|
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 57461
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT;
|
Facility
|
OP
|
$835.10
|
|
|
Service Code
|
CPT 57420
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$159.02 |
| Max. Negotiated Rate |
$835.10 |
| Rate for Payer: Aetna Medicare |
$308.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$370.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$370.84
|
| Rate for Payer: BCBS Complete |
$166.97
|
| Rate for Payer: BCBS MAPPO |
$296.67
|
| Rate for Payer: BCN Medicare Advantage |
$296.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$296.67
|
| Rate for Payer: Mclaren Medicaid |
$159.02
|
| Rate for Payer: Mclaren Medicare |
$296.67
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$311.50
|
| Rate for Payer: Meridian Medicaid |
$166.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$341.17
|
| Rate for Payer: PACE Medicare |
$281.84
|
| Rate for Payer: PACE SWMI |
$296.67
|
| Rate for Payer: PHP Medicare Advantage |
$296.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$159.02
|
| Rate for Payer: Priority Health Medicare |
$296.67
|
| Rate for Payer: Railroad Medicare Medicare |
$296.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$835.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$296.67
|
| Rate for Payer: UHC Exchange |
$566.97
|
| Rate for Payer: UHC Medicare Advantage |
$296.67
|
| Rate for Payer: UHCCP Medicaid |
$159.02
|
| Rate for Payer: VA VA |
$296.67
|
|
|
COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX
|
Facility
|
OP
|
$2,390.47
|
|
|
Service Code
|
CPT 57421
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$455.18 |
| Max. Negotiated Rate |
$2,390.47 |
| Rate for Payer: Aetna Medicare |
$883.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,061.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,061.53
|
| Rate for Payer: BCBS Complete |
$477.94
|
| Rate for Payer: BCBS MAPPO |
$849.22
|
| Rate for Payer: BCN Medicare Advantage |
$849.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$849.22
|
| Rate for Payer: Mclaren Medicaid |
$455.18
|
| Rate for Payer: Mclaren Medicare |
$849.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$891.68
|
| Rate for Payer: Meridian Medicaid |
$477.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$976.60
|
| Rate for Payer: PACE Medicare |
$806.76
|
| Rate for Payer: PACE SWMI |
$849.22
|
| Rate for Payer: PHP Medicare Advantage |
$849.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$455.18
|
| Rate for Payer: Priority Health Medicare |
$849.22
|
| Rate for Payer: Railroad Medicare Medicare |
$849.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,390.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$849.22
|
| Rate for Payer: UHC Exchange |
$1,622.94
|
| Rate for Payer: UHC Medicare Advantage |
$849.22
|
| Rate for Payer: UHCCP Medicaid |
$455.18
|
| Rate for Payer: VA VA |
$849.22
|
|
|
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S)
|
Facility
|
OP
|
$835.10
|
|
|
Service Code
|
CPT 56821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$159.02 |
| Max. Negotiated Rate |
$835.10 |
| Rate for Payer: Aetna Medicare |
$308.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$370.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$370.84
|
| Rate for Payer: BCBS Complete |
$166.97
|
| Rate for Payer: BCBS MAPPO |
$296.67
|
| Rate for Payer: BCN Medicare Advantage |
$296.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$296.67
|
| Rate for Payer: Mclaren Medicaid |
$159.02
|
| Rate for Payer: Mclaren Medicare |
$296.67
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$311.50
|
| Rate for Payer: Meridian Medicaid |
$166.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$341.17
|
| Rate for Payer: PACE Medicare |
$281.84
|
| Rate for Payer: PACE SWMI |
$296.67
|
| Rate for Payer: PHP Medicare Advantage |
$296.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$159.02
|
| Rate for Payer: Priority Health Medicare |
$296.67
|
| Rate for Payer: Railroad Medicare Medicare |
$296.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$835.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$296.67
|
| Rate for Payer: UHC Exchange |
$566.97
|
| Rate for Payer: UHC Medicare Advantage |
$296.67
|
| Rate for Payer: UHCCP Medicaid |
$159.02
|
| Rate for Payer: VA VA |
$296.67
|
|
|
COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 57260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR
|
Facility
|
OP
|
$13,552.11
|
|
|
Service Code
|
CPT 57265
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$13,552.11 |
| Rate for Payer: Aetna Medicare |
$5,007.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,552.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$9,200.84
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
COMPLEX CYSTOMETROGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE), ANY TECHNIQUE
|
Facility
|
OP
|
$1,832.42
|
|
|
Service Code
|
CPT 51728
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$348.92 |
| Max. Negotiated Rate |
$1,832.42 |
| Rate for Payer: Aetna Medicare |
$677.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$813.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$813.71
|
| Rate for Payer: BCBS Complete |
$366.37
|
| Rate for Payer: BCBS MAPPO |
$650.97
|
| Rate for Payer: BCN Medicare Advantage |
$650.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$650.97
|
| Rate for Payer: Mclaren Medicaid |
$348.92
|
| Rate for Payer: Mclaren Medicare |
$650.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$683.52
|
| Rate for Payer: Meridian Medicaid |
$366.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$748.62
|
| Rate for Payer: PACE Medicare |
$618.42
|
| Rate for Payer: PACE SWMI |
$650.97
|
| Rate for Payer: PHP Medicare Advantage |
$650.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$348.92
|
| Rate for Payer: Priority Health Medicare |
$650.97
|
| Rate for Payer: Railroad Medicare Medicare |
