|
ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$4,142.04
|
|
|
Service Code
|
HCPCS J7511
|
| Hospital Charge Code |
24585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,822.50 |
| Max. Negotiated Rate |
$3,727.84 |
| Rate for Payer: Aetna American Axle |
$2,692.33
|
| Rate for Payer: Aetna Commercial |
$3,520.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,692.33
|
| Rate for Payer: Cash Price |
$3,313.63
|
| Rate for Payer: Cofinity Commercial |
$2,899.43
|
| Rate for Payer: Cofinity Commercial |
$3,562.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,899.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,313.63
|
| Rate for Payer: Healthscope Commercial |
$3,727.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,899.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,106.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,520.73
|
| Rate for Payer: PHP Commercial |
$3,520.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,692.33
|
| Rate for Payer: Priority Health SBD |
$2,609.49
|
| Rate for Payer: UMR Bronson Commercial |
$1,822.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,106.53
|
|
|
ANTI-THYMO IMMUNE GLOBULIN (ATGAM) 5 MCG/0.1 ML TEST DOSE
|
Facility
|
OP
|
$22.54
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
169802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$14,454.76 |
| Rate for Payer: Aetna American Axle |
$14.65
|
| Rate for Payer: Aetna Commercial |
$19.16
|
| Rate for Payer: Aetna Medicare |
$5,340.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,418.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,418.86
|
| Rate for Payer: BCBS Complete |
$2,890.03
|
| Rate for Payer: BCBS MAPPO |
$5,135.09
|
| Rate for Payer: BCN Medicare Advantage |
$5,135.09
|
| Rate for Payer: Cash Price |
$18.03
|
| Rate for Payer: Cash Price |
$18.03
|
| Rate for Payer: Cofinity Commercial |
$19.38
|
| Rate for Payer: Cofinity Commercial |
$15.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,135.09
|
| Rate for Payer: Healthscope Commercial |
$20.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.91
|
| Rate for Payer: Mclaren Medicaid |
$2,752.41
|
| Rate for Payer: Mclaren Medicare |
$5,135.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,391.84
|
| Rate for Payer: Meridian Medicaid |
$2,890.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,905.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.16
|
| Rate for Payer: PACE Medicare |
$4,878.34
|
| Rate for Payer: PACE SWMI |
$5,135.09
|
| Rate for Payer: PHP Commercial |
$19.16
|
| Rate for Payer: PHP Medicare Advantage |
$5,135.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,752.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.65
|
| Rate for Payer: Priority Health Medicare |
$5,135.09
|
| Rate for Payer: Priority Health SBD |
$14.20
|
| Rate for Payer: Railroad Medicare Medicare |
$5,135.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,454.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,135.09
|
| Rate for Payer: UHC Exchange |
$9,813.67
|
| Rate for Payer: UHC Medicare Advantage |
$5,135.09
|
| Rate for Payer: UHCCP Medicaid |
$2,752.41
|
| Rate for Payer: UMR Bronson Commercial |
$8.34
|
| Rate for Payer: VA VA |
$5,135.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.91
|
|
|
ANTI-THYMO IMMUNE GLOBULIN (ATGAM) 5 MCG/0.1 ML TEST DOSE
|
Facility
|
IP
|
$22.54
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
169802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$20.29 |
| Rate for Payer: Aetna American Axle |
$14.65
|
| Rate for Payer: Aetna Commercial |
$19.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.65
|
| Rate for Payer: Cash Price |
$18.03
|
| Rate for Payer: Cofinity Commercial |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$19.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.03
|
| Rate for Payer: Healthscope Commercial |
$20.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.16
|
| Rate for Payer: PHP Commercial |
$19.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.65
|
| Rate for Payer: Priority Health SBD |
$14.20
|
| Rate for Payer: UMR Bronson Commercial |
$9.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.91
|
|
|
ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION
|
Facility
|
OP
|
$3,775.65
|
|
|
Service Code
|
HCPCS J0841
|
| Hospital Charge Code |
188592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$560.20 |
| Max. Negotiated Rate |
