|
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
|
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
|
|
|
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
|
|
|
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
|
|
|
APREPITANT 125 MG (25 MG/ML FINAL CONCENTRATION) ORAL SUSPENSION
|
Facility
|
IP
|
$1,176.23
|
|
|
Service Code
|
NDC 0006-3066-03
|
| Hospital Charge Code |
179507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$517.54 |
| Max. Negotiated Rate |
$1,058.61 |
| Rate for Payer: Aetna American Axle |
$764.55
|
| Rate for Payer: Aetna Commercial |
$999.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$764.55
|
| Rate for Payer: Cash Price |
$940.98
|
| Rate for Payer: Cofinity Commercial |
$1,011.56
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$940.98
|
| Rate for Payer: Healthscope Commercial |
$1,058.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$823.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$882.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$999.80
|
| Rate for Payer: PHP Commercial |
$999.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$823.36
|
| Rate for Payer: Priority Health SBD |
$741.02
|
| Rate for Payer: UMR Bronson Commercial |
$517.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$882.17
|
|
|
APREPITANT 125 MG (25 MG/ML FINAL CONCENTRATION) ORAL SUSPENSION
|
Facility
|
IP
|
$1,176.23
|
|
|
Service Code
|
NDC 0006-3066-01
|
| Hospital Charge Code |
179507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$517.54 |
| Max. Negotiated Rate |
$1,058.61 |
| Rate for Payer: Aetna American Axle |
$764.55
|
| Rate for Payer: Aetna Commercial |
$999.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$764.55
|
| Rate for Payer: Cash Price |
$940.98
|
| Rate for Payer: Cofinity Commercial |
$1,011.56
|
| Rate for Payer: Cofinity Commercial |
$823.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$940.98
|
| Rate for Payer: Healthscope Commercial |
$1,058.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$823.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$882.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$999.80
|
| Rate for Payer: PHP Commercial |
$999.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$823.36
|
| Rate for Payer: Priority Health SBD |
$741.02
|
| Rate for Payer: UMR Bronson Commercial |
$517.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$882.17
|
|
|
APREPITANT 125 MG CAPSULE
|
Facility
|
IP
|
$739.51
|
|
|
Service Code
|
NDC 0781-2323-06
|
| Hospital Charge Code |
35489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$325.38 |
| Max. Negotiated Rate |
$665.56 |
| Rate for Payer: Aetna American Axle |
$480.68
|
| Rate for Payer: Aetna Commercial |
$628.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$480.68
|
| Rate for Payer: Cash Price |
$591.61
|
| Rate for Payer: Cofinity Commercial |
$517.66
|
| Rate for Payer: Cofinity Commercial |
$635.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$591.61
|
| Rate for Payer: Healthscope Commercial |
$665.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$517.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$554.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$628.58
|
| Rate for Payer: PHP Commercial |
$628.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$517.66
|
| Rate for Payer: Priority Health SBD |
$465.89
|
| Rate for Payer: UMR Bronson Commercial |
$325.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$554.63
|
|
|
APREPITANT 125 MG CAPSULE
|
Facility
|
IP
|
$4,437.05
|
|
|
Service Code
|
NDC 0781-2323-68
|
| Hospital Charge Code |
35489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,952.30 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Aetna American Axle |
$2,884.08
|
| Rate for Payer: Aetna Commercial |
$3,771.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,884.08
|
| Rate for Payer: Cash Price |
$3,549.64
|
| Rate for Payer: Cofinity Commercial |
$3,105.94
|
| Rate for Payer: Cofinity Commercial |
$3,815.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,549.64
|
| Rate for Payer: Healthscope Commercial |
$3,993.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,105.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,327.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,771.49
|
| Rate for Payer: PHP Commercial |
$3,771.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,105.94
|
| Rate for Payer: Priority Health SBD |
$2,795.34
|
| Rate for Payer: UMR Bronson Commercial |
$1,952.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,327.79
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$255.38
|
|
|
Service Code
|
NDC 0781-2321-06
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.37 |
| Max. Negotiated Rate |
$229.84 |
| Rate for Payer: Aetna American Axle |
$166.00
|
| Rate for Payer: Aetna Commercial |
$217.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.00
|
| Rate for Payer: Cash Price |
$204.30
|
| Rate for Payer: Cofinity Commercial |
$178.77
|
| Rate for Payer: Cofinity Commercial |
$219.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.30
|
| Rate for Payer: Healthscope Commercial |
$229.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.07
|
| Rate for Payer: PHP Commercial |
$217.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.77
|
| Rate for Payer: Priority Health SBD |
$160.89
|
| Rate for Payer: UMR Bronson Commercial |
$112.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.54
