
|
NDC 66993008169
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.82 |
| Max. Negotiated Rate |
$85.54 |
| 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 |
$66.54
|
| Rate for Payer: Cofinity Commercial |
$81.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.04
|
| Rate for Payer: Healthscope Commercial |
$85.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.54
|
| 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 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 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 |
$17.60
|
| 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 |
$15.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.78
|
| 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 |
$17.60
|
| Rate for Payer: PHP Commercial |
$17.60
|
| 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 |
$15.52
|
| 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 |
$19.78
|
|
|
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 |
$16.17
|
| Rate for Payer: Aetna American Axle |
$13.46
|
| Rate for Payer: Aetna American Axle |
$17.67
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| 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 Medicare |
$12.44
|
| Rate for Payer: Aetna Medicare |
$13.19
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna Medicare |
$10.35
|
| Rate for Payer: Aetna Medicare |
$13.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.15
|
| 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) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: BCBS Complete |
$10.55
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: BCBS Complete |
$9.95
|
| Rate for Payer: BCBS Trust/PPO |
$13.23
|
| Rate for Payer: BCBS Trust/PPO |
$13.23
|
| Rate for Payer: BCBS Trust/PPO |
$13.23
|
| Rate for Payer: BCBS Trust/PPO |
$13.23
|
| Rate for Payer: BCBS Trust/PPO |
$13.23
|
| Rate for Payer: BCN Commercial |
$13.23
|
| Rate for Payer: BCN Commercial |
$13.23
|
| Rate for Payer: BCN Commercial |
$13.23
|
| Rate for Payer: BCN Commercial |
$13.23
|
| Rate for Payer: BCN Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| 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 |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Cofinity Commercial |
$18.47
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| 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 |
$16.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| 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 |
$18.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.66
|
| 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 |
$22.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$21.15
|
| 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 |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: Priority Health SBD |
$16.62
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: UMR Bronson Commercial |
$9.21
|
| Rate for Payer: UMR Bronson Commercial |
$9.19
|
| Rate for Payer: UMR Bronson Commercial |
$9.76
|
| Rate for Payer: UMR Bronson Commercial |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.52
|
|
|
SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)
|
Facility
|
OP
|
$5,042.00
|
|
|
Service Code
|
CPT 58180
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$936.44 |
| Max. Negotiated Rate |
$5,042.00 |
| Rate for Payer: BCBS Trust/PPO |
$3,458.12
|
| Rate for Payer: BCN Commercial |
$3,458.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,030.08
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Exchange |
$936.44
|
|
|
SUPRAHYOID LYMPHADENECTOMY
|
Facility
|
OP
|
$20,082.39
|
|
|
Service Code
|
CPT 38700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$777.69 |
| Max. Negotiated Rate |
$20,082.39 |
| Rate for Payer: Aetna Medicare |
$6,645.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,987.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,987.00
|
| Rate for Payer: BCBS Complete |
$3,596.07
|
| Rate for Payer: BCBS MAPPO |
$6,389.60
|
| Rate for Payer: BCBS Trust/PPO |
$3,014.45
|
| Rate for Payer: BCN Commercial |
$3,014.45
|
| Rate for Payer: BCN Medicare Advantage |
$6,389.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,389.60
|
| Rate for Payer: Mclaren Medicaid |
$3,424.83
|
| Rate for Payer: Mclaren Medicare |
$6,389.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,709.08
|
| Rate for Payer: Meridian Medicaid |
$3,596.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,348.04
|
| Rate for Payer: Nomi Health Commercial |
$13,418.16
|
| Rate for Payer: PACE Medicare |
$6,070.12
|
| Rate for Payer: PACE SWMI |
$6,389.60
|
| Rate for Payer: PHP Medicare Advantage |