$3,398.09 |
| Rate for Payer: Aetna American Axle |
$2,454.17
|
| Rate for Payer: Aetna Commercial |
$3,209.30
|
| Rate for Payer: Aetna Medicare |
$1,086.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,454.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,306.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,306.44
|
| Rate for Payer: BCBS Complete |
$588.21
|
| Rate for Payer: BCBS MAPPO |
$1,045.15
|
| Rate for Payer: BCN Medicare Advantage |
$1,045.15
|
| Rate for Payer: Cash Price |
$3,020.52
|
| Rate for Payer: Cash Price |
$3,020.52
|
| Rate for Payer: Cofinity Commercial |
$3,247.06
|
| Rate for Payer: Cofinity Commercial |
$2,642.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,642.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,020.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,045.15
|
| Rate for Payer: Healthscope Commercial |
$3,398.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,642.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,831.74
|
| Rate for Payer: Mclaren Medicaid |
$560.20
|
| Rate for Payer: Mclaren Medicare |
$1,045.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,097.41
|
| Rate for Payer: Meridian Medicaid |
$588.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,201.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,209.30
|
| Rate for Payer: PACE Medicare |
$992.89
|
| Rate for Payer: PACE SWMI |
$1,045.15
|
| Rate for Payer: PHP Commercial |
$3,209.30
|
| Rate for Payer: PHP Medicare Advantage |
$1,045.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$560.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,454.17
|
| Rate for Payer: Priority Health Medicare |
$1,045.15
|
| Rate for Payer: Priority Health SBD |
$2,378.66
|
| Rate for Payer: Railroad Medicare Medicare |
$1,045.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,941.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,045.15
|
| Rate for Payer: UHC Exchange |
$1,997.39
|
| Rate for Payer: UHC Medicare Advantage |
$1,045.15
|
| Rate for Payer: UHCCP Medicaid |
$560.20
|
| Rate for Payer: UMR Bronson Commercial |
$1,396.99
|
| Rate for Payer: VA VA |
$1,045.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,831.74
|
|
|
ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION
|
Facility
|
IP
|
$3,775.65
|
|
|
Service Code
|
HCPCS J0841
|
| Hospital Charge Code |
188592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,661.29 |
| Max. Negotiated Rate |
$3,398.09 |
| Rate for Payer: Aetna American Axle |
$2,454.17
|
| Rate for Payer: Aetna Commercial |
$3,209.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,454.17
|
| Rate for Payer: Cash Price |
$3,020.52
|
| Rate for Payer: Cofinity Commercial |
$2,642.95
|
| Rate for Payer: Cofinity Commercial |
$3,247.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,642.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,020.52
|
| Rate for Payer: Healthscope Commercial |
$3,398.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,642.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,831.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,209.30
|
| Rate for Payer: PHP Commercial |
$3,209.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,454.17
|
| Rate for Payer: Priority Health SBD |
$2,378.66
|
| Rate for Payer: UMR Bronson Commercial |
$1,661.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,831.74
|
|
|
ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$123.31
|
|
|
Service Code
|
NDC 00006542402
|
| Hospital Charge Code |
24188
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.62 |
| Max. Negotiated Rate |
$110.98 |
| Rate for Payer: Aetna American Axle |
$80.15
|
| Rate for Payer: Aetna Commercial |
$104.81
|
| Rate for Payer: Aetna Medicare |
$61.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.15
|
| Rate for Payer: BCBS Complete |
$49.32
|
| Rate for Payer: Cash Price |
$98.65
|
| Rate for Payer: Cofinity Commercial |
$106.05
|
| Rate for Payer: Cofinity Commercial |
$86.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.65
|
| Rate for Payer: Healthscope Commercial |
$110.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.81
|
| Rate for Payer: PHP Commercial |
$104.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.15
|
| Rate for Payer: Priority Health SBD |
$77.69
|
| Rate for Payer: UMR Bronson Commercial |
$45.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.48
|
|
|
ANTIVENIN LATRODECTUS MACTANS 6,000 UNIT SOLUTION FOR INJECTION
