|
GAMMAKED 5 GRAM/50 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$1,960.58
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
153285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$1,764.52 |
| Rate for Payer: Aetna American Axle |
$1,274.38
|
| Rate for Payer: Aetna Commercial |
$1,666.49
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,274.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.20
|
| Rate for Payer: BCBS Complete |
$27.55
|
| Rate for Payer: BCBS MAPPO |
$48.96
|
| Rate for Payer: BCN Medicare Advantage |
$48.96
|
| Rate for Payer: Cash Price |
$1,568.46
|
| Rate for Payer: Cash Price |
$1,568.46
|
| Rate for Payer: Cofinity Commercial |
$1,686.10
|
| Rate for Payer: Cofinity Commercial |
$1,372.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,372.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,568.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.96
|
| Rate for Payer: Healthscope Commercial |
$1,764.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,372.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,470.43
|
| Rate for Payer: Mclaren Medicaid |
$26.24
|
| Rate for Payer: Mclaren Medicare |
$48.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.41
|
| Rate for Payer: Meridian Medicaid |
$27.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,666.49
|
| Rate for Payer: PACE Medicare |
$46.51
|
| Rate for Payer: PACE SWMI |
$48.96
|
| Rate for Payer: PHP Commercial |
$1,666.49
|
| Rate for Payer: PHP Medicare Advantage |
$48.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,274.38
|
| Rate for Payer: Priority Health Medicare |
$48.96
|
| Rate for Payer: Priority Health SBD |
$1,235.17
|
| Rate for Payer: Railroad Medicare Medicare |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.96
|
| Rate for Payer: UHC Exchange |
$93.57
|
| Rate for Payer: UHC Medicare Advantage |
$48.96
|
| Rate for Payer: UHCCP Medicaid |
$26.24
|
| Rate for Payer: UMR Bronson Commercial |
$725.41
|
| Rate for Payer: VA VA |
$48.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,470.43
|
|
|
GAMMAKED 5 GRAM/50 ML (10 %) INJECTION SOLUTION
|
Facility
|
IP
|
$1,960.58
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
153285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$862.66 |
| Max. Negotiated Rate |
$1,764.52 |
| Rate for Payer: Aetna American Axle |
$1,274.38
|
| Rate for Payer: Aetna Commercial |
$1,666.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,274.38
|
| Rate for Payer: Cash Price |
$1,568.46
|
| Rate for Payer: Cofinity Commercial |
$1,372.41
|
| Rate for Payer: Cofinity Commercial |
$1,686.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,372.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,568.46
|
| Rate for Payer: Healthscope Commercial |
$1,764.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,372.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,470.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,666.49
|
| Rate for Payer: PHP Commercial |
$1,666.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,274.38
|
| Rate for Payer: Priority Health SBD |
$1,235.17
|
| Rate for Payer: UMR Bronson Commercial |
$862.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,470.43
|
|
|
GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$4,304.54
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$3,874.09 |
| Rate for Payer: Aetna American Axle |
$2,797.95
|
| Rate for Payer: Aetna Commercial |
$3,658.86
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,797.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.20
|
| Rate for Payer: BCBS Complete |
$27.55
|
| Rate for Payer: BCBS MAPPO |
$48.96
|
| Rate for Payer: BCN Medicare Advantage |
$48.96
|
| Rate for Payer: Cash Price |
$3,443.63
|
| Rate for Payer: Cash Price |
$3,443.63
|
| Rate for Payer: Cofinity Commercial |
$3,701.90
|
| Rate for Payer: Cofinity Commercial |
$3,013.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,013.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,443.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.96
|
| Rate for Payer: Healthscope Commercial |
$3,874.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,013.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,228.41
|
| Rate for Payer: Mclaren Medicaid |
$26.24
|
| Rate for Payer: Mclaren Medicare |
$48.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.41
|
| Rate for Payer: Meridian Medicaid |
$27.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,658.86
