|
ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION
|
Facility
IP
|
$123.31
|
|
|
Service Code
|
NDC 0006-5424-02
|
| Hospital Charge Code |
24188
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.26 |
| Max. Negotiated Rate |
$110.98 |
| Rate for Payer: Aetna American Axle |
$80.15
|
| Rate for Payer: Aetna Commercial |
$104.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.15
|
| Rate for Payer: Cash Price |
$98.65
|
| Rate for Payer: Cofinity Commercial |
$106.05
|
| Rate for Payer: Cofinity Commercial |
$86.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.65
|
| Rate for Payer: Healthscope Commercial |
$110.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.81
|
| Rate for Payer: PHP Commercial |
$104.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.32
|
| Rate for Payer: Priority Health SBD |
$77.69
|
| Rate for Payer: UMR Bronson Commercial |
$54.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.48
|
|
|
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC
|
Facility
IP
|
$115,422.52
|
|
|
Service Code
|
MS-DRG 268
|
| Min. Negotiated Rate |
$50,668.16 |
| Max. Negotiated Rate |
$115,422.52 |
| Rate for Payer: Aetna Medicare |
$55,468.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66,668.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66,668.62
|
| Rate for Payer: BCBS MAPPO |
$53,334.90
|
| Rate for Payer: BCBS Trust/PPO |
$115,422.52
|
| Rate for Payer: BCN Medicare Advantage |
$53,334.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$53,334.90
|
| Rate for Payer: Mclaren Medicare |
$53,334.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$56,001.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61,335.14
|
| Rate for Payer: PACE Medicare |
$50,668.16
|
| Rate for Payer: PACE SWMI |
$53,334.90
|
| Rate for Payer: PHP Medicare Advantage |
$53,334.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$98,364.40
|
| Rate for Payer: Priority Health Medicare |
$53,334.90
|
| Rate for Payer: Priority Health Narrow Network |
$78,691.52
|
| Rate for Payer: Railroad Medicare Medicare |
$53,334.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104,561.59
|
| Rate for Payer: UHC Core |
$85,738.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$53,334.90
|
| Rate for Payer: UHC Exchange |
$68,163.14
|
| Rate for Payer: UHC Medicare Advantage |
$54,934.95
|
| Rate for Payer: VA VA |
$53,334.90
|
|
|
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC
|
Facility
IP
|
$74,638.16
|
|
|
Service Code
|
MS-DRG 269
|
| Min. Negotiated Rate |
$30,930.74 |
| Max. Negotiated Rate |
$74,638.16 |
| Rate for Payer: Aetna Medicare |
$33,861.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$40,698.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$40,698.34
|
| Rate for Payer: BCBS MAPPO |
$32,558.67
|
| Rate for Payer: BCBS Trust/PPO |
$74,638.16
|
| Rate for Payer: BCN Medicare Advantage |
$32,558.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32,558.67
|
| Rate for Payer: Mclaren Medicare |
$32,558.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$34,186.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37,442.47
|
| Rate for Payer: PACE Medicare |
$30,930.74
|
| Rate for Payer: PACE SWMI |
$32,558.67
|
| Rate for Payer: PHP Medicare Advantage |
$32,558.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$59,675.58
|
| Rate for Payer: Priority Health Medicare |
$32,558.67
|
| Rate for Payer: Priority Health Narrow Network |
$47,740.46
|
| Rate for Payer: Railroad Medicare Medicare |
$32,558.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63,435.28
|
| Rate for Payer: UHC Core |
$52,015.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$32,558.67
|
| Rate for Payer: UHC Exchange |
$41,353.12
|
| Rate for Payer: UHC Medicare Advantage |
$33,535.43
|
| Rate for Payer: VA VA |
$32,558.67
|
|
|
APIXABAN 2.5 MG TABLET
|
Facility
IP
|
$401.76
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
163984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.77 |
| Max. Negotiated Rate |
$361.58 |
| Rate for Payer: Aetna American Axle |
$261.14
|
| Rate for Payer: Aetna Commercial |
$341.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.14
|
| Rate for Payer: Cash Price |
$321.41
|
| Rate for Payer: Cofinity Commercial |
$281.23
|
| Rate for Payer: Cofinity Commercial |
$345.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.41
|
| Rate for Payer: Healthscope Commercial |
$361.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$341.50
|
| Rate for Payer: PHP Commercial |