$6,389.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,424.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,082.39
|
| Rate for Payer: Priority Health Medicare |
$6,389.60
|
| Rate for Payer: Priority Health Narrow Network |
$16,065.91
|
| Rate for Payer: Railroad Medicare Medicare |
$6,389.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$855.46
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,389.60
|
| Rate for Payer: UHC Exchange |
$777.69
|
| Rate for Payer: UHC Medicare Advantage |
$6,389.60
|
| Rate for Payer: UHCCP Medicaid |
$3,424.83
|
| Rate for Payer: VA VA |
$6,389.60
|
|
|
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; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$86.84 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$451.99
|
| Rate for Payer: BCN Commercial |
$451.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.52
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$86.84
|
|
|
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; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15005
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$86.84 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$451.99
|
| Rate for Payer: BCN Commercial |
$451.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.52
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$86.84
|
|
|
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
|
$1,885.01
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$248.66 |
| Max. Negotiated Rate |
$1,885.01 |
| Rate for Payer: Aetna Medicare |
$623.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$749.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$749.69
|
| Rate for Payer: BCBS Complete |
$337.54
|
| Rate for Payer: BCBS MAPPO |
$599.75
|
| Rate for Payer: BCBS Trust/PPO |
$381.33
|
| Rate for Payer: BCN Commercial |
$381.33
|
| Rate for Payer: BCN Medicare Advantage |
$599.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$599.75
|
| Rate for Payer: Mclaren Medicaid |
$321.47
|
| Rate for Payer: Mclaren Medicare |
$599.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$629.74
|
| Rate for Payer: Meridian Medicaid |
$337.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$689.71
|
| Rate for Payer: Nomi Health Commercial |
$1,259.48
|
| Rate for Payer: PACE Medicare |
$569.76
|
| Rate for Payer: PACE SWMI |
$599.75
|
| Rate for Payer: PHP Medicare Advantage |
$599.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$321.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,885.01
|
| Rate for Payer: Priority Health Medicare |
$599.75
|
| Rate for Payer: Priority Health Narrow Network |
$1,508.01
|
| Rate for Payer: Railroad Medicare Medicare |
$599.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.53
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$599.75
|
| Rate for Payer: UHC Exchange |
$248.66
|
| Rate for Payer: UHC Medicare Advantage |
$599.75
|
| Rate for Payer: UHCCP Medicaid |
$321.47
|
| Rate for Payer: VA VA |
$599.75
|
|
|
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
|
$1,885.01
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$248.66 |
| Max. Negotiated Rate |
$1,885.01 |
| Rate for Payer: Aetna Medicare |
$623.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$749.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$749.69
|
| Rate for Payer: BCBS Complete |
$337.54
|
| Rate for Payer: BCBS MAPPO |
$599.75
|
| Rate for Payer: BCBS Trust/PPO |
$381.33
|
| Rate for Payer: BCN Commercial |
$381.33
|
| Rate for Payer: BCN Medicare Advantage |
$599.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$599.75
|
| Rate for Payer: Mclaren Medicaid |
$321.47
|
| Rate for Payer: Mclaren Medicare |
$599.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$629.74
|
| Rate for Payer: Meridian Medicaid |
$337.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$689.71
|
| Rate for Payer: Nomi Health Commercial |
$1,259.48
|
| Rate for Payer: PACE Medicare |
$569.76
|
| Rate for Payer: PACE SWMI |
$599.75
|
| Rate for Payer: PHP Medicare Advantage |
$599.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$321.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,885.01
|
| Rate for Payer: Priority Health Medicare |
$599.75
|
| Rate for Payer: Priority Health Narrow Network |
$1,508.01
|
| Rate for Payer: Railroad Medicare Medicare |
$599.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.53
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$599.75
|
| Rate for Payer: UHC Exchange |
$248.66
|
| Rate for Payer: UHC Medicare Advantage |
$599.75
|
| Rate for Payer: UHCCP Medicaid |
$321.47
|
| Rate for Payer: VA VA |
$599.75
|
|
|