|
| Rate for Payer: PACE Medicare |
$46.51
|
| Rate for Payer: PACE SWMI |
$48.96
|
| Rate for Payer: PHP Commercial |
$3,658.86
|
| Rate for Payer: PHP Medicare Advantage |
$48.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,797.95
|
| Rate for Payer: Priority Health Medicare |
$48.96
|
| Rate for Payer: Priority Health SBD |
$2,711.86
|
| Rate for Payer: Railroad Medicare Medicare |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.96
|
| Rate for Payer: UHC Exchange |
$93.57
|
| Rate for Payer: UHC Medicare Advantage |
$48.96
|
| Rate for Payer: UHCCP Medicaid |
$26.24
|
| Rate for Payer: UMR Bronson Commercial |
$1,592.68
|
| Rate for Payer: VA VA |
$48.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,228.41
|
|
|
GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION SOLUTION
|
Facility
|
IP
|
$4,304.54
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,894.00 |
| Max. Negotiated Rate |
$3,874.09 |
| Rate for Payer: Aetna American Axle |
$2,797.95
|
| Rate for Payer: Aetna Commercial |
$3,658.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,797.95
|
| Rate for Payer: Cash Price |
$3,443.63
|
| Rate for Payer: Cofinity Commercial |
$3,013.18
|
| Rate for Payer: Cofinity Commercial |
$3,701.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,013.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,443.63
|
| Rate for Payer: Healthscope Commercial |
$3,874.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,013.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,228.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,658.86
|
| Rate for Payer: PHP Commercial |
$3,658.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,797.95
|
| Rate for Payer: Priority Health SBD |
$2,711.86
|
| Rate for Payer: UMR Bronson Commercial |
$1,894.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,228.41
|
|
|
GAMUNEX-C 2.5 GRAM/25 ML (10 %) INJECTION SOLUTION
|
Facility
|
IP
|
$1,076.14
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$473.50 |
| Max. Negotiated Rate |
$968.53 |
| Rate for Payer: Aetna American Axle |
$699.49
|
| Rate for Payer: Aetna Commercial |
$914.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$699.49
|
| Rate for Payer: Cash Price |
$860.91
|
| Rate for Payer: Cofinity Commercial |
$753.30
|
| Rate for Payer: Cofinity Commercial |
$925.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$753.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$860.91
|
| Rate for Payer: Healthscope Commercial |
$968.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$753.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$807.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$914.72
|
| Rate for Payer: PHP Commercial |
$914.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$699.49
|
| Rate for Payer: Priority Health SBD |
$677.97
|
| Rate for Payer: UMR Bronson Commercial |
$473.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$807.11
|
|
|
GAMUNEX-C 2.5 GRAM/25 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$1,076.14
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$968.53 |
| Rate for Payer: Aetna American Axle |
$699.49
|
| Rate for Payer: Aetna Commercial |
$914.72
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$699.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.20
|
| Rate for Payer: BCBS Complete |
$27.55
|
| Rate for Payer: BCBS MAPPO |
$48.96
|
| Rate for Payer: BCN Medicare Advantage |
$48.96
|
| Rate for Payer: Cash Price |
$860.91
|
| Rate for Payer: Cash Price |
$860.91
|
| Rate for Payer: Cofinity Commercial |
$925.48
|
| Rate for Payer: Cofinity Commercial |
$753.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$753.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$860.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.96
|
| Rate for Payer: Healthscope Commercial |
$968.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$753.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$807.11
|
| Rate for Payer: Mclaren Medicaid |
$26.24
|
| Rate for Payer: Mclaren Medicare |
$48.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.41
|
| Rate for Payer: Meridian Medicaid |
$27.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$914.72
|
| Rate for Payer: PACE Medicare |
$46.51
|
| Rate for Payer: PACE SWMI |
$48.96
|
| Rate for Payer: PHP Commercial |
$914.72
|
| Rate for Payer: PHP Medicare Advantage |
$48.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$699.49
|
| Rate for Payer: Priority Health Medicare |
