|
TRIPROLIDINE-PSEUDOEPHEDRINE 2.5 MG-60 MG TABLET
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 00904025059
|
| Hospital Charge Code |
8213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.94
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$35.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
TRIPROLIDINE-PSEUDOEPHEDRINE 2.5 MG-60 MG TABLET
|
Facility
|
OP
|
$79.90
|
|
|
Service Code
|
NDC 00904025059
|
| Hospital Charge Code |
8213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna Medicare |
$39.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: BCBS Complete |
$31.96
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.94
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$29.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
|
IP
|
$17,316.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,619.04 |
| Max. Negotiated Rate |
$15,584.40 |
| Rate for Payer: Aetna American Axle |
$11,255.40
|
| Rate for Payer: Aetna Commercial |
$14,718.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,255.40
|
| Rate for Payer: Cash Price |
$13,852.80
|
| Rate for Payer: Cofinity Commercial |
$12,121.20
|
| Rate for Payer: Cofinity Commercial |
$14,891.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,121.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,852.80
|
| Rate for Payer: Healthscope Commercial |
$15,584.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,121.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,987.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,718.60
|
| Rate for Payer: PHP Commercial |
$14,718.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,255.40
|
| Rate for Payer: Priority Health SBD |
$10,909.08
|
| Rate for Payer: UMR Bronson Commercial |
$7,619.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,987.00
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
|
OP
|
$17,316.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.97 |
| Max. Negotiated Rate |
$15,584.40 |
| Rate for Payer: Aetna American Axle |
$11,255.40
|
| Rate for Payer: Aetna Commercial |
$14,718.60
|
| Rate for Payer: Aetna Medicare |
$500.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,255.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$601.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$601.61
|
| Rate for Payer: BCBS Complete |
$270.87
|
| Rate for Payer: BCBS MAPPO |
$481.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,297.72
|
| Rate for Payer: BCN Commercial |
$1,297.72
|
| Rate for Payer: BCN Medicare Advantage |
$481.29
|
| Rate for Payer: Cash Price |
$13,852.80
|
| Rate for Payer: Cash Price |
$13,852.80
|
| Rate for Payer: Cofinity Commercial |
$14,891.76
|
| Rate for Payer: Cofinity Commercial |
$12,121.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,121.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,852.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$481.29
|
| Rate for Payer: Healthscope Commercial |
$15,584.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,121.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,987.00
|
| Rate for Payer: Mclaren Medicaid |
$257.97
|
| Rate for Payer: Mclaren Medicare |
$481.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$505.35
|
| Rate for Payer: Meridian Medicaid |
$270.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$553.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,718.60
|
| Rate for Payer: Nomi Health Commercial |
$1,443.87
|
| Rate for Payer: PACE Medicare |
$457.23
|
| Rate for Payer: PACE SWMI |
$481.29
|
| Rate for Payer: PHP Commercial |
$14,718.60
|
| Rate for Payer: PHP Medicare Advantage |
$481.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$257.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,255.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,343.25
|
| Rate for Payer: Priority Health Medicare |
$481.29
|
| Rate for Payer: Priority Health Narrow Network |
$1,074.60
|
| Rate for Payer: Priority Health SBD |
$10,909.08
|
| Rate for Payer: Railroad Medicare Medicare |
$481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,354.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$481.29
|
| Rate for Payer: UHC Exchange |
$919.79
|
| Rate for Payer: UHC Medicare Advantage |
$481.29
|
| Rate for Payer: UHCCP Medicaid |
$257.97
|
| Rate for Payer: UMR Bronson Commercial |
$6,406.92
|
| Rate for Payer: VA VA |
$481.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,987.00
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
OP
|
$2,340.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.97 |
| Max. Negotiated Rate |
$2,106.00 |
| Rate for Payer: Aetna American Axle |
$1,521.00
|
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Medicare |
$500.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,521.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$601.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$601.61
|
| Rate for Payer: BCBS Complete |
$270.87
|
| Rate for Payer: BCBS MAPPO |