|
Facility
|
IP
|
$123.31
|
|
|
Service Code
|
NDC 00006542402
|
| Hospital Charge Code |
24188
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.26 |
| Max. Negotiated Rate |
$110.98 |
| Rate for Payer: Aetna American Axle |
$80.15
|
| Rate for Payer: Aetna Commercial |
$104.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.15
|
| Rate for Payer: Cash Price |
$98.65
|
| Rate for Payer: Cofinity Commercial |
$106.05
|
| Rate for Payer: Cofinity Commercial |
$86.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.65
|
| Rate for Payer: Healthscope Commercial |
$110.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.81
|
| Rate for Payer: PHP Commercial |
$104.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.15
|
| Rate for Payer: Priority Health SBD |
$77.69
|
| Rate for Payer: UMR Bronson Commercial |
$54.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.48
|
|
|
APIXABAN 2.5 MG TABLET
|
Facility
|
OP
|
$421.35
|
|
|
Service Code
|
NDC 00003089321
|
| Hospital Charge Code |
163984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.90 |
| Max. Negotiated Rate |
$379.21 |
| Rate for Payer: Aetna American Axle |
$273.88
|
| Rate for Payer: Aetna Commercial |
$358.15
|
| Rate for Payer: Aetna Medicare |
$210.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.88
|
| Rate for Payer: BCBS Complete |
$168.54
|
| Rate for Payer: Cash Price |
$337.08
|
| Rate for Payer: Cofinity Commercial |
$294.94
|
| Rate for Payer: Cofinity Commercial |
$362.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.08
|
| Rate for Payer: Healthscope Commercial |
$379.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$358.15
|
| Rate for Payer: PHP Commercial |
$358.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.88
|
| Rate for Payer: Priority Health SBD |
$265.45
|
| Rate for Payer: UMR Bronson Commercial |
$155.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.01
|
|
|
APIXABAN 2.5 MG TABLET
|
Facility
|
IP
|
$421.35
|
|
|
Service Code
|
NDC 00003089321
|
| Hospital Charge Code |
163984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.39 |
| Max. Negotiated Rate |
$379.21 |
| Rate for Payer: Aetna American Axle |
$273.88
|
| Rate for Payer: Aetna Commercial |
$358.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.88
|
| Rate for Payer: Cash Price |
$337.08
|
| Rate for Payer: Cofinity Commercial |
$294.94
|
| Rate for Payer: Cofinity Commercial |
$362.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.08
|
| Rate for Payer: Healthscope Commercial |
$379.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$358.15
|
| Rate for Payer: PHP Commercial |
$358.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.88
|
| Rate for Payer: Priority Health SBD |
$265.45
|
| Rate for Payer: UMR Bronson Commercial |
$185.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.01
|
|
|
APIXABAN 2.5 MG TABLET
|
Facility
|
OP
|
$702.24
|
|
|
Service Code
|
NDC 00003089331
|
| Hospital Charge Code |
163984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$259.83 |
| Max. Negotiated Rate |
$632.02 |
| Rate for Payer: Aetna American Axle |
$456.46
|
| Rate for Payer: Aetna Commercial |
$596.90
|
| Rate for Payer: Aetna Medicare |
$351.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$456.46
|
| Rate for Payer: BCBS Complete |
$280.90
|
| Rate for Payer: Cash Price |
$561.79
|
| Rate for Payer: Cofinity Commercial |
$491.57
|
| Rate for Payer: Cofinity Commercial |
$603.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$491.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$561.79
|
| Rate for Payer: Healthscope Commercial |
$632.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$491.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$526.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$596.90
|
| Rate for Payer: PHP Commercial |
$596.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$456.46
|
| Rate for Payer: Priority Health SBD |
$442.41
|
| Rate for Payer: UMR Bronson Commercial |
$259.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$526.68
|
|
|
APIXABAN 2.5 MG TABLET
|
Facility
|
IP
|
$702.24
|
|
|
Service Code
|
NDC 00003089331
|
| Hospital Charge Code |
163984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$308.99 |
| Max. Negotiated Rate |
$632.02 |
| Rate for Payer: Aetna American Axle |
$456.46
|
| Rate for Payer: Aetna Commercial |
$596.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$456.46
|