$48.96
|
| Rate for Payer: Priority Health SBD |
$677.97
|
| Rate for Payer: Railroad Medicare Medicare |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.96
|
| Rate for Payer: UHC Exchange |
$93.57
|
| Rate for Payer: UHC Medicare Advantage |
$48.96
|
| Rate for Payer: UHCCP Medicaid |
$26.24
|
| Rate for Payer: UMR Bronson Commercial |
$398.17
|
| Rate for Payer: VA VA |
$48.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$807.11
|
|
|
GAMUNEX-C 5 GRAM/50 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$2,152.27
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107778
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$1,937.04 |
| Rate for Payer: Aetna American Axle |
$1,398.98
|
| Rate for Payer: Aetna Commercial |
$1,829.43
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,398.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.20
|
| Rate for Payer: BCBS Complete |
$27.55
|
| Rate for Payer: BCBS MAPPO |
$48.96
|
| Rate for Payer: BCN Medicare Advantage |
$48.96
|
| Rate for Payer: Cash Price |
$1,721.82
|
| Rate for Payer: Cash Price |
$1,721.82
|
| Rate for Payer: Cofinity Commercial |
$1,850.95
|
| Rate for Payer: Cofinity Commercial |
$1,506.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,506.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,721.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.96
|
| Rate for Payer: Healthscope Commercial |
$1,937.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,506.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,614.20
|
| Rate for Payer: Mclaren Medicaid |
$26.24
|
| Rate for Payer: Mclaren Medicare |
$48.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.41
|
| Rate for Payer: Meridian Medicaid |
$27.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,829.43
|
| Rate for Payer: PACE Medicare |
$46.51
|
| Rate for Payer: PACE SWMI |
$48.96
|
| Rate for Payer: PHP Commercial |
$1,829.43
|
| Rate for Payer: PHP Medicare Advantage |
$48.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,398.98
|
| Rate for Payer: Priority Health Medicare |
$48.96
|
| Rate for Payer: Priority Health SBD |
$1,355.93
|
| Rate for Payer: Railroad Medicare Medicare |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.96
|
| Rate for Payer: UHC Exchange |
$93.57
|
| Rate for Payer: UHC Medicare Advantage |
$48.96
|
| Rate for Payer: UHCCP Medicaid |
$26.24
|
| Rate for Payer: UMR Bronson Commercial |
$796.34
|
| Rate for Payer: VA VA |
$48.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,614.20
|
|
|
GAMUNEX-C 5 GRAM/50 ML (10 %) INJECTION SOLUTION
|
Facility
|
IP
|
$2,152.27
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107778
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$947.00 |
| Max. Negotiated Rate |
$1,937.04 |
| Rate for Payer: Aetna American Axle |
$1,398.98
|
| Rate for Payer: Aetna Commercial |
$1,829.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,398.98
|
| Rate for Payer: Cash Price |
$1,721.82
|
| Rate for Payer: Cofinity Commercial |
$1,506.59
|
| Rate for Payer: Cofinity Commercial |
$1,850.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,506.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,721.82
|
| Rate for Payer: Healthscope Commercial |
$1,937.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,506.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,614.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,829.43
|
| Rate for Payer: PHP Commercial |
$1,829.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,398.98
|
| Rate for Payer: Priority Health SBD |
$1,355.93
|
| Rate for Payer: UMR Bronson Commercial |
$947.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,614.20
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$138.64
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.00 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna American Axle |
$129.85
|
| Rate for Payer: Aetna American Axle |
$134.50
|
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: Aetna Commercial |
$117.84
|
| Rate for Payer: Aetna Commercial |
$175.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.85
|
| Rate for Payer: Cash Price |
$165.54
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cash Price |
$110.91
|
| Rate for Payer: Cofinity Commercial |
$97.05
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Cofinity Commercial |
$139.84
|
| Rate for Payer: Cofinity Commercial |
$177.96
|
| Rate for Payer: Cofinity Commercial |
$144.85