$481.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,297.72
|
| Rate for Payer: BCN Commercial |
$1,297.72
|
| Rate for Payer: BCN Medicare Advantage |
$481.29
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cofinity Commercial |
$2,012.40
|
| Rate for Payer: Cofinity Commercial |
$1,638.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,638.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,872.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$481.29
|
| Rate for Payer: Healthscope Commercial |
$2,106.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,638.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,755.00
|
| Rate for Payer: Mclaren Medicaid |
$257.97
|
| Rate for Payer: Mclaren Medicare |
$481.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$505.35
|
| Rate for Payer: Meridian Medicaid |
$270.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$553.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,989.00
|
| Rate for Payer: Nomi Health Commercial |
$1,443.87
|
| Rate for Payer: PACE Medicare |
$457.23
|
| Rate for Payer: PACE SWMI |
$481.29
|
| Rate for Payer: PHP Commercial |
$1,989.00
|
| Rate for Payer: PHP Medicare Advantage |
$481.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$257.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,521.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,343.25
|
| Rate for Payer: Priority Health Medicare |
$481.29
|
| Rate for Payer: Priority Health Narrow Network |
$1,074.60
|
| Rate for Payer: Priority Health SBD |
$1,474.20
|
| Rate for Payer: Railroad Medicare Medicare |
$481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,354.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$481.29
|
| Rate for Payer: UHC Exchange |
$919.79
|
| Rate for Payer: UHC Medicare Advantage |
$481.29
|
| Rate for Payer: UHCCP Medicaid |
$257.97
|
| Rate for Payer: UMR Bronson Commercial |
$865.80
|
| Rate for Payer: VA VA |
$481.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,755.00
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
IP
|
$2,340.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,029.60 |
| Max. Negotiated Rate |
$2,106.00 |
| Rate for Payer: Aetna American Axle |
$1,521.00
|
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,521.00
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cofinity Commercial |
$1,638.00
|
| Rate for Payer: Cofinity Commercial |
$2,012.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,638.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,872.00
|
| Rate for Payer: Healthscope Commercial |
$2,106.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,638.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,755.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,989.00
|
| Rate for Payer: PHP Commercial |
$1,989.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,521.00
|
| Rate for Payer: Priority Health SBD |
$1,474.20
|
| Rate for Payer: UMR Bronson Commercial |
$1,029.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,755.00
|
|
|
TROPICAMIDE 0.02%/ PHENYLEPHRINE 0.31%/ LIDOCAINE 1% FORMULATION INTRACAMERAL INJECTION 0.8 ML SYRINGE
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
NDC 09900001996
|
| Hospital Charge Code |
301844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna American Axle |
$32.50
|
| Rate for Payer: Aetna Commercial |
$42.50
|
| Rate for Payer: Aetna Medicare |
$25.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.50
|
| Rate for Payer: BCBS Complete |
$20.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cofinity Commercial |
$35.00
|
| Rate for Payer: Cofinity Commercial |
$43.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.00
|
| Rate for Payer: Healthscope Commercial |
$45.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.50
|
| Rate for Payer: PHP Commercial |
$42.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.50
|
| Rate for Payer: Priority Health SBD |
$31.50
|
| Rate for Payer: UMR Bronson Commercial |
$18.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.50
|
|
|
TROPICAMIDE 0.02%/ PHENYLEPHRINE 0.31%/ LIDOCAINE 1% FORMULATION INTRACAMERAL INJECTION 0.8 ML SYRINGE
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
NDC 09900001996
|
| Hospital Charge Code |
301844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna American Axle |
$32.50
|
| Rate for Payer: Aetna Commercial |
$42.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.50
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cofinity Commercial |
$35.00
|
| Rate for Payer: Cofinity Commercial |
$43.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.00
|
| Rate for Payer: Healthscope Commercial |
$45.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.50
|
| Rate for Payer: PHP Commercial |
$42.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.50
|
| Rate for Payer: Priority Health SBD |
$31.50
|
| Rate for Payer: UMR Bronson Commercial |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.50