| Rate for Payer: Cash Price |
$561.79
|
| Rate for Payer: Cofinity Commercial |
$491.57
|
| Rate for Payer: Cofinity Commercial |
$603.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$491.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$561.79
|
| Rate for Payer: Healthscope Commercial |
$632.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$491.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$526.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$596.90
|
| Rate for Payer: PHP Commercial |
$596.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$456.46
|
| Rate for Payer: Priority Health SBD |
$442.41
|
| Rate for Payer: UMR Bronson Commercial |
$308.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$526.68
|
|
|
APIXABAN 5 MG TABLET
|
Facility
|
IP
|
$702.24
|
|
|
Service Code
|
NDC 00003089431
|
| Hospital Charge Code |
164098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$308.99 |
| Max. Negotiated Rate |
$632.02 |
| Rate for Payer: Aetna American Axle |
$456.46
|
| Rate for Payer: Aetna Commercial |
$596.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$456.46
|
| Rate for Payer: Cash Price |
$561.79
|
| Rate for Payer: Cofinity Commercial |
$491.57
|
| Rate for Payer: Cofinity Commercial |
$603.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$491.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$561.79
|
| Rate for Payer: Healthscope Commercial |
$632.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$491.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$526.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$596.90
|
| Rate for Payer: PHP Commercial |
$596.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$456.46
|
| Rate for Payer: Priority Health SBD |
$442.41
|
| Rate for Payer: UMR Bronson Commercial |
$308.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$526.68
|
|
|
APIXABAN 5 MG TABLET
|
Facility
|
OP
|
$702.24
|
|
|
Service Code
|
NDC 00003089431
|
| Hospital Charge Code |
164098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$259.83 |
| Max. Negotiated Rate |
$632.02 |
| Rate for Payer: Aetna American Axle |
$456.46
|
| Rate for Payer: Aetna Commercial |
$596.90
|
| Rate for Payer: Aetna Medicare |
$351.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$456.46
|
| Rate for Payer: BCBS Complete |
$280.90
|
| Rate for Payer: Cash Price |
$561.79
|
| Rate for Payer: Cofinity Commercial |
$491.57
|
| Rate for Payer: Cofinity Commercial |
$603.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$491.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$561.79
|
| Rate for Payer: Healthscope Commercial |
$632.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$491.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$526.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$596.90
|
| Rate for Payer: PHP Commercial |
$596.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$456.46
|
| Rate for Payer: Priority Health SBD |
$442.41
|
| Rate for Payer: UMR Bronson Commercial |
$259.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$526.68
|
|
|
APIXABAN 5 MG TABLET
|
Facility
|
OP
|
$421.35
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
164098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.90 |
| Max. Negotiated Rate |
$379.21 |
| Rate for Payer: Aetna American Axle |
$273.88
|
| Rate for Payer: Aetna Commercial |
$358.15
|
| Rate for Payer: Aetna Medicare |
$210.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.88
|
| Rate for Payer: BCBS Complete |
$168.54
|
| Rate for Payer: Cash Price |
$337.08
|
| Rate for Payer: Cofinity Commercial |
$294.94
|
| Rate for Payer: Cofinity Commercial |
$362.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.08
|
| Rate for Payer: Healthscope Commercial |
$379.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$358.15
|
| Rate for Payer: PHP Commercial |
$358.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.88
|
| Rate for Payer: Priority Health SBD |
$265.45
|
| Rate for Payer: UMR Bronson Commercial |
$155.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.01
|
|
|
APIXABAN 5 MG TABLET
|
Facility
|
IP
|
$421.35
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
164098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.39 |
| Max. Negotiated Rate |
$379.21 |
| Rate for Payer: Aetna American Axle |
$273.88
|
| Rate for Payer: Aetna Commercial |
$358.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.88
|
