|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS
|
Facility
|
OP
|
$74.18
|
|
|
Service Code
|
NDC 00517920325
|
| Hospital Charge Code |
18266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$66.76 |
| Rate for Payer: Aetna American Axle |
$48.22
|
| Rate for Payer: Aetna Commercial |
$63.05
|
| Rate for Payer: Aetna Medicare |
$37.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.22
|
| Rate for Payer: BCBS Complete |
$29.67
|
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Cofinity Commercial |
$51.93
|
| Rate for Payer: Cofinity Commercial |
$63.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.34
|
| Rate for Payer: Healthscope Commercial |
$66.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.05
|
| Rate for Payer: PHP Commercial |
$63.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.22
|
| Rate for Payer: Priority Health SBD |
$46.73
|
| Rate for Payer: UMR Bronson Commercial |
$27.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.63
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS
|
Facility
|
IP
|
$74.18
|
|
|
Service Code
|
NDC 00517920325
|
| Hospital Charge Code |
18266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.64 |
| Max. Negotiated Rate |
$66.76 |
| Rate for Payer: Aetna American Axle |
$48.22
|
| Rate for Payer: Aetna Commercial |
$63.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.22
|
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Cofinity Commercial |
$51.93
|
| Rate for Payer: Cofinity Commercial |
$63.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.34
|
| Rate for Payer: Healthscope Commercial |
$66.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.05
|
| Rate for Payer: PHP Commercial |
$63.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.22
|
| Rate for Payer: Priority Health SBD |
$46.73
|
| Rate for Payer: UMR Bronson Commercial |
$32.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.63
|
|
|
TRACE ELEMENTS ADULT INJECTION (NORWAY)
|
Facility
|
IP
|
$97.48
|
|
|
Service Code
|
NDC 00517720125
|
| Hospital Charge Code |
168908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.89 |
| Max. Negotiated Rate |
$87.73 |
| Rate for Payer: Aetna American Axle |
$63.36
|
| Rate for Payer: Aetna Commercial |
$82.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.36
|
| Rate for Payer: Cash Price |
$77.98
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$83.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.98
|
| Rate for Payer: Healthscope Commercial |
$87.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.86
|
| Rate for Payer: PHP Commercial |
$82.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.36
|
| Rate for Payer: Priority Health SBD |
$61.41
|
| Rate for Payer: UMR Bronson Commercial |
$42.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.11
|
|
|
TRACE ELEMENTS ADULT INJECTION (NORWAY)
|
Facility
|
OP
|
$97.48
|
|
|
Service Code
|
NDC 00517720125
|
| Hospital Charge Code |
168908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.07 |
| Max. Negotiated Rate |
$87.73 |
| Rate for Payer: Aetna American Axle |
$63.36
|
| Rate for Payer: Aetna Commercial |
$82.86
|
| Rate for Payer: Aetna Medicare |
$48.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.36
|
| Rate for Payer: BCBS Complete |
$38.99
|
| Rate for Payer: Cash Price |
$77.98
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$83.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.98
|
| Rate for Payer: Healthscope Commercial |
$87.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.86
|
| Rate for Payer: PHP Commercial |
$82.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.36
|
| Rate for Payer: Priority Health SBD |
$61.41
|
| Rate for Payer: UMR Bronson Commercial |
$36.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.11
|
|
|
TRACE ELEMENTS ADULT INJECTION (NORWAY)
|
Facility
|
OP
|
$90.92
|
|
|
Service Code
|
NDC 09900000558
|
| Hospital Charge Code |
168908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.64 |
| Max. Negotiated Rate |
$81.83 |
| Rate for Payer: Aetna American Axle |
$59.10
|
| Rate for Payer: Aetna Commercial |
$77.28
|
| Rate for Payer: Aetna Medicare |
$45.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.10
|
| Rate for Payer: BCBS Complete |
$36.37
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cofinity Commercial |
$63.64
|
| Rate for Payer: Cofinity Commercial |
$78.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.74
|
| Rate for Payer: Healthscope Commercial |
$81.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.28
|
| Rate for Payer: PHP Commercial |
$77.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.10
|
| Rate for Payer: Priority Health SBD |
$57.28
|
| Rate for Payer: UMR Bronson Commercial |
$33.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.19
|
|
|
TRACE ELEMENTS ADULT INJECTION (NORWAY)
|
Facility
|
IP
|
$90.92
|
|
|
Service Code
|
NDC 09900000558
|
| Hospital Charge Code |
168908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$81.83 |