|
|
|
TROPICAMIDE 0.5 % EYE DROPS
|
Facility
|
OP
|
$69.62
|
|
|
Service Code
|
NDC 61314035401
|
| Hospital Charge Code |
8249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$62.66 |
| Rate for Payer: Aetna American Axle |
$45.25
|
| Rate for Payer: Aetna Commercial |
$59.18
|
| Rate for Payer: Aetna Medicare |
$34.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.25
|
| Rate for Payer: BCBS Complete |
$27.85
|
| Rate for Payer: Cash Price |
$55.70
|
| Rate for Payer: Cofinity Commercial |
$48.73
|
| Rate for Payer: Cofinity Commercial |
$59.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.70
|
| Rate for Payer: Healthscope Commercial |
$62.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.18
|
| Rate for Payer: PHP Commercial |
$59.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.25
|
| Rate for Payer: Priority Health SBD |
$43.86
|
| Rate for Payer: UMR Bronson Commercial |
$25.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.22
|
|
|
TROPICAMIDE 0.5 % EYE DROPS
|
Facility
|
IP
|
$21.84
|
|
|
Service Code
|
NDC 17478010112
|
| Hospital Charge Code |
8249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.56
|
| Rate for Payer: Aetna American Axle |
$14.20
|
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.20
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Cofinity Commercial |
$18.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.47
|
| Rate for Payer: Healthscope Commercial |
$19.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.38
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.20
|
| Rate for Payer: Priority Health SBD |
$13.76
|
| Rate for Payer: UMR Bronson Commercial |
$9.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.38
|
|
|
TROPICAMIDE 0.5 % EYE DROPS
|
Facility
|
IP
|
$69.62
|
|
|
Service Code
|
NDC 61314035401
|
| Hospital Charge Code |
8249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.63 |
| Max. Negotiated Rate |
$62.66 |
| Rate for Payer: Aetna American Axle |
$45.25
|
| Rate for Payer: Aetna Commercial |
$59.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.25
|
| Rate for Payer: Cash Price |
$55.70
|
| Rate for Payer: Cofinity Commercial |
$48.73
|
| Rate for Payer: Cofinity Commercial |
$59.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.70
|
| Rate for Payer: Healthscope Commercial |
$62.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.18
|
| Rate for Payer: PHP Commercial |
$59.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.25
|
| Rate for Payer: Priority Health SBD |
$43.86
|
| Rate for Payer: UMR Bronson Commercial |
$30.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.22
|
|
|
TROPICAMIDE 0.5 % EYE DROPS
|
Facility
|
OP
|
$21.84
|
|
|
Service Code
|
NDC 17478010112
|
| Hospital Charge Code |
8249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna American Axle |
$14.20
|
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna Medicare |
$10.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.20
|
| Rate for Payer: BCBS Complete |
$8.74
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Cofinity Commercial |
$18.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.47
|
| Rate for Payer: Healthscope Commercial |
$19.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.56
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.20
|
| Rate for Payer: Priority Health SBD |
$13.76
|
| Rate for Payer: UMR Bronson Commercial |
$8.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.38
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$33.18
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.28 |
| Max. Negotiated Rate |
$29.86 |
| Rate for Payer: Aetna American Axle |
$21.57
|
| Rate for Payer: Aetna Commercial |
$28.20
|
| Rate for Payer: Aetna Medicare |
$16.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.57
|
| Rate for Payer: BCBS Complete |
$13.27
|
| Rate for Payer: Cash Price |
$26.54
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Cofinity Commercial |
$28.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.54
|
| Rate for Payer: Healthscope Commercial |
$29.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.20
|
| Rate for Payer: PHP Commercial |
$28.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.57
|
| Rate for Payer: Priority Health SBD |
$20.90
|
| Rate for Payer: UMR Bronson Commercial |
$12.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.88
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$33.18
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$29.86 |
| Rate for Payer: Aetna American Axle |
$21.57
|
| Rate for Payer: Aetna Commercial |
$28.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.57
|
| Rate for Payer: Cash Price |
$26.54
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Cofinity Commercial |
$28.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.54
|
| Rate for Payer: Healthscope Commercial |
$29.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.20
|