| Rate for Payer: Cash Price |
$337.08
|
| Rate for Payer: Cofinity Commercial |
$294.94
|
| Rate for Payer: Cofinity Commercial |
$362.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$294.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.08
|
| Rate for Payer: Healthscope Commercial |
$379.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$358.15
|
| Rate for Payer: PHP Commercial |
$358.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.88
|
| Rate for Payer: Priority Health SBD |
$265.45
|
| Rate for Payer: UMR Bronson Commercial |
$185.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.01
|
|
|
APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)
|
Facility
|
OP
|
$35,323.48
|
|
|
Service Code
|
CPT 20692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,726.13 |
| Max. Negotiated Rate |
$35,323.48 |
| Rate for Payer: Aetna Medicare |
$13,050.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,685.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,685.94
|
| Rate for Payer: BCBS Complete |
$7,062.44
|
| Rate for Payer: BCBS MAPPO |
$12,548.75
|
| Rate for Payer: BCN Medicare Advantage |
$12,548.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,548.75
|
| Rate for Payer: Mclaren Medicaid |
$6,726.13
|
| Rate for Payer: Mclaren Medicare |
$12,548.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,176.19
|
| Rate for Payer: Meridian Medicaid |
$7,062.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,431.06
|
| Rate for Payer: PACE Medicare |
$11,921.31
|
| Rate for Payer: PACE SWMI |
$12,548.75
|
| Rate for Payer: PHP Medicare Advantage |
$12,548.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,726.13
|
| Rate for Payer: Priority Health Medicare |
$12,548.75
|
| Rate for Payer: Railroad Medicare Medicare |
$12,548.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35,323.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,548.75
|
| Rate for Payer: UHC Exchange |
$23,981.92
|
| Rate for Payer: UHC Medicare Advantage |
$12,548.75
|
| Rate for Payer: UHCCP Medicaid |
$6,726.13
|
| Rate for Payer: VA VA |
$12,548.75
|
|
|
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 20690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Exchange |
$13,314.90
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,734.39
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND)
|
Facility
|
OP
|
$433.18
|
|
|
Service Code
|
CPT 29105
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$82.49 |
| Max. Negotiated Rate |
$433.18 |
| Rate for Payer: Aetna Medicare |
$160.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$192.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$192.36
|
| Rate for Payer: BCBS Complete |
$86.61
|
| Rate for Payer: BCBS MAPPO |
$153.89
|
| Rate for Payer: BCN Medicare Advantage |
$153.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$153.89
|
| Rate for Payer: Mclaren Medicaid |
$82.49
|
| Rate for Payer: Mclaren Medicare |
$153.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$161.58
|
| Rate for Payer: Meridian Medicaid |
$86.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$176.97
|
| Rate for Payer: PACE Medicare |
$146.20
|
| Rate for Payer: PACE SWMI |
$153.89
|
| Rate for Payer: PHP Medicare Advantage |
$153.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$82.49
|
| Rate for Payer: Priority Health Medicare |
$153.89
|
| Rate for Payer: Railroad Medicare Medicare |
$153.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$433.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$153.89
|
| Rate for Payer: UHC Exchange |
$294.10
|
| Rate for Payer: UHC Medicare Advantage |
$153.89
|
| Rate for Payer: UHCCP Medicaid |
$82.49
|
| Rate for Payer: VA VA |
$153.89
|
|
|
APPLICATION OF LONG LEG CAST (THIGH TO TOES);
|
Facility
|
OP
|
$729.09
|
|
|
Service Code
|
CPT 29345
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$138.83 |
| Max. Negotiated Rate |
$729.09 |
| Rate for Payer: Aetna Medicare |
$269.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$323.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$323.76
|
| Rate for Payer: BCBS Complete |
$145.77
|
| Rate for Payer: BCBS MAPPO |
$259.01
|
| Rate for Payer: BCN Medicare Advantage |
$259.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$259.01
|
| Rate for Payer: Mclaren Medicaid |
$138.83
|
| Rate for Payer: Mclaren Medicare |
$259.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$271.96
|
| Rate for Payer: Meridian Medicaid |