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, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15003
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$318.86
|
| Rate for Payer: BCN Commercial |
$318.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48.24
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$43.85
|
|
|
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, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$211.09 |
| 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 |
$1,023.65
|
| Rate for Payer: BCN Commercial |
$1,023.65
|
| 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) |
$232.20
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$211.09
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$2,798.47
|
|
|
Service Code
|
CPT S2900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,798.47 |
| Max. Negotiated Rate |
$2,798.47 |
| Rate for Payer: BCBS Trust/PPO |
$2,798.47
|
| Rate for Payer: BCN Commercial |
$2,798.47
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC
|
Facility
|
OP
|
$8,445.02
|
|
|
Service Code
|
CPT 46275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$405.56 |
| Max. Negotiated Rate |
$8,445.02 |
| Rate for Payer: Aetna Medicare |
$2,794.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,358.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,358.68
|
| Rate for Payer: BCBS Complete |
$1,512.21
|
| Rate for Payer: BCBS MAPPO |
$2,686.94
|
| Rate for Payer: BCBS Trust/PPO |
$2,338.49
|
| Rate for Payer: BCN Commercial |
$2,338.49
|
| Rate for Payer: BCN Medicare Advantage |
$2,686.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,686.94
|
| Rate for Payer: Mclaren Medicaid |
$1,440.20
|
| Rate for Payer: Mclaren Medicare |
$2,686.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,821.29
|
| Rate for Payer: Meridian Medicaid |
$1,512.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,089.98
|
| Rate for Payer: Nomi Health Commercial |
$5,642.57
|
| Rate for Payer: PACE Medicare |
$2,552.59
|
| Rate for Payer: PACE SWMI |
$2,686.94
|
| Rate for Payer: PHP Medicare Advantage |
$2,686.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,440.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,445.02
|
| Rate for Payer: Priority Health Medicare |
$2,686.94
|
| Rate for Payer: Priority Health Narrow Network |
$6,756.02
|
| Rate for Payer: Railroad Medicare Medicare |
$2,686.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$446.12
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,686.94
|
| Rate for Payer: UHC Exchange |
$405.56
|
| Rate for Payer: UHC Medicare Advantage |
$2,686.94
|
| Rate for Payer: UHCCP Medicaid |
$1,440.20
|
| Rate for Payer: VA VA |
$2,686.94
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE
|
Facility
|
OP
|
$8,445.02
|
|
|
Service Code
|
CPT 46285
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$406.92 |
| Max. Negotiated Rate |
$8,445.02 |
| Rate for Payer: Aetna Medicare |
$2,794.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,358.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,358.68
|
| Rate for Payer: BCBS Complete |
$1,512.21
|
| Rate for Payer: BCBS MAPPO |
$2,686.94
|
| Rate for Payer: BCBS Trust/PPO |
$1,735.18
|
| Rate for Payer: BCN Commercial |
$1,735.18
|
| Rate for Payer: BCN Medicare Advantage |
$2,686.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,686.94
|
| Rate for Payer: Mclaren Medicaid |
$1,440.20
|
| Rate for Payer: Mclaren Medicare |
$2,686.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,821.29
|
| Rate for Payer: Meridian Medicaid |
$1,512.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,089.98
|
| Rate for Payer: Nomi Health Commercial |
$5,642.57
|
| Rate for Payer: PACE Medicare |
$2,552.59
|
| Rate for Payer: PACE SWMI |
$2,686.94
|
| Rate for Payer: PHP Medicare Advantage |
$2,686.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,440.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,445.02
|
| Rate for Payer: Priority Health Medicare |
$2,686.94
|
| Rate for Payer: Priority Health Narrow Network |
$6,756.02
|
| Rate for Payer: Railroad Medicare Medicare |
$2,686.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$447.61
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,686.94
|
| Rate for Payer: UHC Exchange |
$406.92
|
| Rate for Payer: UHC Medicare Advantage |
$2,686.94
|
| Rate for Payer: UHCCP Medicaid |
$1,440.20
|
| Rate for Payer: VA VA |
$2,686.94
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS
|
Facility
|
OP
|
$8,445.02
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$385.18 |
| Max. Negotiated Rate |
$8,445.02 |
| Rate for Payer: Aetna Medicare |