| Rate for Payer: PHP Commercial |
$28.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.57
|
| Rate for Payer: Priority Health SBD |
$20.90
|
| Rate for Payer: UMR Bronson Commercial |
$14.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.88
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$26.20
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna American Axle |
$17.03
|
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UMR Bronson Commercial |
$9.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.65
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$26.20
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna American Axle |
$17.03
|
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UMR Bronson Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.65
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE
|
Facility
|
IP
|
$182.04
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$163.84 |
| Rate for Payer: Aetna American Axle |
$118.33
|
| Rate for Payer: Aetna Commercial |
$154.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.33
|
| Rate for Payer: Cash Price |
$145.63
|
| Rate for Payer: Cofinity Commercial |
$127.43
|
| Rate for Payer: Cofinity Commercial |
$156.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.63
|
| Rate for Payer: Healthscope Commercial |
$163.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.73
|
| Rate for Payer: PHP Commercial |
$154.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.33
|
| Rate for Payer: Priority Health SBD |
$114.69
|
| Rate for Payer: UMR Bronson Commercial |
$80.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.53
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE
|
Facility
|
OP
|
$182.04
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.35 |
| Max. Negotiated Rate |
$163.84 |
| Rate for Payer: Aetna American Axle |
$118.33
|
| Rate for Payer: Aetna Commercial |
$154.73
|
| Rate for Payer: Aetna Medicare |
$91.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.33
|
| Rate for Payer: BCBS Complete |
$72.82
|
| Rate for Payer: Cash Price |
$145.63
|
| Rate for Payer: Cofinity Commercial |
$127.43
|
| Rate for Payer: Cofinity Commercial |
$156.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.63
|
| Rate for Payer: Healthscope Commercial |
$163.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.73
|
| Rate for Payer: PHP Commercial |
$154.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.33
|
| Rate for Payer: Priority Health SBD |
$114.69
|
| Rate for Payer: UMR Bronson Commercial |
$67.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.53
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION
|
Facility
|
OP
|
$1,138.84
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.33 |
| Max. Negotiated Rate |
$1,024.96 |
| Rate for Payer: Aetna American Axle |
$188.11
|
| Rate for Payer: Aetna American Axle |
$740.25
|
| Rate for Payer: Aetna American Axle |
$172.91
|
| Rate for Payer: Aetna Commercial |
$245.99
|
| Rate for Payer: Aetna Commercial |
$968.01
|
| Rate for Payer: Aetna Commercial |
$226.11
|
| Rate for Payer: Aetna Medicare |
$24.95
|
| Rate for Payer: Aetna Medicare |
$24.95
|
| Rate for Payer: Aetna Medicare |
$24.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$740.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.99
|
| Rate for Payer: BCBS Complete |
$13.50
|
| Rate for Payer: BCBS Complete |
$13.50
|
| Rate for Payer: BCBS Complete |
$13.50
|
| Rate for Payer: BCBS MAPPO |
$23.99
|
| Rate for Payer: BCBS MAPPO |
$23.99
|
| Rate for Payer: BCBS MAPPO |
$23.99
|
| Rate for Payer: BCBS Trust/PPO |
$15.90
|
| Rate for Payer: BCBS Trust/PPO |
$15.90
|
| Rate for Payer: BCBS Trust/PPO |
$15.90
|
| Rate for Payer: BCN Commercial |
$15.90
|
| Rate for Payer: BCN Commercial |
$15.90
|
| Rate for Payer: BCN Commercial |
$15.90
|
| Rate for Payer: BCN Medicare Advantage |
$23.99
|
| Rate for Payer: BCN Medicare Advantage |
$23.99
|
| Rate for Payer: BCN Medicare Advantage |
$23.99
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$911.07
|
| Rate for Payer: Cash Price |
$911.07
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$212.81
|
| Rate for Payer: Cash Price |
$212.81
|
| Rate for Payer: Cofinity Commercial |
$248.88
|
| Rate for Payer: Cofinity Commercial |
$979.40
|
| Rate for Payer: Cofinity Commercial |
$797.19
|
| Rate for Payer: Cofinity Commercial |
$228.77
|
| Rate for Payer: Cofinity Commercial |
$186.21
|
| Rate for Payer: Cofinity Commercial |
$202.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$797.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$911.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.99
|
| Rate for Payer: Healthscope Commercial |
$1,024.96
|
| Rate for Payer: Healthscope Commercial |
$260.46
|
| Rate for Payer: Healthscope Commercial |
$239.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$797.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$854.13
|
| Rate for Payer: Mclaren Medicaid |
$12.86
|