$145.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$297.86
|
| Rate for Payer: PACE Medicare |
$246.06
|
| Rate for Payer: PACE SWMI |
$259.01
|
| Rate for Payer: PHP Medicare Advantage |
$259.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$138.83
|
| Rate for Payer: Priority Health Medicare |
$259.01
|
| Rate for Payer: Railroad Medicare Medicare |
$259.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$729.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$259.01
|
| Rate for Payer: UHC Exchange |
$494.99
|
| Rate for Payer: UHC Medicare Advantage |
$259.01
|
| Rate for Payer: UHCCP Medicaid |
$138.83
|
| Rate for Payer: VA VA |
$259.01
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$1,680.50
|
|
|
Service Code
|
CPT C5275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$319.99 |
| Max. Negotiated Rate |
$1,680.50 |
| Rate for Payer: Aetna Medicare |
$620.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$746.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$746.25
|
| Rate for Payer: BCBS Complete |
$335.99
|
| Rate for Payer: BCBS MAPPO |
$597.00
|
| Rate for Payer: BCN Medicare Advantage |
$597.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$597.00
|
| Rate for Payer: Mclaren Medicaid |
$319.99
|
| Rate for Payer: Mclaren Medicare |
$597.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$626.85
|
| Rate for Payer: Meridian Medicaid |
$335.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$686.55
|
| Rate for Payer: PACE Medicare |
$567.15
|
| Rate for Payer: PACE SWMI |
$597.00
|
| Rate for Payer: PHP Medicare Advantage |
$597.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$319.99
|
| Rate for Payer: Priority Health Medicare |
$597.00
|
| Rate for Payer: Railroad Medicare Medicare |
$597.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,680.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$597.00
|
| Rate for Payer: UHC Exchange |
$1,140.93
|
| Rate for Payer: UHC Medicare Advantage |
$597.00
|
| Rate for Payer: UHCCP Medicaid |
$319.99
|
| Rate for Payer: VA VA |
$597.00
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT C5273
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Exchange |
$3,409.42
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$956.23
|
| Rate for Payer: VA VA |
$1,784.01
|
|
|
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT)
|
Facility
|
OP
|
$433.18
|
|
|
Service Code
|
CPT 29515
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$82.49 |
| Max. Negotiated Rate |
$433.18 |
| Rate for Payer: Aetna Medicare |
$160.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$192.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$192.36
|
| Rate for Payer: BCBS Complete |
$86.61
|
| Rate for Payer: BCBS MAPPO |
$153.89
|
| Rate for Payer: BCN Medicare Advantage |
$153.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$153.89
|
| Rate for Payer: Mclaren Medicaid |
$82.49
|
| Rate for Payer: Mclaren Medicare |
$153.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$161.58
|
| Rate for Payer: Meridian Medicaid |
$86.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$176.97
|
| Rate for Payer: PACE Medicare |
$146.20
|
| Rate for Payer: PACE SWMI |
$153.89
|
| Rate for Payer: PHP Medicare Advantage |
$153.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$82.49
|
| Rate for Payer: Priority Health Medicare |
$153.89
|
| Rate for Payer: Railroad Medicare Medicare |
$153.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$433.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$153.89
|
| Rate for Payer: UHC Exchange |
$294.10
|
| Rate for Payer: UHC Medicare Advantage |
$153.89
|
| Rate for Payer: UHCCP Medicaid |
$82.49
|
| Rate for Payer: VA VA |
$153.89
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT 15277
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Exchange |
$3,409.42
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$956.23
|
| Rate for Payer: VA VA |
$1,784.01
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT 15277
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Exchange |
$3,409.42
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$956.23
|
| Rate for Payer: VA VA |
$1,784.01
|
|
|
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
|
$5,021.81
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Exchange |
$3,409.42
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$956.23
|
| Rate for Payer: VA VA |
$1,784.01
|
|