|
| Rate for Payer: Cofinity Commercial |
$119.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Healthscope Commercial |
$186.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: PHP Commercial |
$175.89
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: PHP Commercial |
$117.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$130.37
|
| Rate for Payer: Priority Health SBD |
$125.86
|
| Rate for Payer: Priority Health SBD |
$87.34
|
| Rate for Payer: UMR Bronson Commercial |
$61.00
|
| Rate for Payer: UMR Bronson Commercial |
$91.05
|
| Rate for Payer: UMR Bronson Commercial |
$87.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.83
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$206.93
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.56 |
| Max. Negotiated Rate |
$186.24 |
| Rate for Payer: Aetna American Axle |
$134.50
|
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna American Axle |
$129.85
|
| Rate for Payer: Aetna Commercial |
$175.89
|
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: Aetna Commercial |
$117.84
|
| Rate for Payer: Aetna Medicare |
$103.47
|
| Rate for Payer: Aetna Medicare |
$99.89
|
| Rate for Payer: Aetna Medicare |
$69.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: BCBS Complete |
$79.91
|
| Rate for Payer: BCBS Complete |
$82.77
|
| Rate for Payer: Cash Price |
$165.54
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cash Price |
$110.91
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Cofinity Commercial |
$119.23
|
| Rate for Payer: Cofinity Commercial |
$97.05
|
| Rate for Payer: Cofinity Commercial |
$177.96
|
| Rate for Payer: Cofinity Commercial |
$144.85
|
| Rate for Payer: Cofinity Commercial |
$139.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.54
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: Healthscope Commercial |
$186.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.89
|
| Rate for Payer: PHP Commercial |
$117.84
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: PHP Commercial |
$175.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$125.86
|
| Rate for Payer: Priority Health SBD |
$87.34
|
| Rate for Payer: Priority Health SBD |
$130.37
|
| Rate for Payer: UMR Bronson Commercial |
$76.56
|
| Rate for Payer: UMR Bronson Commercial |
$51.30
|
| Rate for Payer: UMR Bronson Commercial |
$73.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.20
|
|
|
GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$148.68
|
|
|
Service Code
|
NDC 25021018510
|
| Hospital Charge Code |
186410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.01 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna American Axle |
$96.64
|
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: Aetna Medicare |
$74.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.64
|
| Rate for Payer: BCBS Complete |
$59.47
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Commercial |
$104.08
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.38
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.64
|
| Rate for Payer: Priority Health SBD |
$93.67
|
| Rate for Payer: UMR Bronson Commercial |
$55.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.51
|
|
|
GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$148.68
|
|
|
Service Code
|
NDC 25021018510
|
| Hospital Charge Code |
186410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.42 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna American Axle |
$96.64
|
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.64
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Commercial |
$104.08
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.38
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.64
|
| Rate for Payer: Priority Health SBD |
$93.67
|
| Rate for Payer: UMR Bronson Commercial |
$65.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.51
|
|
|
GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 27687
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Exchange |
$6,047.48
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,696.12
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT
|
Facility
|
OP
|
$2,573.89
|
|
|
Service Code
|
CPT 91110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$490.11 |
| Max. Negotiated Rate |
$2,573.89 |
| Rate for Payer: Aetna Medicare |
$950.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,142.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,142.97
|
| Rate for Payer: BCBS Complete |