$341.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.23
|
| Rate for Payer: Priority Health SBD |
$253.11
|
| Rate for Payer: UMR Bronson Commercial |
$176.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.32
|
|
|
APIXABAN 2.5 MG TABLET
|
Facility
IP
|
$669.60
|
|
|
Service Code
|
NDC 0003-0893-31
|
| Hospital Charge Code |
163984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.62 |
| Max. Negotiated Rate |
$602.64 |
| Rate for Payer: Aetna American Axle |
$435.24
|
| Rate for Payer: Aetna Commercial |
$569.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$435.24
|
| Rate for Payer: Cash Price |
$535.68
|
| Rate for Payer: Cofinity Commercial |
$468.72
|
| Rate for Payer: Cofinity Commercial |
$575.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$535.68
|
| Rate for Payer: Healthscope Commercial |
$602.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$468.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$502.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$569.16
|
| Rate for Payer: PHP Commercial |
$569.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.72
|
| Rate for Payer: Priority Health SBD |
$421.85
|
| Rate for Payer: UMR Bronson Commercial |
$294.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$502.20
|
|
|
APIXABAN 5 MG TABLET
|
Facility
IP
|
$401.76
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
164098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.77 |
| Max. Negotiated Rate |
$361.58 |
| Rate for Payer: Aetna American Axle |
$261.14
|
| Rate for Payer: Aetna Commercial |
$341.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.14
|
| Rate for Payer: Cash Price |
$321.41
|
| Rate for Payer: Cofinity Commercial |
$281.23
|
| Rate for Payer: Cofinity Commercial |
$345.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.41
|
| Rate for Payer: Healthscope Commercial |
$361.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$341.50
|
| Rate for Payer: PHP Commercial |
$341.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.23
|
| Rate for Payer: Priority Health SBD |
$253.11
|
| Rate for Payer: UMR Bronson Commercial |
$176.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.32
|
|
|
APIXABAN 5 MG TABLET
|
Facility
IP
|
$669.60
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
164098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.62 |
| Max. Negotiated Rate |
$602.64 |
| Rate for Payer: Aetna American Axle |
$435.24
|
| Rate for Payer: Aetna Commercial |
$569.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$435.24
|
| Rate for Payer: Cash Price |
$535.68
|
| Rate for Payer: Cofinity Commercial |
$468.72
|
| Rate for Payer: Cofinity Commercial |
$575.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$535.68
|
| Rate for Payer: Healthscope Commercial |
$602.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$468.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$502.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$569.16
|
| Rate for Payer: PHP Commercial |
$569.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.72
|
| Rate for Payer: Priority Health SBD |
$421.85
|
| Rate for Payer: UMR Bronson Commercial |
$294.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$502.20
|
|
|
APPENDECTOMY; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (NOT AS SEPARATE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
CPT 44955
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.21 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$293.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.33
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$81.21
|
|
|
APPENDIX PROCEDURES WITH CC
|
Facility
IP
|
$28,905.89
|
|
|
Service Code
|
MS-DRG 398
|
| Min. Negotiated Rate |
$11,565.19 |
| Max. Negotiated Rate |
$28,905.89 |
| Rate for Payer: Aetna Medicare |
$12,660.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,217.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,217.35
|
| Rate for Payer: BCBS MAPPO |
$12,173.88
|
| Rate for Payer: BCBS Trust/PPO |
$28,905.89
|
| Rate for Payer: BCN Medicare Advantage |
$12,173.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,173.88
|
| Rate for Payer: Mclaren Medicare |
$12,173.88
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,782.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,999.96
|
| Rate for Payer: PACE Medicare |
$11,565.19
|
| Rate for Payer: PACE SWMI |
$12,173.88
|
| Rate for Payer: PHP Medicare Advantage |