$650.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,832.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$650.97
|
| Rate for Payer: UHC Exchange |
$1,244.07
|
| Rate for Payer: UHC Medicare Advantage |
$650.97
|
| Rate for Payer: UHCCP Medicaid |
$348.92
|
| Rate for Payer: VA VA |
$650.97
|
|
|
COMPOUNDING VEHICLE NO.8 ORAL LIQUID
|
Facility
|
IP
|
$153.26
|
|
|
Service Code
|
NDC 00395009016
|
| Hospital Charge Code |
119063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.43 |
| Max. Negotiated Rate |
$137.93 |
| Rate for Payer: Aetna American Axle |
$99.62
|
| Rate for Payer: Aetna Commercial |
$130.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.62
|
| Rate for Payer: Cash Price |
$122.61
|
| Rate for Payer: Cofinity Commercial |
$107.28
|
| Rate for Payer: Cofinity Commercial |
$131.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.61
|
| Rate for Payer: Healthscope Commercial |
$137.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.27
|
| Rate for Payer: PHP Commercial |
$130.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.62
|
| Rate for Payer: Priority Health SBD |
$96.55
|
| Rate for Payer: UMR Bronson Commercial |
$67.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.94
|
|
|
COMPOUNDING VEHICLE NO.8 ORAL LIQUID
|
Facility
|
OP
|
$210.02
|
|
|
Service Code
|
NDC 00574030416
|
| Hospital Charge Code |
119063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna American Axle |
$136.51
|
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna Medicare |
$105.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: BCBS Complete |
$84.01
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
| Rate for Payer: UMR Bronson Commercial |
$77.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.51
|
|
|
COMPOUNDING VEHICLE NO.8 ORAL LIQUID
|
Facility
|
IP
|
$210.02
|
|
|
Service Code
|
NDC 00574030416
|
| Hospital Charge Code |
119063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.41 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna American Axle |
$136.51
|
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
| Rate for Payer: UMR Bronson Commercial |
$92.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.51
|
|
|
COMPOUNDING VEHICLE NO.8 ORAL LIQUID
|
Facility
|
OP
|
$153.26
|
|
|
Service Code
|
NDC 00395009016
|
| Hospital Charge Code |
119063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.71 |
| Max. Negotiated Rate |
$137.93 |
| Rate for Payer: Aetna American Axle |
$99.62
|
| Rate for Payer: Aetna Commercial |
$130.27
|
| Rate for Payer: Aetna Medicare |
$76.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.62
|
| Rate for Payer: BCBS Complete |
$61.30
|
| Rate for Payer: Cash Price |
$122.61
|
| Rate for Payer: Cofinity Commercial |
$107.28
|
| Rate for Payer: Cofinity Commercial |
$131.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.61
|
| Rate for Payer: Healthscope Commercial |
$137.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.27
|
| Rate for Payer: PHP Commercial |
$130.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.62
|
| Rate for Payer: Priority Health SBD |
$96.55
|
| Rate for Payer: UMR Bronson Commercial |
$56.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.94
|
|
|
COMPOUNDING VEHICLE SUGAR-FREE NO.9 ORAL LIQUID
|
Facility
|
OP
|
$153.26
|
|
|
Service Code
|
NDC 00395009416
|
| Hospital Charge Code |
119062
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.71 |
| Max. Negotiated Rate |
$137.93 |
| Rate for Payer: Aetna American Axle |
$99.62
|
| Rate for Payer: Aetna Commercial |
$130.27
|
| Rate for Payer: Aetna Medicare |
$76.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.62
|
| Rate for Payer: BCBS Complete |
$61.30
|
| Rate for Payer: Cash Price |
$122.61
|
| Rate for Payer: Cofinity Commercial |
$107.28
|
| Rate for Payer: Cofinity Commercial |
$131.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.61
|
| Rate for Payer: Healthscope Commercial |
$137.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.27
|
| Rate for Payer: PHP Commercial |
$130.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.62
|
| Rate for Payer: Priority Health SBD |
$96.55
|
| Rate for Payer: UMR Bronson Commercial |
$56.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.94
|
|
|
COMPOUNDING VEHICLE SUGAR-FREE NO.9 ORAL LIQUID
|
Facility
|
IP
|
$153.26
|
|
|
Service Code
|
NDC 00395009416
|
| Hospital Charge Code |
119062
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.43 |
| Max. Negotiated Rate |
$137.93 |
| Rate for Payer: Aetna American Axle |
$99.62
|
| Rate for Payer: Aetna Commercial |
$130.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.62
|
| Rate for Payer: Cash Price |
$122.61
|
| Rate for Payer: Cofinity Commercial |
$107.28
|
| Rate for Payer: Cofinity Commercial |
$131.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.61
|
| Rate for Payer: Healthscope Commercial |
$137.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.27
|
| Rate for Payer: PHP Commercial |
$130.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.62
|
| Rate for Payer: Priority Health SBD |
$96.55
|
| Rate for Payer: UMR Bronson Commercial |
$67.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.94
|
|
|
COMPOUNDING VEHICLE SUSPENSION NO.19 ORAL
|
Facility
|
IP
|
$210.02
|
|
|
Service Code
|
NDC 00574031116
|
| Hospital Charge Code |
176496
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.41 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna American Axle |
$136.51
|
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
| Rate for Payer: UMR Bronson Commercial |
$92.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.51
|
|
|
COMPOUNDING VEHICLE SUSPENSION NO.19 ORAL
|
Facility
|
OP
|
$210.02
|
|
|
Service Code
|
NDC 00574031116
|
| Hospital Charge Code |
176496
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna American Axle |
$136.51
|
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna Medicare |
$105.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: BCBS Complete |
$84.01
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
