|
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 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 |
$157.52
|
| 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 |
$157.52
|
|
|
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 |
$157.52
|
| 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 |
$157.52
|
|
|
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 |
$157.52
|
| 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 |
$157.52
|
|
|
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 |
$157.52
|
| 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 |
$157.52
|
|
|
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 |
$157.52
|
| 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 |
$157.52
|
|
|
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 |
$157.52
|
| 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 |
$157.52
|
|
|
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 |
$82.30
|
| 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 |
$92.24
|
| Rate for Payer: Aetna Commercial |
$120.62
|
| Rate for Payer: Aetna Medicare |
$70.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.24
|
| 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 |
$120.62
|
| Rate for Payer: PHP Commercial |
$120.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.24
|
| 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 |
$92.24
|
| Rate for Payer: Aetna Commercial |
$120.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.24
|
| 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 |
$120.62
|
| Rate for Payer: PHP Commercial |
$120.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.24
|
| 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
|
|
|
COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON FLUOROSCOPIC IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 0054T
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: UHC Core |
$700.00
|
|
|
COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 20985
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$139.93 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: UHC All Payor (Choice/PPO) |
$153.92
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$139.93
|
|
|
CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 57520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$286.45 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$2,977.44
|
| Rate for Payer: BCCCP Commercial |
$342.31
|
| Rate for Payer: BCN Commercial |
$2,977.44
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$315.10
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$286.45
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,669.77
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 57522
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$246.81 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$2,308.51
|
| Rate for Payer: BCCCP Commercial |
$293.81
|
| Rate for Payer: BCN Commercial |
$2,308.51
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$271.49
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$246.81
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,669.77
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
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 |
$2,296.04 |
| 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 |
$1,785.80
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.80
|
| 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 |
$2,296.04 |
| 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 |
$1,785.80
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.80
|
| 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
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM
|
Facility
|
OP
|
$1,572.69
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
9977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.90 |
| Max. Negotiated Rate |
$1,415.42 |
| Rate for Payer: Aetna American Axle |
$1,022.25
|
| Rate for Payer: Aetna Commercial |
$1,336.79
|
| Rate for Payer: Aetna Medicare |
$786.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.25
|
| Rate for Payer: BCBS Complete |
$629.08
|
| Rate for Payer: Cash Price |
$1,258.15
|
| Rate for Payer: Cofinity Commercial |
$1,100.88
|
| Rate for Payer: Cofinity Commercial |
$1,352.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,100.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.15
|
| Rate for Payer: Healthscope Commercial |
$1,415.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,100.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,179.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,336.79
|
| Rate for Payer: PHP Commercial |
$1,336.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,022.25
|
| Rate for Payer: Priority Health SBD |
$990.79
|
| Rate for Payer: UMR Bronson Commercial |
$581.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,179.52
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM
|
Facility
|
IP
|
$1,572.69
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
9977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$691.98 |
| Max. Negotiated Rate |
$1,415.42 |
| Rate for Payer: Aetna American Axle |
$1,022.25
|
| Rate for Payer: Aetna Commercial |
$1,336.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.25
|
| Rate for Payer: Cash Price |
$1,258.15
|
| Rate for Payer: Cofinity Commercial |
$1,100.88
|
| Rate for Payer: Cofinity Commercial |
$1,352.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,100.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.15
|
| Rate for Payer: Healthscope Commercial |
$1,415.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,100.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,179.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,336.79
|
| Rate for Payer: PHP Commercial |
$1,336.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,022.25
|
| Rate for Payer: Priority Health SBD |
$990.79
|
| Rate for Payer: UMR Bronson Commercial |
$691.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,179.52
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET
|
Facility
|
OP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$943.93 |
| Max. Negotiated Rate |
$2,296.04 |
| 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 |
$1,785.80
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.80
|
| 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 0.625 MG TABLET
|
Facility
|
IP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,122.51 |
| Max. Negotiated Rate |
$2,296.04 |
| 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 |
$1,785.80
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.80
|
| 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
|
|
|
CONJUGATED ESTROGENS 1.25 MG TABLET
|
Facility
|
OP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110481
|
| Hospital Charge Code |
2938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$943.93 |
| Max. Negotiated Rate |
$2,296.04 |
| 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 |
$1,785.80
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.80
|
| 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
|
|