| Rate for Payer: Aetna American Axle |
$59.10
|
| Rate for Payer: Aetna Commercial |
$77.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.10
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cofinity Commercial |
$63.64
|
| Rate for Payer: Cofinity Commercial |
$78.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.74
|
| Rate for Payer: Healthscope Commercial |
$81.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.28
|
| Rate for Payer: PHP Commercial |
$77.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.10
|
| Rate for Payer: Priority Health SBD |
$57.28
|
| Rate for Payer: UMR Bronson Commercial |
$40.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.19
|
|
|
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS
|
Facility
|
OP
|
$14.12
|
|
|
Service Code
|
NDC 00517620225
|
| Hospital Charge Code |
18267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$12.71 |
| Rate for Payer: Aetna American Axle |
$9.18
|
| Rate for Payer: Aetna Commercial |
$12.00
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.18
|
| Rate for Payer: BCBS Complete |
$5.65
|
| Rate for Payer: Cash Price |
$11.30
|
| Rate for Payer: Cofinity Commercial |
$12.14
|
| Rate for Payer: Cofinity Commercial |
$9.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.30
|
| Rate for Payer: Healthscope Commercial |
$12.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.00
|
| Rate for Payer: PHP Commercial |
$12.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.18
|
| Rate for Payer: Priority Health SBD |
$8.90
|
| Rate for Payer: UMR Bronson Commercial |
$5.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.59
|
|
|
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG-25 MCG-1.5MG/ML INTRAVENOUS
|
Facility
|
IP
|
$14.12
|
|
|
Service Code
|
NDC 00517620225
|
| Hospital Charge Code |
18267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.21 |
| Max. Negotiated Rate |
$12.71 |
| Rate for Payer: Aetna American Axle |
$9.18
|
| Rate for Payer: Aetna Commercial |
$12.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.18
|
| Rate for Payer: Cash Price |
$11.30
|
| Rate for Payer: Cofinity Commercial |
$12.14
|
| Rate for Payer: Cofinity Commercial |
$9.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.30
|
| Rate for Payer: Healthscope Commercial |
$12.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.00
|
| Rate for Payer: PHP Commercial |
$12.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.18
|
| Rate for Payer: Priority Health SBD |
$8.90
|
| Rate for Payer: UMR Bronson Commercial |
$6.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.59
|
|
|
TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN
|
Facility
|
OP
|
$47.26
|
|
|
Service Code
|
NDC 00517720125
|
| Hospital Charge Code |
18262
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.49 |
| Max. Negotiated Rate |
$42.53 |
| Rate for Payer: Aetna American Axle |
$30.72
|
| Rate for Payer: Aetna Commercial |
$40.17
|
| Rate for Payer: Aetna Medicare |
$23.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.72
|
| Rate for Payer: BCBS Complete |
$18.90
|
| Rate for Payer: Cash Price |
$37.81
|
| Rate for Payer: Cofinity Commercial |
$33.08
|
| Rate for Payer: Cofinity Commercial |
$40.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$33.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.81
|
| Rate for Payer: Healthscope Commercial |
$42.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.17
|
| Rate for Payer: PHP Commercial |
$40.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.72
|
| Rate for Payer: Priority Health SBD |
$29.77
|
| Rate for Payer: UMR Bronson Commercial |
$17.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.45
|
|
|
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION
|
Facility
|
OP
|
$96.02
|
|
|
Service Code
|
NDC 00517930525
|
| Hospital Charge Code |
194947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.53 |
| Max. Negotiated Rate |
$86.42 |
| Rate for Payer: Aetna American Axle |
$62.41
|
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Aetna Medicare |
$48.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.41
|
| Rate for Payer: BCBS Complete |
$38.41
|
| Rate for Payer: Cash Price |
$76.82
|
| Rate for Payer: Cofinity Commercial |
$67.21
|
| Rate for Payer: Cofinity Commercial |
$82.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.82
|
| Rate for Payer: Healthscope Commercial |
$86.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.62
|
| Rate for Payer: PHP Commercial |
$81.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.41
|
| Rate for Payer: Priority Health SBD |
$60.49
|
| Rate for Payer: UMR Bronson Commercial |
$35.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.02
|
|
|
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION
|
Facility
|
IP
|
$96.02
|
|
|
Service Code
|
NDC 00517930525
|
| Hospital Charge Code |
194947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.25 |
| Max. Negotiated Rate |
$86.42 |
| Rate for Payer: Aetna American Axle |