$514.61
|
| Rate for Payer: BCBS MAPPO |
$914.38
|
| Rate for Payer: BCN Medicare Advantage |
$914.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$914.38
|
| Rate for Payer: Mclaren Medicaid |
$490.11
|
| Rate for Payer: Mclaren Medicare |
$914.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$960.10
|
| Rate for Payer: Meridian Medicaid |
$514.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,051.54
|
| Rate for Payer: PACE Medicare |
$868.66
|
| Rate for Payer: PACE SWMI |
$914.38
|
| Rate for Payer: PHP Medicare Advantage |
$914.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$490.11
|
| Rate for Payer: Priority Health Medicare |
$914.38
|
| Rate for Payer: Railroad Medicare Medicare |
$914.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,573.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$914.38
|
| Rate for Payer: UHC Exchange |
$1,747.47
|
| Rate for Payer: UHC Medicare Advantage |
$914.38
|
| Rate for Payer: UHCCP Medicaid |
$490.11
|
| Rate for Payer: VA VA |
$914.38
|
|
|
GASTROSTOMY, OPEN; WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$5,207.85
|
|
|
Service Code
|
CPT 43830
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$991.65 |
| Max. Negotiated Rate |
$5,207.85 |
| Rate for Payer: Aetna Medicare |
$1,924.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,312.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,312.62
|
| Rate for Payer: BCBS Complete |
$1,041.24
|
| Rate for Payer: BCBS MAPPO |
$1,850.10
|
| Rate for Payer: BCN Medicare Advantage |
$1,850.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,850.10
|
| Rate for Payer: Mclaren Medicaid |
$991.65
|
| Rate for Payer: Mclaren Medicare |
$1,850.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,942.61
|
| Rate for Payer: Meridian Medicaid |
$1,041.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,127.61
|
| Rate for Payer: PACE Medicare |
$1,757.60
|
| Rate for Payer: PACE SWMI |
$1,850.10
|
| Rate for Payer: PHP Medicare Advantage |
$1,850.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$991.65
|
| Rate for Payer: Priority Health Medicare |
$1,850.10
|
| Rate for Payer: Railroad Medicare Medicare |
$1,850.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,207.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,850.10
|
| Rate for Payer: UHC Exchange |
$3,535.73
|
| Rate for Payer: UHC Medicare Advantage |
$1,850.10
|
| Rate for Payer: UHCCP Medicaid |
$991.65
|
| Rate for Payer: VA VA |
$1,850.10
|
|
|
GELATIN ABSORBABLE EYE FILM
|
Facility
|
IP
|
$999.82
|
|
|
Service Code
|
NDC 00009029703
|
| Hospital Charge Code |
28028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$439.92 |
| Max. Negotiated Rate |
$899.84 |
| Rate for Payer: Aetna American Axle |
$649.88
|
| Rate for Payer: Aetna Commercial |
$849.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$649.88
|
| Rate for Payer: Cash Price |
$799.86
|
| Rate for Payer: Cofinity Commercial |
$699.87
|
| Rate for Payer: Cofinity Commercial |
$859.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$699.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$799.86
|
| Rate for Payer: Healthscope Commercial |
$899.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$699.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$749.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$849.85
|
| Rate for Payer: PHP Commercial |
$849.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.88
|
| Rate for Payer: Priority Health SBD |
$629.89
|
| Rate for Payer: UMR Bronson Commercial |
$439.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$749.87
|
|
|
GELATIN ABSORBABLE EYE FILM
|
Facility
|
OP
|
$999.82
|
|
|
Service Code
|
NDC 00009029703
|
| Hospital Charge Code |
28028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$369.93 |
| Max. Negotiated Rate |
$899.84 |
| Rate for Payer: Aetna American Axle |
$649.88
|
| Rate for Payer: Aetna Commercial |
$849.85
|
| Rate for Payer: Aetna Medicare |
$499.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$649.88
|
| Rate for Payer: BCBS Complete |
$399.93
|
| Rate for Payer: Cash Price |
$799.86
|
| Rate for Payer: Cofinity Commercial |
$699.87
|
| Rate for Payer: Cofinity Commercial |
$859.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$699.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$799.86
|
| Rate for Payer: Healthscope Commercial |
$899.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$699.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$749.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$849.85
