|
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION
|
Facility
|
IP
|
$1,684.64
|
|
|
Service Code
|
NDC 31722001647
|
| Hospital Charge Code |
107829
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$741.24 |
| Max. Negotiated Rate |
$1,516.18 |
| Rate for Payer: Aetna American Axle |
$1,095.02
|
| Rate for Payer: Aetna Commercial |
$1,431.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,095.02
|
| Rate for Payer: Cash Price |
$1,347.71
|
| Rate for Payer: Cofinity Commercial |
$1,179.25
|
| Rate for Payer: Cofinity Commercial |
$1,448.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,179.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,347.71
|
| Rate for Payer: Healthscope Commercial |
$1,516.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,179.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,263.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,431.94
|
| Rate for Payer: PHP Commercial |
$1,431.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,095.02
|
| Rate for Payer: Priority Health SBD |
$1,061.32
|
| Rate for Payer: UMR Bronson Commercial |
$741.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,263.48
|
|
|
GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION
|
Facility
|
OP
|
$1,366.79
|
|
|
Service Code
|
NDC 51672531609
|
| Hospital Charge Code |
107829
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$505.71 |
| Max. Negotiated Rate |
$1,230.11 |
| Rate for Payer: Aetna American Axle |
$888.41
|
| Rate for Payer: Aetna Commercial |
$1,161.77
|
| Rate for Payer: Aetna Medicare |
$683.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$888.41
|
| Rate for Payer: BCBS Complete |
$546.72
|
| Rate for Payer: Cash Price |
$1,093.43
|
| Rate for Payer: Cofinity Commercial |
$1,175.44
|
| Rate for Payer: Cofinity Commercial |
$956.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$956.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,093.43
|
| Rate for Payer: Healthscope Commercial |
$1,230.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$956.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,025.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,161.77
|
| Rate for Payer: PHP Commercial |
$1,161.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$888.41
|
| Rate for Payer: Priority Health SBD |
$861.08
|
| Rate for Payer: UMR Bronson Commercial |
$505.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,025.09
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 49884006501
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.45 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$168.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$246.75
|
|
|
Service Code
|
NDC 23155060601
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.57 |
| Max. Negotiated Rate |
$222.08 |
| Rate for Payer: Aetna American Axle |
$160.39
|
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.39
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$172.72
|
| Rate for Payer: Cofinity Commercial |
$212.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.74
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.39
|
| Rate for Payer: Priority Health SBD |
$155.45
|
| Rate for Payer: UMR Bronson Commercial |
$108.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$407.04
|
|
|
Service Code
|
NDC 55111064801
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.60 |
| Max. Negotiated Rate |
$366.34 |
| Rate for Payer: Aetna American Axle |
$264.58
|
| Rate for Payer: Aetna Commercial |
$345.98
|
| Rate for Payer: Aetna Medicare |
$203.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.58
|
| Rate for Payer: BCBS Complete |
$162.82
|
| Rate for Payer: Cash Price |
$325.63
|
| Rate for Payer: Cofinity Commercial |
$284.93
|
| Rate for Payer: Cofinity Commercial |
$350.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.63
|
| Rate for Payer: Healthscope Commercial |
$366.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.98
|
| Rate for Payer: PHP Commercial |
$345.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.58
|
| Rate for Payer: Priority Health SBD |
$256.44
|
| Rate for Payer: UMR Bronson Commercial |
$150.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.28
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$407.04
|
|
|
Service Code
|
NDC 55111064801
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.10 |
| Max. Negotiated Rate |
$366.34 |
| Rate for Payer: Aetna American Axle |
$264.58
|
| Rate for Payer: Aetna Commercial |
$345.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.58
|
| Rate for Payer: Cash Price |
$325.63
|
| Rate for Payer: Cofinity Commercial |
$284.93
|
| Rate for Payer: Cofinity Commercial |
$350.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.63
|
| Rate for Payer: Healthscope Commercial |
$366.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.98
|
| Rate for Payer: PHP Commercial |
$345.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.58
|
| Rate for Payer: Priority Health SBD |
$256.44
|
| Rate for Payer: UMR Bronson Commercial |
$179.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.28
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$392.64
|
|
|
Service Code
|
NDC 69315013901
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.76 |
| Max. Negotiated Rate |
$353.38 |
| Rate for Payer: Aetna American Axle |
$255.22
|
| Rate for Payer: Aetna Commercial |
$333.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.22
|
| Rate for Payer: Cash Price |
$314.11
|
| Rate for Payer: Cofinity Commercial |
$274.85
|
| Rate for Payer: Cofinity Commercial |
$337.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$274.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$314.11
|
| Rate for Payer: Healthscope Commercial |
$353.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$274.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$294.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$333.74
|
| Rate for Payer: PHP Commercial |
$333.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.22
|
| Rate for Payer: Priority Health SBD |
$247.36
|
| Rate for Payer: UMR Bronson Commercial |