$12,173.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,715.73
|
| Rate for Payer: Priority Health Medicare |
$12,173.88
|
| Rate for Payer: Priority Health Narrow Network |
$17,372.58
|
| Rate for Payer: Railroad Medicare Medicare |
$12,173.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23,083.88
|
| Rate for Payer: UHC Core |
$18,928.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,173.88
|
| Rate for Payer: UHC Exchange |
$15,048.26
|
| Rate for Payer: UHC Medicare Advantage |
$12,539.10
|
| Rate for Payer: VA VA |
$12,173.88
|
|
|
APPENDIX PROCEDURES WITH MCC
|
Facility
IP
|
$34,269.64
|
|
|
Service Code
|
MS-DRG 397
|
| Min. Negotiated Rate |
$16,933.49 |
| Max. Negotiated Rate |
$34,269.64 |
| Rate for Payer: Aetna Medicare |
$18,537.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22,280.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22,280.91
|
| Rate for Payer: BCBS MAPPO |
$17,824.73
|
| Rate for Payer: BCBS Trust/PPO |
$33,034.58
|
| Rate for Payer: BCN Medicare Advantage |
$17,824.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,824.73
|
| Rate for Payer: Mclaren Medicare |
$17,824.73
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18,715.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,498.44
|
| Rate for Payer: PACE Medicare |
$16,933.49
|
| Rate for Payer: PACE SWMI |
$17,824.73
|
| Rate for Payer: PHP Medicare Advantage |
$17,824.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32,238.53
|
| Rate for Payer: Priority Health Medicare |
$17,824.73
|
| Rate for Payer: Priority Health Narrow Network |
$25,790.82
|
| Rate for Payer: Railroad Medicare Medicare |
$17,824.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34,269.64
|
| Rate for Payer: UHC Core |
$28,100.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$17,824.73
|
| Rate for Payer: UHC Exchange |
$22,340.19
|
| Rate for Payer: UHC Medicare Advantage |
$18,359.47
|
| Rate for Payer: VA VA |
$17,824.73
|
|
|
APPENDIX PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$24,412.82
|
|
|
Service Code
|
MS-DRG 399
|
| Min. Negotiated Rate |
$8,635.44 |
| Max. Negotiated Rate |
$24,412.82 |
| Rate for Payer: Aetna Medicare |
$9,453.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,362.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,362.42
|
| Rate for Payer: BCBS MAPPO |
$9,089.94
|
| Rate for Payer: BCBS Trust/PPO |
$24,412.82
|
| Rate for Payer: BCN Medicare Advantage |
$9,089.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,089.94
|
| Rate for Payer: Mclaren Medicare |
$9,089.94
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,544.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,453.43
|
| Rate for Payer: PACE Medicare |
$8,635.44
|
| Rate for Payer: PACE SWMI |
$9,089.94
|
| Rate for Payer: PHP Medicare Advantage |
$9,089.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,972.90
|
| Rate for Payer: Priority Health Medicare |
$9,089.94
|
| Rate for Payer: Priority Health Narrow Network |
$12,778.32
|
| Rate for Payer: Railroad Medicare Medicare |
$9,089.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,979.23
|
| Rate for Payer: UHC Core |
$13,922.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,089.94
|
| Rate for Payer: UHC Exchange |
$11,068.67
|
| Rate for Payer: UHC Medicare Advantage |
$9,362.64
|
| Rate for Payer: VA VA |
$9,089.94
|
|
|
APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)
|
Facility
OP
|
$36,827.89
|
|
|
Service Code
|
CPT 20692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,116.25 |
| Max. Negotiated Rate |
$36,827.89 |
| Rate for Payer: Aetna Medicare |
$12,166.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,623.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,623.31
|
| Rate for Payer: BCBS Complete |
$6,719.70
|
| Rate for Payer: BCBS MAPPO |
$11,698.65
|
| Rate for Payer: BCBS Trust/PPO |
$9,565.27
|
| Rate for Payer: BCN Medicare Advantage |
$11,698.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,698.65
|
| Rate for Payer: Mclaren Medicaid |
$6,399.16
|
| Rate for Payer: Mclaren Medicare |
$11,698.65
|
| Rate for Payer: Meridian Medicaid |
$6,719.70
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,283.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,453.45
|
| Rate for Payer: PACE Medicare |
$11,113.72
|
| Rate for Payer: PACE SWMI |
$11,698.65
|
| Rate for Payer: PHP Medicare Advantage |
$11,698.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,399.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$36,827.89
|