|
| Rate for Payer: PHP Commercial |
$849.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.88
|
| Rate for Payer: Priority Health SBD |
$629.89
|
| Rate for Payer: UMR Bronson Commercial |
$369.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$749.87
|
|
|
GELATIN ABSORBABLE IMPLANT FILM
|
Facility
|
IP
|
$7,006.40
|
|
|
Service Code
|
NDC 00009028301
|
| Hospital Charge Code |
109149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,082.82 |
| Max. Negotiated Rate |
$6,305.76 |
| Rate for Payer: Aetna American Axle |
$4,554.16
|
| Rate for Payer: Aetna Commercial |
$5,955.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,554.16
|
| Rate for Payer: Cash Price |
$5,605.12
|
| Rate for Payer: Cofinity Commercial |
$4,904.48
|
| Rate for Payer: Cofinity Commercial |
$6,025.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,904.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,605.12
|
| Rate for Payer: Healthscope Commercial |
$6,305.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,904.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,254.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,955.44
|
| Rate for Payer: PHP Commercial |
$5,955.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,554.16
|
| Rate for Payer: Priority Health SBD |
$4,414.03
|
| Rate for Payer: UMR Bronson Commercial |
$3,082.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,254.80
|
|
|
GELATIN ABSORBABLE IMPLANT FILM
|
Facility
|
OP
|
$7,006.40
|
|
|
Service Code
|
NDC 00009028301
|
| Hospital Charge Code |
109149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,592.37 |
| Max. Negotiated Rate |
$6,305.76 |
| Rate for Payer: Aetna American Axle |
$4,554.16
|
| Rate for Payer: Aetna Commercial |
$5,955.44
|
| Rate for Payer: Aetna Medicare |
$3,503.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,554.16
|
| Rate for Payer: BCBS Complete |
$2,802.56
|
| Rate for Payer: Cash Price |
$5,605.12
|
| Rate for Payer: Cofinity Commercial |
$4,904.48
|
| Rate for Payer: Cofinity Commercial |
$6,025.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,904.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,605.12
|
| Rate for Payer: Healthscope Commercial |
$6,305.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,904.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,254.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,955.44
|
| Rate for Payer: PHP Commercial |
$5,955.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,554.16
|
| Rate for Payer: Priority Health SBD |
$4,414.03
|
| Rate for Payer: UMR Bronson Commercial |
$2,592.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,254.80
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER
|
Facility
|
OP
|
$273.09
|
|
|
Service Code
|
NDC 00009043304
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.04 |
| Max. Negotiated Rate |
$245.78 |
| Rate for Payer: Aetna American Axle |
$177.51
|
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna Medicare |
$136.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.51
|
| Rate for Payer: BCBS Complete |
$109.24
|
| Rate for Payer: Cash Price |
$218.47
|
| Rate for Payer: Cofinity Commercial |
$191.16
|
| Rate for Payer: Cofinity Commercial |
$234.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$191.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.47
|
| Rate for Payer: Healthscope Commercial |
$245.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.13
|
| Rate for Payer: PHP Commercial |
$232.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.51
|
| Rate for Payer: Priority Health SBD |
$172.05
|
| Rate for Payer: UMR Bronson Commercial |
$101.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.82
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER
|
Facility
|
IP
|
$273.09
|
|
|
Service Code
|
NDC 00009043304
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.16 |
| Max. Negotiated Rate |
$245.78 |
| Rate for Payer: Aetna American Axle |
$177.51
|
| Rate for Payer: Aetna Commercial |
$232.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.51
|
| Rate for Payer: Cash Price |
$218.47
|
| Rate for Payer: Cofinity Commercial |
$191.16
|
| Rate for Payer: Cofinity Commercial |
$234.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$191.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.47
|
| Rate for Payer: Healthscope Commercial |
$245.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.13