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$907.84
|
|
|
Service Code
|
NDC 13668-591-82
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$399.45 |
| Max. Negotiated Rate |
$817.06 |
| Rate for Payer: Aetna American Axle |
$590.10
|
| Rate for Payer: Aetna Commercial |
$771.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$590.10
|
| Rate for Payer: Cash Price |
$726.27
|
| Rate for Payer: Cofinity Commercial |
$635.49
|
| Rate for Payer: Cofinity Commercial |
$780.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$726.27
|
| Rate for Payer: Healthscope Commercial |
$817.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$635.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$680.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$771.66
|
| Rate for Payer: PHP Commercial |
$771.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$635.49
|
| Rate for Payer: Priority Health SBD |
$571.94
|
| Rate for Payer: UMR Bronson Commercial |
$399.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$680.88
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$1,545.68
|
|
|
Service Code
|
NDC 68462-583-85
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$680.10 |
| Max. Negotiated Rate |
$1,391.11 |
| Rate for Payer: Aetna American Axle |
$1,004.69
|
| Rate for Payer: Aetna Commercial |
$1,313.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,004.69
|
| Rate for Payer: Cash Price |
$1,236.54
|
| Rate for Payer: Cofinity Commercial |
$1,081.98
|
| Rate for Payer: Cofinity Commercial |
$1,329.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,236.54
|
| Rate for Payer: Healthscope Commercial |
$1,391.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,081.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,159.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,313.83
|
| Rate for Payer: PHP Commercial |
$1,313.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,081.98
|
| Rate for Payer: Priority Health SBD |
$973.78
|
| Rate for Payer: UMR Bronson Commercial |
$680.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,159.26
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$371.92
|
|
|
Service Code
|
NDC 0006-0464-01
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.64 |
| Max. Negotiated Rate |
$334.73 |
| Rate for Payer: Aetna American Axle |
$241.75
|
| Rate for Payer: Aetna Commercial |
$316.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.75
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Cofinity Commercial |
$260.34
|
| Rate for Payer: Cofinity Commercial |
$319.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.54
|
| Rate for Payer: Healthscope Commercial |
$334.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$316.13
|
| Rate for Payer: PHP Commercial |
$316.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.34
|
| Rate for Payer: Priority Health SBD |
$234.31
|
| Rate for Payer: UMR Bronson Commercial |
$163.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.94
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$309.14
|
|
|
Service Code
|
NDC 68462-583-40
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.02 |
| Max. Negotiated Rate |
$278.23 |
| Rate for Payer: Aetna American Axle |
$200.94
|
| Rate for Payer: Aetna Commercial |
$262.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.94
|
| Rate for Payer: Cash Price |
$247.31
|
| Rate for Payer: Cofinity Commercial |
$216.40
|
| Rate for Payer: Cofinity Commercial |
$265.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.31
|
| Rate for Payer: Healthscope Commercial |
$278.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$262.77
|
| Rate for Payer: PHP Commercial |
$262.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.40
|
| Rate for Payer: Priority Health SBD |
$194.76
|
| Rate for Payer: UMR Bronson Commercial |
$136.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.86
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$1,276.73
|
|
|
Service Code
|
NDC 0781-2321-51
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$561.76 |
| Max. Negotiated Rate |
$1,149.06 |
| Rate for Payer: Aetna American Axle |
$829.87
|
| Rate for Payer: Aetna Commercial |
$1,085.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$829.87
|
| Rate for Payer: Cash Price |
$1,021.38
|
| Rate for Payer: Cofinity Commercial |
$1,097.99
|
| Rate for Payer: Cofinity Commercial |
$893.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,021.38
|
| Rate for Payer: Healthscope Commercial |
$1,149.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$893.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$957.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,085.22
|
| Rate for Payer: PHP Commercial |
$1,085.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$893.71
|
| Rate for Payer: Priority Health SBD |
$804.34
|
| Rate for Payer: UMR Bronson Commercial |
$561.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$957.55
|
|
|
APREPITANT 40 MG CAPSULE
|
Facility
|
IP
|
$169.69
|
|
|
Service Code
|
NDC 13668-591-80
|
| Hospital Charge Code |
76843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.66 |
| Max. Negotiated Rate |
$152.72 |
| Rate for Payer: Aetna American Axle |
$110.30
|
| Rate for Payer: Aetna Commercial |
$144.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.30
|
| Rate for Payer: Cash Price |
$135.75
|
| Rate for Payer: Cofinity Commercial |
$118.78
|
| Rate for Payer: Cofinity Commercial |