$62.41
|
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.41
|
| Rate for Payer: Cash Price |
$76.82
|
| Rate for Payer: Cofinity Commercial |
$67.21
|
| Rate for Payer: Cofinity Commercial |
$82.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.82
|
| Rate for Payer: Healthscope Commercial |
$86.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.62
|
| Rate for Payer: PHP Commercial |
$81.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.41
|
| Rate for Payer: Priority Health SBD |
$60.49
|
| Rate for Payer: UMR Bronson Commercial |
$42.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.02
|
|
|
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION
|
Facility
|
OP
|
$96.02
|
|
|
Service Code
|
NDC 00517930501
|
| Hospital Charge Code |
194947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.53 |
| Max. Negotiated Rate |
$86.42 |
| Rate for Payer: Aetna American Axle |
$62.41
|
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Aetna Medicare |
$48.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.41
|
| Rate for Payer: BCBS Complete |
$38.41
|
| Rate for Payer: Cash Price |
$76.82
|
| Rate for Payer: Cofinity Commercial |
$67.21
|
| Rate for Payer: Cofinity Commercial |
$82.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.82
|
| Rate for Payer: Healthscope Commercial |
$86.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.62
|
| Rate for Payer: PHP Commercial |
$81.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.41
|
| Rate for Payer: Priority Health SBD |
$60.49
|
| Rate for Payer: UMR Bronson Commercial |
$35.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.02
|
|
|
TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION
|
Facility
|
IP
|
$96.02
|
|
|
Service Code
|
NDC 00517930501
|
| Hospital Charge Code |
194947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.25 |
| Max. Negotiated Rate |
$86.42 |
| Rate for Payer: Aetna American Axle |
$62.41
|
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.41
|
| Rate for Payer: Cash Price |
$76.82
|
| Rate for Payer: Cofinity Commercial |
$67.21
|
| Rate for Payer: Cofinity Commercial |
$82.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.82
|
| Rate for Payer: Healthscope Commercial |
$86.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.62
|
| Rate for Payer: PHP Commercial |
$81.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.41
|
| Rate for Payer: Priority Health SBD |
$60.49
|
| Rate for Payer: UMR Bronson Commercial |
$42.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.02
|
|
|
TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 57530
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 57720
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT
|
Facility
|
OP
|
$637.52
|
|
|
Service Code
|
CPT 31502
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$121.39 |
| Max. Negotiated Rate |
$637.52 |
| Rate for Payer: Aetna Medicare |
$235.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$283.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$283.10
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: BCBS MAPPO |
$226.48
|
| Rate for Payer: BCN Medicare Advantage |
$226.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$226.48
|
| Rate for Payer: Mclaren Medicaid |
$121.39
|
| Rate for Payer: Mclaren Medicare |
$226.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$237.80
|
| Rate for Payer: Meridian Medicaid |
$127.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.45
|
| Rate for Payer: PACE Medicare |
$215.16
|
| Rate for Payer: PACE SWMI |
$226.48
|
| Rate for Payer: PHP Medicare Advantage |
$226.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$121.39
|
| Rate for Payer: Priority Health Medicare |
$226.48
|
| Rate for Payer: Railroad Medicare Medicare |
$226.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$637.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$226.48
|
| Rate for Payer: UHC Exchange |
$432.83
|
| Rate for Payer: UHC Medicare Advantage |
$226.48
|
| Rate for Payer: UHCCP Medicaid |
$121.39
|
| Rate for Payer: VA VA |
$226.48
|
|
|
TRAMADOL 25 MG TABLET
|
Facility
|
IP
|
$378.51
|
|
|
Service Code
|
NDC 72888016230
|
| Hospital Charge Code |
206318
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.54 |
| Max. Negotiated Rate |
$340.66 |
| Rate for Payer: Aetna American Axle |
$246.03
|
| Rate for Payer: Aetna Commercial |
$321.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.03
|
| Rate for Payer: Cash Price |
$302.81
|
| Rate for Payer: Cofinity Commercial |
$264.96
|
| Rate for Payer: Cofinity Commercial |
$325.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$264.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$302.81
|
| Rate for Payer: Healthscope Commercial |
$340.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$264.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$283.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$321.73
|
| Rate for Payer: PHP Commercial |