| Rate for Payer: Mclaren Medicaid |
$12.86
|
| Rate for Payer: Mclaren Medicaid |
$12.86
|
| Rate for Payer: Mclaren Medicare |
$23.99
|
| Rate for Payer: Mclaren Medicare |
$23.99
|
| Rate for Payer: Mclaren Medicare |
$23.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.19
|
| Rate for Payer: Meridian Medicaid |
$13.50
|
| Rate for Payer: Meridian Medicaid |
$13.50
|
| Rate for Payer: Meridian Medicaid |
$13.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$968.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.11
|
| Rate for Payer: Nomi Health Commercial |
$71.97
|
| Rate for Payer: Nomi Health Commercial |
$71.97
|
| Rate for Payer: Nomi Health Commercial |
$71.97
|
| Rate for Payer: PACE Medicare |
$22.79
|
| Rate for Payer: PACE Medicare |
$22.79
|
| Rate for Payer: PACE Medicare |
$22.79
|
| Rate for Payer: PACE SWMI |
$23.99
|
| Rate for Payer: PACE SWMI |
$23.99
|
| Rate for Payer: PACE SWMI |
$23.99
|
| Rate for Payer: PHP Commercial |
$226.11
|
| Rate for Payer: PHP Commercial |
$968.01
|
| Rate for Payer: PHP Commercial |
$245.99
|
| Rate for Payer: PHP Medicare Advantage |
$23.99
|
| Rate for Payer: PHP Medicare Advantage |
$23.99
|
| Rate for Payer: PHP Medicare Advantage |
$23.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$740.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.43
|
| Rate for Payer: Priority Health Medicare |
$23.99
|
| Rate for Payer: Priority Health Medicare |
$23.99
|
| Rate for Payer: Priority Health Medicare |
$23.99
|
| Rate for Payer: Priority Health Narrow Network |
$60.34
|
| Rate for Payer: Priority Health Narrow Network |
$60.34
|
| Rate for Payer: Priority Health Narrow Network |
$60.34
|
| Rate for Payer: Priority Health SBD |
$717.47
|
| Rate for Payer: Priority Health SBD |
$167.59
|
| Rate for Payer: Priority Health SBD |
$182.32
|
| Rate for Payer: Railroad Medicare Medicare |
$23.99
|
| Rate for Payer: Railroad Medicare Medicare |
$23.99
|
| Rate for Payer: Railroad Medicare Medicare |
$23.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.26
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.99
|
| Rate for Payer: UHC Exchange |
$9.33
|
| Rate for Payer: UHC Exchange |
$9.33
|
| Rate for Payer: UHC Exchange |
$9.33
|
| Rate for Payer: UHC Medicare Advantage |
$23.99
|
| Rate for Payer: UHC Medicare Advantage |
$23.99
|
| Rate for Payer: UHC Medicare Advantage |
$23.99
|
| Rate for Payer: UHCCP Medicaid |
$12.86
|
| Rate for Payer: UHCCP Medicaid |
$12.86
|
| Rate for Payer: UHCCP Medicaid |
$12.86
|
| Rate for Payer: UMR Bronson Commercial |
$98.42
|
| Rate for Payer: UMR Bronson Commercial |
$421.37
|
| Rate for Payer: UMR Bronson Commercial |
$107.08
|
| Rate for Payer: VA VA |
$23.99
|
| Rate for Payer: VA VA |
$23.99
|
| Rate for Payer: VA VA |
$23.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$854.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.51
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION
|
Facility
|
IP
|
$1,138.84
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$501.09 |
| Max. Negotiated Rate |
$1,024.96 |
| Rate for Payer: Aetna American Axle |
$740.25
|
| Rate for Payer: Aetna American Axle |
$172.91
|
| Rate for Payer: Aetna American Axle |
$188.11
|
| Rate for Payer: Aetna Commercial |
$226.11
|
| Rate for Payer: Aetna Commercial |
$968.01
|
| Rate for Payer: Aetna Commercial |
$245.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$740.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.91
|
| Rate for Payer: Cash Price |
$231.52
|
| Rate for Payer: Cash Price |
$212.81
|
| Rate for Payer: Cash Price |
$911.07
|
| Rate for Payer: Cofinity Commercial |
$979.40
|
| Rate for Payer: Cofinity Commercial |
$228.77
|
| Rate for Payer: Cofinity Commercial |
$186.21
|
| Rate for Payer: Cofinity Commercial |
$248.88
|
| Rate for Payer: Cofinity Commercial |
$202.58
|
| Rate for Payer: Cofinity Commercial |
$797.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$797.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$911.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.81
|
| Rate for Payer: Healthscope Commercial |
$239.41
|
| Rate for Payer: Healthscope Commercial |
$1,024.96
|
| Rate for Payer: Healthscope Commercial |
$260.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$797.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$854.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$968.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.11
|
| Rate for Payer: PHP Commercial |
$245.99
|
| Rate for Payer: PHP Commercial |
$226.11
|
| Rate for Payer: PHP Commercial |
$968.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$740.25
|
| Rate for Payer: Priority Health SBD |
$182.32
|
| Rate for Payer: Priority Health SBD |
$167.59
|
| Rate for Payer: Priority Health SBD |
$717.47
|
| Rate for Payer: UMR Bronson Commercial |
$501.09
|
| Rate for Payer: UMR Bronson Commercial |
$127.34
|
| Rate for Payer: UMR Bronson Commercial |