| Rate for Payer: UMR Bronson Commercial |
$77.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.51
|
|
|
COMPOUNDING VEHICLE SUSPENSION NO.7 ORAL
|
Facility
|
OP
|
$210.02
|
|
|
Service Code
|
NDC 00574030316
|
| Hospital Charge Code |
118921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna American Axle |
$136.51
|
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna Medicare |
$105.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: BCBS Complete |
$84.01
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
| Rate for Payer: UMR Bronson Commercial |
$77.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.51
|
|
|
COMPOUNDING VEHICLE SUSPENSION NO.7 ORAL
|
Facility
|
IP
|
$210.02
|
|
|
Service Code
|
NDC 00574030316
|
| Hospital Charge Code |
118921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.41 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna American Axle |
$136.51
|
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
| Rate for Payer: UMR Bronson Commercial |
$92.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.51
|
|
|
COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL
|
Facility
|
IP
|
$164.61
|
|
|
Service Code
|
NDC 39328001416
|
| Hospital Charge Code |
176500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.43 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna American Axle |
$107.00
|
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.00
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$115.23
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.69
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.92
|
| Rate for Payer: PHP Commercial |
$139.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.00
|
| Rate for Payer: Priority Health SBD |
$103.70
|
| Rate for Payer: UMR Bronson Commercial |
$72.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.46
|
|
|
COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL
|
Facility
|
OP
|
$164.61
|
|
|
Service Code
|
NDC 39328001416
|
| Hospital Charge Code |
176500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.91 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna American Axle |
$107.00
|
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: Aetna Medicare |
$82.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.00
|
| Rate for Payer: BCBS Complete |
$65.84
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$115.23
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.69
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.92
|
| Rate for Payer: PHP Commercial |
$139.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.00
|
| Rate for Payer: Priority Health SBD |
$103.70
|
| Rate for Payer: UMR Bronson Commercial |
$60.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.46
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23
|
Facility
|
OP
|
$141.90
|
|
|
Service Code
|
NDC 31722095901
|
| Hospital Charge Code |
187071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$127.71 |
| Rate for Payer: Aetna American Axle |
$92.23
|
| Rate for Payer: Aetna Commercial |
$120.61
|
| Rate for Payer: Aetna Medicare |
$70.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.23
|
| Rate for Payer: BCBS Complete |
$56.76
|
| Rate for Payer: Cash Price |
$113.52
|
| Rate for Payer: Cofinity Commercial |
$122.03
|
| Rate for Payer: Cofinity Commercial |
$99.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.52
|
| Rate for Payer: Healthscope Commercial |
$127.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.61
|
| Rate for Payer: PHP Commercial |
$120.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.23
|
| Rate for Payer: Priority Health SBD |
$89.40
|
| Rate for Payer: UMR Bronson Commercial |
$52.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.42
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23
|
Facility
|
IP
|
$141.90
|
|
|
Service Code
|
NDC 31722095901
|
| Hospital Charge Code |
187071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$127.71 |
| Rate for Payer: Aetna American Axle |
$92.23
|
| Rate for Payer: Aetna Commercial |
$120.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.23
|
| Rate for Payer: Cash Price |
$113.52
|
| Rate for Payer: Cofinity Commercial |
$122.03
|
| Rate for Payer: Cofinity Commercial |
$99.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.52
|
| Rate for Payer: Healthscope Commercial |
$127.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.61
|
| Rate for Payer: PHP Commercial |
$120.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.23
|
| Rate for Payer: Priority Health SBD |
$89.40
|
| Rate for Payer: UMR Bronson Commercial |
$62.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.42
|
|
|
CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 57520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 57522
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET
|
Facility
|
OP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110081
|
| Hospital Charge Code |
9973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$943.93 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna American Axle |
$1,658.25
|
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna Medicare |
$1,275.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: BCBS Complete |
$1,020.46
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,913.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
| Rate for Payer: UMR Bronson Commercial |
$943.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,913.36
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET
|
Facility
|
IP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110081
|
| Hospital Charge Code |
9973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,122.51 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna American Axle |
$1,658.25
|
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,913.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
| Rate for Payer: UMR Bronson Commercial |
$1,122.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,913.36
|
|