$321.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.03
|
| Rate for Payer: Priority Health SBD |
$238.46
|
| Rate for Payer: UMR Bronson Commercial |
$166.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$283.88
|
|
|
TRAMADOL 25 MG TABLET
|
Facility
|
OP
|
$378.51
|
|
|
Service Code
|
NDC 72888016230
|
| Hospital Charge Code |
206318
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.05 |
| Max. Negotiated Rate |
$340.66 |
| Rate for Payer: Aetna American Axle |
$246.03
|
| Rate for Payer: Aetna Commercial |
$321.73
|
| Rate for Payer: Aetna Medicare |
$189.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.03
|
| Rate for Payer: BCBS Complete |
$151.40
|
| Rate for Payer: Cash Price |
$302.81
|
| Rate for Payer: Cofinity Commercial |
$264.96
|
| Rate for Payer: Cofinity Commercial |
$325.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$264.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$302.81
|
| Rate for Payer: Healthscope Commercial |
$340.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$264.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$283.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$321.73
|
| Rate for Payer: PHP Commercial |
$321.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.03
|
| Rate for Payer: Priority Health SBD |
$238.46
|
| Rate for Payer: UMR Bronson Commercial |
$140.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$283.88
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
IP
|
$72.85
|
|
|
Service Code
|
NDC 72888008001
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.05 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna American Axle |
$47.35
|
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Commercial |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.35
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UMR Bronson Commercial |
$32.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.64
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 55154254104
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.97 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.59
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.59
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.59
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$59.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
OP
|
$101.05
|
|
|
Service Code
|
NDC 51079099120
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.39 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna Medicare |
$50.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: BCBS Complete |
$40.42
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.73
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$37.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
OP
|
$305.50
|
|
|
Service Code
|
NDC 60687079501
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.03 |
| Max. Negotiated Rate |
$274.95 |
| Rate for Payer: Aetna American Axle |
$198.57
|
| Rate for Payer: Aetna Commercial |
$259.68
|
| Rate for Payer: Aetna Medicare |
$152.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.57
|
| Rate for Payer: BCBS Complete |
$122.20
|
| Rate for Payer: Cash Price |
$244.40
|
| Rate for Payer: Cofinity Commercial |
$213.85
|
| Rate for Payer: Cofinity Commercial |
$262.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.40
|
| Rate for Payer: Healthscope Commercial |
$274.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$229.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.68
|
| Rate for Payer: PHP Commercial |
$259.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.57
|
| Rate for Payer: Priority Health SBD |
$192.47
|
| Rate for Payer: UMR Bronson Commercial |
$113.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$229.12
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 51079099120
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.73
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$44.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 60687079511
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna American Axle |
$1.99
|
| Rate for Payer: Aetna Commercial |
$2.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.99
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: Cofinity Commercial |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.45
|
| Rate for Payer: Healthscope Commercial |
$2.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.60
|
| Rate for Payer: PHP Commercial |
$2.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.99
|
| Rate for Payer: Priority Health SBD |
$1.93
|
| Rate for Payer: UMR Bronson Commercial |
$1.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 55154254104
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.59
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna Medicare |
$68.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.59
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.59
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$50.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