| Rate for Payer: Priority Health Medicare |
$11,698.65
|
| Rate for Payer: Priority Health Narrow Network |
$29,462.31
|
| Rate for Payer: Railroad Medicare Medicare |
$11,698.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,227.88
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,698.65
|
| Rate for Payer: UHC Exchange |
$1,116.25
|
| Rate for Payer: UHC Medicare Advantage |
$12,049.61
|
| Rate for Payer: VA VA |
$11,698.65
|
|
|
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM
|
Facility
OP
|
$20,018.71
|
|
|
Service Code
|
CPT 20690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$590.71 |
| Max. Negotiated Rate |
$20,018.71 |
| Rate for Payer: Aetna Medicare |
$6,613.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,948.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,948.86
|
| Rate for Payer: BCBS Complete |
$3,652.66
|
| Rate for Payer: BCBS MAPPO |
$6,359.09
|
| Rate for Payer: BCBS Trust/PPO |
$3,934.75
|
| Rate for Payer: BCN Medicare Advantage |
$6,359.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,359.09
|
| Rate for Payer: Mclaren Medicaid |
$3,478.42
|
| Rate for Payer: Mclaren Medicare |
$6,359.09
|
| Rate for Payer: Meridian Medicaid |
$3,652.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,677.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,312.95
|
| Rate for Payer: PACE Medicare |
$6,041.14
|
| Rate for Payer: PACE SWMI |
$6,359.09
|
| Rate for Payer: PHP Medicare Advantage |
$6,359.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,478.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,018.71
|
| Rate for Payer: Priority Health Medicare |
$6,359.09
|
| Rate for Payer: Priority Health Narrow Network |
$16,014.97
|
| Rate for Payer: Railroad Medicare Medicare |
$6,359.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$649.78
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,359.09
|
| Rate for Payer: UHC Exchange |
$590.71
|
| Rate for Payer: UHC Medicare Advantage |
$6,549.86
|
| Rate for Payer: VA VA |
$6,359.09
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
CPT C5276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: UHC Core |
$700.00
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$1,757.43
|
|
|
Service Code
|
CPT C5275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$305.37 |
| Max. Negotiated Rate |
$1,757.43 |
| Rate for Payer: Aetna Medicare |
$580.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$697.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$697.82
|
| Rate for Payer: BCBS Complete |
$320.66
|
| Rate for Payer: BCBS MAPPO |
$558.26
|
| Rate for Payer: BCBS Trust/PPO |
$424.19
|
| Rate for Payer: BCN Medicare Advantage |
$558.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$558.26
|
| Rate for Payer: Mclaren Medicaid |
$305.37
|
| Rate for Payer: Mclaren Medicare |
$558.26
|
| Rate for Payer: Meridian Medicaid |
$320.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$586.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$642.00
|
| Rate for Payer: PACE Medicare |
$530.35
|
| Rate for Payer: PACE SWMI |
$558.26
|
| Rate for Payer: PHP Medicare Advantage |
$558.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$305.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,757.43
|
| Rate for Payer: Priority Health Medicare |
$558.26
|
| Rate for Payer: Priority Health Narrow Network |
$1,405.94
|
| Rate for Payer: Railroad Medicare Medicare |
$558.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,565.19
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$558.26
|
| Rate for Payer: UHC Exchange |
$1,066.89
|
| Rate for Payer: UHC Medicare Advantage |
$575.01
|
| Rate for Payer: VA VA |
$558.26
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
CPT 15278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$54.03 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$293.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.43
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$54.03
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15277
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$216.44 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$4,132.50
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.08
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$216.44
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
CPT 15276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$24.23 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$119.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.65