|
| Rate for Payer: PHP Commercial |
$232.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.51
|
| Rate for Payer: Priority Health SBD |
$172.05
|
| Rate for Payer: UMR Bronson Commercial |
$120.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.82
|
|
|
GELATIN POWDER 1G WITH THROMBIN 5000 UNITS IN 6 ML NS
|
Facility
|
OP
|
$277.21
|
|
|
Service Code
|
NDC 00009000301
|
| Hospital Charge Code |
500530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.57 |
| Max. Negotiated Rate |
$249.49 |
| Rate for Payer: Aetna American Axle |
$180.19
|
| Rate for Payer: Aetna Commercial |
$235.63
|
| Rate for Payer: Aetna Medicare |
$138.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.19
|
| Rate for Payer: BCBS Complete |
$110.88
|
| Rate for Payer: Cash Price |
$221.77
|
| Rate for Payer: Cofinity Commercial |
$194.05
|
| Rate for Payer: Cofinity Commercial |
$238.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.77
|
| Rate for Payer: Healthscope Commercial |
$249.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.63
|
| Rate for Payer: PHP Commercial |
$235.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.19
|
| Rate for Payer: Priority Health SBD |
$174.64
|
| Rate for Payer: UMR Bronson Commercial |
$102.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.91
|
|
|
GELATIN POWDER 1G WITH THROMBIN 5000 UNITS IN 6 ML NS
|
Facility
|
IP
|
$277.21
|
|
|
Service Code
|
NDC 00009000301
|
| Hospital Charge Code |
500530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.97 |
| Max. Negotiated Rate |
$249.49 |
| Rate for Payer: Aetna American Axle |
$180.19
|
| Rate for Payer: Aetna Commercial |
$235.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.19
|
| Rate for Payer: Cash Price |
$221.77
|
| Rate for Payer: Cofinity Commercial |
$194.05
|
| Rate for Payer: Cofinity Commercial |
$238.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.77
|
| Rate for Payer: Healthscope Commercial |
$249.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.63
|
| Rate for Payer: PHP Commercial |
$235.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.19
|
| Rate for Payer: Priority Health SBD |
$174.64
|
| Rate for Payer: UMR Bronson Commercial |
$121.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.91
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$898.28
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$395.24 |
| Max. Negotiated Rate |
$808.45 |
| Rate for Payer: Aetna American Axle |
$583.88
|
| Rate for Payer: Aetna Commercial |
$763.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$583.88
|
| Rate for Payer: Cash Price |
$718.62
|
| Rate for Payer: Cofinity Commercial |
$628.80
|
| Rate for Payer: Cofinity Commercial |
$772.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$628.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.62
|
| Rate for Payer: Healthscope Commercial |
$808.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$628.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$673.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.54
|
| Rate for Payer: PHP Commercial |
$763.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.88
|
| Rate for Payer: Priority Health SBD |
$565.92
|
| Rate for Payer: UMR Bronson Commercial |
$395.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$673.71
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
OP
|
$659.90
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.16 |
| Max. Negotiated Rate |
$593.91 |
| Rate for Payer: Aetna American Axle |
$428.94
|
| Rate for Payer: Aetna Commercial |
$560.91
|
| Rate for Payer: Aetna Medicare |
$329.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$428.94
|
| Rate for Payer: BCBS Complete |
$263.96
|
| Rate for Payer: Cash Price |
$527.92
|
| Rate for Payer: Cofinity Commercial |
$461.93
|
| Rate for Payer: Cofinity Commercial |
$567.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$461.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$527.92
|
| Rate for Payer: Healthscope Commercial |
$593.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$461.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$494.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$560.91
|
| Rate for Payer: PHP Commercial |
$560.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$428.94
|
| Rate for Payer: Priority Health SBD |
$415.74
|
| Rate for Payer: UMR Bronson Commercial |
$244.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$494.93
|
|