$145.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.75
|
| Rate for Payer: Healthscope Commercial |
$152.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$144.24
|
| Rate for Payer: PHP Commercial |
$144.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.78
|
| Rate for Payer: Priority Health SBD |
$106.90
|
| Rate for Payer: UMR Bronson Commercial |
$74.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.27
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION
|
Facility
|
OP
|
$1,253.15
|
|
|
Service Code
|
HCPCS J0185
|
| Hospital Charge Code |
185153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1,127.84 |
| Rate for Payer: Aetna American Axle |
$814.55
|
| Rate for Payer: Aetna Commercial |
$1,065.18
|
| Rate for Payer: Aetna Medicare |
$1.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$814.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.16
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: BCBS MAPPO |
$1.73
|
| Rate for Payer: BCBS Trust/PPO |
$5.58
|
| Rate for Payer: BCN Medicare Advantage |
$1.73
|
| Rate for Payer: Cash Price |
$1,002.52
|
| Rate for Payer: Cash Price |
$1,002.52
|
| Rate for Payer: Cofinity Commercial |
$877.20
|
| Rate for Payer: Cofinity Commercial |
$1,077.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,002.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.73
|
| Rate for Payer: Healthscope Commercial |
$1,127.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$877.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$939.86
|
| Rate for Payer: Mclaren Medicaid |
$0.95
|
| Rate for Payer: Mclaren Medicare |
$1.73
|
| Rate for Payer: Meridian Medicaid |
$0.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,065.18
|
| Rate for Payer: PACE Medicare |
$1.64
|
| Rate for Payer: PACE SWMI |
$1.73
|
| Rate for Payer: PHP Commercial |
$1,065.18
|
| Rate for Payer: PHP Medicare Advantage |
$1.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$877.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.11
|
| Rate for Payer: Priority Health Medicare |
$1.73
|
| Rate for Payer: Priority Health Narrow Network |
$4.09
|
| Rate for Payer: Priority Health SBD |
$789.48
|
| Rate for Payer: Railroad Medicare Medicare |
$1.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.73
|
| Rate for Payer: UHC Medicare Advantage |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$463.67
|
| Rate for Payer: VA VA |
$1.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$939.86
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
|
IP
|
$1,505.57
|
|
|
Service Code
|
NDC 0006-0461-02
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$662.45 |
| Max. Negotiated Rate |
$1,355.01 |
| Rate for Payer: Aetna American Axle |
$978.62
|
| Rate for Payer: Aetna Commercial |
$1,279.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$978.62
|
| Rate for Payer: Cash Price |
$1,204.46
|
| Rate for Payer: Cofinity Commercial |
$1,053.90
|
| Rate for Payer: Cofinity Commercial |
$1,294.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,204.46
|
| Rate for Payer: Healthscope Commercial |
$1,355.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,053.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,129.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,279.73
|
| Rate for Payer: PHP Commercial |
$1,279.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,053.90
|
| Rate for Payer: Priority Health SBD |
$948.51
|
| Rate for Payer: UMR Bronson Commercial |
$662.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,129.18
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
|
IP
|
$946.65
|
|
|
Service Code
|
NDC 0781-2322-46
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$416.53 |
| Max. Negotiated Rate |
$851.98 |
| Rate for Payer: Aetna American Axle |
$615.32
|
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$615.32
|
| Rate for Payer: Cash Price |
$757.32
|
| Rate for Payer: Cofinity Commercial |
$662.66
|
| Rate for Payer: Cofinity Commercial |
$814.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$757.32
|
| Rate for Payer: Healthscope Commercial |
$851.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$662.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$709.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$804.65
|
| Rate for Payer: PHP Commercial |
$804.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$662.66
|
| Rate for Payer: Priority Health SBD |
$596.39
|
| Rate for Payer: UMR Bronson Commercial |
$416.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$709.99
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
|
IP
|
$473.33
|
|
|
Service Code
|
NDC 0781-2322-06
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.27 |
| Max. Negotiated Rate |
$426.00 |
| Rate for Payer: Aetna American Axle |
$307.66
|
| Rate for Payer: Aetna Commercial |
$402.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.66
|
| Rate for Payer: Cash Price |
$378.66
|
| Rate for Payer: Cofinity Commercial |
$331.33
|
| Rate for Payer: Cofinity Commercial |
$407.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.66
|
| Rate for Payer: Healthscope Commercial |
$426.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$355.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$402.33
|
| Rate for Payer: PHP Commercial |
$402.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$331.33
|
| Rate for Payer: Priority Health SBD |
$298.20
|
| Rate for Payer: UMR Bronson Commercial |