$2,794.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,358.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,358.68
|
| Rate for Payer: BCBS Complete |
$1,512.21
|
| Rate for Payer: BCBS MAPPO |
$2,686.94
|
| Rate for Payer: BCBS Trust/PPO |
$2,309.61
|
| Rate for Payer: BCN Commercial |
$2,309.61
|
| Rate for Payer: BCN Medicare Advantage |
$2,686.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,686.94
|
| Rate for Payer: Mclaren Medicaid |
$1,440.20
|
| Rate for Payer: Mclaren Medicare |
$2,686.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,821.29
|
| Rate for Payer: Meridian Medicaid |
$1,512.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,089.98
|
| Rate for Payer: Nomi Health Commercial |
$5,642.57
|
| Rate for Payer: PACE Medicare |
$2,552.59
|
| Rate for Payer: PACE SWMI |
$2,686.94
|
| Rate for Payer: PHP Medicare Advantage |
$2,686.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,440.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,445.02
|
| Rate for Payer: Priority Health Medicare |
$2,686.94
|
| Rate for Payer: Priority Health Narrow Network |
$6,756.02
|
| Rate for Payer: Railroad Medicare Medicare |
$2,686.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$423.70
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,686.94
|
| Rate for Payer: UHC Exchange |
$385.18
|
| Rate for Payer: UHC Medicare Advantage |
$2,686.94
|
| Rate for Payer: UHCCP Medicaid |
$1,440.20
|
| Rate for Payer: VA VA |
$2,686.94
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED
|
Facility
|
OP
|
$8,445.02
|
|
|
Service Code
|
CPT 46280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$461.75 |
| Max. Negotiated Rate |
$8,445.02 |
| Rate for Payer: Aetna Medicare |
$2,794.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,358.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,358.68
|
| Rate for Payer: BCBS Complete |
$1,512.21
|
| Rate for Payer: BCBS MAPPO |
$2,686.94
|
| Rate for Payer: BCBS Trust/PPO |
$3,041.67
|
| Rate for Payer: BCN Commercial |
$3,041.67
|
| Rate for Payer: BCN Medicare Advantage |
$2,686.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,686.94
|
| Rate for Payer: Mclaren Medicaid |
$1,440.20
|
| Rate for Payer: Mclaren Medicare |
$2,686.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,821.29
|
| Rate for Payer: Meridian Medicaid |
$1,512.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,089.98
|
| Rate for Payer: Nomi Health Commercial |
$5,642.57
|
| Rate for Payer: PACE Medicare |
$2,552.59
|
| Rate for Payer: PACE SWMI |
$2,686.94
|
| Rate for Payer: PHP Medicare Advantage |
$2,686.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,440.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,445.02
|
| Rate for Payer: Priority Health Medicare |
$2,686.94
|
| Rate for Payer: Priority Health Narrow Network |
$6,756.02
|
| Rate for Payer: Railroad Medicare Medicare |
$2,686.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$507.92
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,686.94
|
| Rate for Payer: UHC Exchange |
$461.75
|
| Rate for Payer: UHC Medicare Advantage |
$2,686.94
|
| Rate for Payer: UHCCP Medicaid |
$1,440.20
|
| Rate for Payer: VA VA |
$2,686.94
|
|
|
SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH
|
Facility
|
OP
|
$5,042.00
|
|
|
Service Code
|
CPT 59120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$808.80 |
| Max. Negotiated Rate |
$5,042.00 |
| Rate for Payer: BCBS Trust/PPO |
$2,887.04
|
| Rate for Payer: BCN Commercial |
$2,887.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$889.68
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Exchange |
$808.80
|
|
|
SURGICEL, OXIDIZED 2" X 1" MISC
|
Facility
|
OP
|
$310.06
|
|
|
Service Code
|
NDC 63713001961
|
| Hospital Charge Code |
200200150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$279.05 |
| Rate for Payer: Aetna American Axle |
$201.54
|
| Rate for Payer: Aetna Commercial |
$263.55
|
| Rate for Payer: Aetna Medicare |
$155.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.54
|
| Rate for Payer: BCBS Complete |
$124.02
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cofinity Commercial |
$217.04
|
| Rate for Payer: Cofinity Commercial |
$266.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$217.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.05
|
| Rate for Payer: Healthscope Commercial |
$279.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$217.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.55
|
| Rate for Payer: PHP Commercial |
$263.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.54
|
| Rate for Payer: Priority Health SBD |
$195.34
|
| Rate for Payer: UMR Bronson Commercial |