$117.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$854.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.51
|
|
|
TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$4,783.71
|
|
|
Service Code
|
CPT 32551
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$150.33 |
| Max. Negotiated Rate |
$4,783.71 |
| Rate for Payer: Aetna Medicare |
$1,582.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,902.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,902.54
|
| Rate for Payer: BCBS Complete |
$856.60
|
| Rate for Payer: BCBS MAPPO |
$1,522.03
|
| Rate for Payer: BCBS Trust/PPO |
$873.76
|
| Rate for Payer: BCN Commercial |
$873.76
|
| Rate for Payer: BCN Medicare Advantage |
$1,522.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,522.03
|
| Rate for Payer: Mclaren Medicaid |
$815.81
|
| Rate for Payer: Mclaren Medicare |
$1,522.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,598.13
|
| Rate for Payer: Meridian Medicaid |
$856.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,750.33
|
| Rate for Payer: Nomi Health Commercial |
$3,196.26
|
| Rate for Payer: PACE Medicare |
$1,445.93
|
| Rate for Payer: PACE SWMI |
$1,522.03
|
| Rate for Payer: PHP Medicare Advantage |
$1,522.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$815.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,783.71
|
| Rate for Payer: Priority Health Medicare |
$1,522.03
|
| Rate for Payer: Priority Health Narrow Network |
$3,826.97
|
| Rate for Payer: Railroad Medicare Medicare |
$1,522.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$165.36
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,522.03
|
| Rate for Payer: UHC Exchange |
$150.33
|
| Rate for Payer: UHC Medicare Advantage |
$1,522.03
|
| Rate for Payer: UHCCP Medicaid |
$815.81
|
| Rate for Payer: VA VA |
$1,522.03
|
|
|
TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH
|
Facility
|
OP
|
$4,561.52
|
|
|
Service Code
|
CPT 69610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$275.89 |
| Max. Negotiated Rate |
$4,561.52 |
| Rate for Payer: Aetna Medicare |
$1,509.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,814.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,814.16
|
| Rate for Payer: BCBS Complete |
$816.81
|
| Rate for Payer: BCBS MAPPO |
$1,451.33
|
| Rate for Payer: BCBS Trust/PPO |
$275.89
|
| Rate for Payer: BCN Commercial |
$275.89
|
| Rate for Payer: BCN Medicare Advantage |
$1,451.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,451.33
|
| Rate for Payer: Mclaren Medicaid |
$777.91
|
| Rate for Payer: Mclaren Medicare |
$1,451.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,523.90
|
| Rate for Payer: Meridian Medicaid |
$816.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,669.03
|
| Rate for Payer: Nomi Health Commercial |
$3,047.79
|
| Rate for Payer: PACE Medicare |
$1,378.76
|
| Rate for Payer: PACE SWMI |
$1,451.33
|
| Rate for Payer: PHP Medicare Advantage |
$1,451.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$777.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,561.52
|
| Rate for Payer: Priority Health Medicare |
$1,451.33
|
| Rate for Payer: Priority Health Narrow Network |
$3,649.22
|
| Rate for Payer: Railroad Medicare Medicare |
$1,451.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$305.04
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,451.33
|
| Rate for Payer: UHC Exchange |
$277.31
|
| Rate for Payer: UHC Medicare Advantage |
$1,451.33
|
| Rate for Payer: UHCCP Medicaid |
$777.91
|
| Rate for Payer: VA VA |
$1,451.33
|
|
|
TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 69635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,210.93 |
| 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 |
$3,836.19
|
| Rate for Payer: BCN Commercial |
$3,836.19
|
| 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) |
$1,332.02
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$1,210.93
|
| 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
|
|
|
TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED CANAL WALL, WITH OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 69644
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,422.96 |
| 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 |
$3,968.49
|
| Rate for Payer: BCN Commercial |
$3,968.49
|
| 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) |
$1,565.26
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$1,422.96
|
| 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
|
|
|
TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED WALL, WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 69643
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,164.35 |
| 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 |
$3,836.19
|
| Rate for Payer: BCN Commercial |
$3,836.19
|
| 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) |
$1,280.78
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$1,164.35
|
| 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
|
|