$208.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$355.00
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
|
IP
|
$560.06
|
|
|
Service Code
|
NDC 9900-0011-15
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$246.43 |
| Max. Negotiated Rate |
$504.05 |
| Rate for Payer: Aetna American Axle |
$364.04
|
| Rate for Payer: Aetna Commercial |
$476.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$364.04
|
| Rate for Payer: Cash Price |
$448.05
|
| Rate for Payer: Cofinity Commercial |
$392.04
|
| Rate for Payer: Cofinity Commercial |
$481.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$448.05
|
| Rate for Payer: Healthscope Commercial |
$504.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$392.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$420.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$476.05
|
| Rate for Payer: PHP Commercial |
$476.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$392.04
|
| Rate for Payer: Priority Health SBD |
$352.84
|
| Rate for Payer: UMR Bronson Commercial |
$246.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$420.04
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
|
IP
|
$2,839.61
|
|
|
Service Code
|
NDC 0781-2322-68
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,249.43 |
| Max. Negotiated Rate |
$2,555.65 |
| Rate for Payer: Aetna American Axle |
$1,845.75
|
| Rate for Payer: Aetna Commercial |
$2,413.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,845.75
|
| Rate for Payer: Cash Price |
$2,271.69
|
| Rate for Payer: Cofinity Commercial |
$1,987.73
|
| Rate for Payer: Cofinity Commercial |
$2,442.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,271.69
|
| Rate for Payer: Healthscope Commercial |
$2,555.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,987.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,129.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,413.67
|
| Rate for Payer: PHP Commercial |
$2,413.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,987.73
|
| Rate for Payer: Priority Health SBD |
$1,788.95
|
| Rate for Payer: UMR Bronson Commercial |
$1,249.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,129.71
|
|
|
AQUEOUS SHUNT TO EXTRAOCULAR EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT
|
Facility
|
OP
|
$11,377.15
|
|
|
Service Code
|
CPT 66180
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,108.06 |
| Max. Negotiated Rate |
$11,377.15 |
| Rate for Payer: Aetna Medicare |
$3,758.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,517.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,517.55
|
| Rate for Payer: BCBS Complete |
$2,075.90
|
| Rate for Payer: BCBS MAPPO |
$3,614.04
|
| Rate for Payer: BCBS Trust/PPO |
$6,107.63
|
| Rate for Payer: BCN Medicare Advantage |
$3,614.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,614.04
|
| Rate for Payer: Mclaren Medicaid |
$1,976.88
|
| Rate for Payer: Mclaren Medicare |
$3,614.04
|
| Rate for Payer: Meridian Medicaid |
$2,075.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,794.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,156.15
|
| Rate for Payer: PACE Medicare |
$3,433.34
|
| Rate for Payer: PACE SWMI |
$3,614.04
|
| Rate for Payer: PHP Medicare Advantage |
$3,614.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,976.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,377.15
|
| Rate for Payer: Priority Health Medicare |
$3,614.04
|
| Rate for Payer: Priority Health Narrow Network |
$9,101.72
|
| Rate for Payer: Railroad Medicare Medicare |
$3,614.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,218.87
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,614.04
|
| Rate for Payer: UHC Exchange |
$1,108.06
|
| Rate for Payer: UHC Medicare Advantage |
$3,722.46
|
| Rate for Payer: VA VA |
$3,614.04
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
IP
|
$16.19
|
|
|
Service Code
|
HCPCS J7605
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.12 |
| Max. Negotiated Rate |
$14.57 |
| Rate for Payer: Aetna American Axle |
$10.52
|
| Rate for Payer: Aetna American Axle |
$9.76
|
| Rate for Payer: Aetna American Axle |
$14.35
|
| Rate for Payer: Aetna Commercial |
$18.77
|
| Rate for Payer: Aetna Commercial |
$13.76
|
| Rate for Payer: Aetna Commercial |
$12.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.52
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cash Price |
$12.01
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$11.33
|
| Rate for Payer: Cofinity Commercial |
$10.51
|
| Rate for Payer: Cofinity Commercial |
$12.91
|
| Rate for Payer: Cofinity Commercial |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$18.99
|
| Rate for Payer: Cofinity Commercial |
$15.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.66
|
| Rate for Payer: Healthscope Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$13.51
|
| Rate for Payer: Healthscope Commercial |
$14.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.76
|
| Rate for Payer: PHP Commercial |
$18.77
|
| Rate for Payer: PHP Commercial |
$12.76
|
| Rate for Payer: PHP Commercial |
$13.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.51
|
| Rate for Payer: Priority Health SBD |
$10.20
|
| Rate for Payer: Priority Health SBD |
$9.46
|
| Rate for Payer: Priority Health SBD |
$13.91
|
| Rate for Payer: UMR Bronson Commercial |
$7.12
|
| Rate for Payer: UMR Bronson Commercial |
$9.72
|
| Rate for Payer: UMR Bronson Commercial |
$6.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.56
|
|