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$24.23
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$90.70 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$1,578.49
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.77
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$90.70
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$90.70 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$1,578.49
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.77
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$90.70
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
CPT 15272
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.37 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$92.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.01
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$16.37
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.86 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$1,971.68
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.05
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$81.86
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$5,102.91
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$81.86 |
| Max. Negotiated Rate |
$5,102.91 |
| Rate for Payer: Aetna Medicare |
$1,685.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,026.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,026.22
|
| Rate for Payer: BCBS Complete |
$931.09
|
| Rate for Payer: BCBS MAPPO |
$1,620.98
|
| Rate for Payer: BCBS Trust/PPO |
$1,971.68
|
| Rate for Payer: BCN Medicare Advantage |
$1,620.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,620.98
|
| Rate for Payer: Mclaren Medicaid |
$886.68
|
| Rate for Payer: Mclaren Medicare |
$1,620.98
|
| Rate for Payer: Meridian Medicaid |
$931.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,702.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,864.13
|
| Rate for Payer: PACE Medicare |
$1,539.93
|
| Rate for Payer: PACE SWMI |
$1,620.98
|
| Rate for Payer: PHP Medicare Advantage |
$1,620.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$886.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,102.91
|
| Rate for Payer: Priority Health Medicare |
$1,620.98
|
| Rate for Payer: Priority Health Narrow Network |
$4,082.33
|
| Rate for Payer: Railroad Medicare Medicare |
$1,620.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.05
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,620.98
|
| Rate for Payer: UHC Exchange |
$81.86
|
| Rate for Payer: UHC Medicare Advantage |
$1,669.61
|
| Rate for Payer: VA VA |
$1,620.98
|
|
|
APRACLONIDINE 0.5 % EYE DROPS
|
Facility
IP
|
$137.41
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
9119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.46 |
| Max. Negotiated Rate |
$123.67 |
| Rate for Payer: Aetna American Axle |
$89.32
|
| Rate for Payer: Aetna Commercial |
$116.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.32
|
| Rate for Payer: Cash Price |
$109.93
|
| Rate for Payer: Cofinity Commercial |
$118.17
|
| Rate for Payer: Cofinity Commercial |
$96.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.93
|
| Rate for Payer: Healthscope Commercial |
$123.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$96.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$116.80
|
| Rate for Payer: PHP Commercial |
$116.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.19
|
| Rate for Payer: Priority Health SBD |
$86.57
|
| Rate for Payer: UMR Bronson Commercial |
$60.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.06
|
|
|
APRACLONIDINE 1 % EYE DROPS IN A DROPPERETTE
|
Facility
IP
|
$95.42
|
|
|
Service Code
|
NDC 0065-0660-10
|
| Hospital Charge Code |
9120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.98 |
| Max. Negotiated Rate |
$85.88 |
| Rate for Payer: Aetna American Axle |
$62.02
|
| Rate for Payer: Aetna Commercial |
$81.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.02
|
| Rate for Payer: Cash Price |
$76.34
|
| Rate for Payer: Cofinity Commercial |
$66.79
|
| Rate for Payer: Cofinity Commercial |
$82.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.34
|
| Rate for Payer: Healthscope Commercial |
$85.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.11
|
| Rate for Payer: PHP Commercial |
$81.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.79
|
| Rate for Payer: Priority Health SBD |
$60.11
|
| Rate for Payer: UMR Bronson Commercial |
$41.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.56
|
|