$114.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.54
|
|
|
SURGICEL, OXIDIZED 2" X 1" MISC
|
Facility
|
IP
|
$310.06
|
|
|
Service Code
|
NDC 63713001961
|
| Hospital Charge Code |
200200150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.43 |
| Max. Negotiated Rate |
$279.05 |
| Rate for Payer: Aetna American Axle |
$201.54
|
| Rate for Payer: Aetna Commercial |
$263.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.54
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cofinity Commercial |
$217.04
|
| Rate for Payer: Cofinity Commercial |
$266.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$217.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.05
|
| Rate for Payer: Healthscope Commercial |
$279.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$217.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.55
|
| Rate for Payer: PHP Commercial |
$263.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.54
|
| Rate for Payer: Priority Health SBD |
$195.34
|
| Rate for Payer: UMR Bronson Commercial |
$136.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.54
|
|
|
SUTIMLIMAB-JOME 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,136.35
|
|
|
Service Code
|
HCPCS J1302
|
| Hospital Charge Code |
199304
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.72 |
| Max. Negotiated Rate |
$5,522.72 |
| Rate for Payer: Aetna American Axle |
$3,988.63
|
| Rate for Payer: Aetna Commercial |
$5,215.90
|
| Rate for Payer: Aetna Medicare |
$18.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,988.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.66
|
| Rate for Payer: BCBS Complete |
$10.20
|
| Rate for Payer: BCBS MAPPO |
$18.13
|
| Rate for Payer: BCBS Trust/PPO |
$48.88
|
| Rate for Payer: BCN Commercial |
$48.88
|
| Rate for Payer: BCN Medicare Advantage |
$18.13
|
| Rate for Payer: Cash Price |
$4,909.08
|
| Rate for Payer: Cash Price |
$4,909.08
|
| Rate for Payer: Cofinity Commercial |
$5,277.26
|
| Rate for Payer: Cofinity Commercial |
$4,295.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,295.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,909.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.13
|
| Rate for Payer: Healthscope Commercial |
$5,522.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,295.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,602.26
|
| Rate for Payer: Mclaren Medicaid |
$9.72
|
| Rate for Payer: Mclaren Medicare |
$18.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.04
|
| Rate for Payer: Meridian Medicaid |
$10.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,215.90
|
| Rate for Payer: Nomi Health Commercial |
$54.39
|
| Rate for Payer: PACE Medicare |
$17.22
|
| Rate for Payer: PACE SWMI |
$18.13
|
| Rate for Payer: PHP Commercial |
$5,215.90
|
| Rate for Payer: PHP Medicare Advantage |
$18.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,988.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52.17
|
| Rate for Payer: Priority Health Medicare |
$18.13
|
| Rate for Payer: Priority Health Narrow Network |
$41.74
|
| Rate for Payer: Priority Health SBD |
$3,865.90
|
| Rate for Payer: Railroad Medicare Medicare |
$18.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.13
|
| Rate for Payer: UHC Exchange |
$34.65
|
| Rate for Payer: UHC Medicare Advantage |
$18.13
|
| Rate for Payer: UHCCP Medicaid |
$9.72
|
| Rate for Payer: UMR Bronson Commercial |
$2,270.45
|
| Rate for Payer: VA VA |
$18.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,602.26
|
|
|
SUTIMLIMAB-JOME 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$6,136.35
|
|
|
Service Code
|
HCPCS J1302
|
| Hospital Charge Code |
199304
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,699.99 |
| Max. Negotiated Rate |
$5,522.72 |
| Rate for Payer: Aetna American Axle |
$3,988.63
|
| Rate for Payer: Aetna Commercial |
$5,215.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,988.63
|
| Rate for Payer: Cash Price |
$4,909.08
|
| Rate for Payer: Cofinity Commercial |
$4,295.44
|
| Rate for Payer: Cofinity Commercial |
$5,277.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,295.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,909.08
|
| Rate for Payer: Healthscope Commercial |
$5,522.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,295.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,602.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,215.90
|
| Rate for Payer: PHP Commercial |
$5,215.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,988.63
|
| Rate for Payer: Priority Health SBD |
$3,865.90
|
| Rate for Payer: UMR Bronson Commercial |
$2,699.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,602.26
|
|