$172.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$294.48
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$385.70
|
|
|
Service Code
|
NDC 69076047501
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.70
|
| Rate for Payer: Aetna Commercial |
$327.84
|
| Rate for Payer: Aetna Medicare |
$192.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.70
|
| Rate for Payer: BCBS Complete |
$154.28
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.84
|
| Rate for Payer: PHP Commercial |
$327.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.70
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$142.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.28
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 69076047501
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.71 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna American Axle |
$250.70
|
| Rate for Payer: Aetna Commercial |
$327.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.70
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$269.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.84
|
| Rate for Payer: PHP Commercial |
$327.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.70
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UMR Bronson Commercial |
$169.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.28
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$246.75
|
|
|
Service Code
|
NDC 23155060601
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.30 |
| Max. Negotiated Rate |
$222.08 |
| Rate for Payer: Aetna American Axle |
$160.39
|
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: Aetna Medicare |
$123.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.39
|
| Rate for Payer: BCBS Complete |
$98.70
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$172.72
|
| Rate for Payer: Cofinity Commercial |
$212.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.74
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.39
|
| Rate for Payer: Priority Health SBD |
$155.45
|
| Rate for Payer: UMR Bronson Commercial |
$91.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$392.64
|
|
|
Service Code
|
NDC 69315013901
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.28 |
| Max. Negotiated Rate |
$353.38 |
| Rate for Payer: Aetna American Axle |
$255.22
|
| Rate for Payer: Aetna Commercial |
$333.74
|
| Rate for Payer: Aetna Medicare |
$196.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.22
|
| Rate for Payer: BCBS Complete |
$157.06
|
| Rate for Payer: Cash Price |
$314.11
|
| Rate for Payer: Cofinity Commercial |
$274.85
|
| Rate for Payer: Cofinity Commercial |
$337.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$274.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$314.11
|
| Rate for Payer: Healthscope Commercial |
$353.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$274.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$294.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$333.74
|
| Rate for Payer: PHP Commercial |
$333.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.22
|
| Rate for Payer: Priority Health SBD |
$247.36
|
| Rate for Payer: UMR Bronson Commercial |
$145.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$294.48
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$382.85
|
|
|
Service Code
|
NDC 49884006501
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna Medicare |
$191.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$141.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$6,234.37
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
167346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,743.12 |
| Max. Negotiated Rate |
$5,610.93 |
| Rate for Payer: Aetna American Axle |
$4,052.34
|
| Rate for Payer: Aetna Commercial |
$5,299.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,052.34
|
| Rate for Payer: Cash Price |
$4,987.50
|
| Rate for Payer: Cofinity Commercial |
$4,364.06
|
| Rate for Payer: Cofinity Commercial |
$5,361.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,364.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,987.50
|
| Rate for Payer: Healthscope Commercial |
$5,610.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,364.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,675.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,299.21
|
| Rate for Payer: PHP Commercial |
$5,299.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,052.34
|
| Rate for Payer: Priority Health SBD |
$3,927.65
|
| Rate for Payer: UMR Bronson Commercial |
$2,743.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,675.78
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,234.37
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
167346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$5,610.93 |
| Rate for Payer: Aetna American Axle |
$4,052.34
|
| Rate for Payer: Aetna Commercial |
$5,299.21
|
| Rate for Payer: Aetna Medicare |
$10.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,052.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.18
|
| Rate for Payer: BCBS Complete |
$5.93
|
| Rate for Payer: BCBS MAPPO |
$10.54
|
| Rate for Payer: BCBS Trust/PPO |
$29.90
|
| Rate for Payer: BCN Commercial |
$29.90
|
| Rate for Payer: BCN Medicare Advantage |
$10.54
|
| Rate for Payer: Cash Price |
$4,987.50
|
| Rate for Payer: Cash Price |
$4,987.50
|
| Rate for Payer: Cofinity Commercial |
$5,361.56
|
| Rate for Payer: Cofinity Commercial |
$4,364.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,364.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,987.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.54
|
| Rate for Payer: Healthscope Commercial |
$5,610.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,364.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,675.78
|
| Rate for Payer: Mclaren Medicaid |
$5.65
|
| Rate for Payer: Mclaren Medicare |
$10.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.07
|
| Rate for Payer: Meridian Medicaid |
$5.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,299.21
|
| Rate for Payer: Nomi Health Commercial |
$31.62
|
| Rate for Payer: PACE Medicare |
$10.01
|
| Rate for Payer: PACE SWMI |
$10.54
|
| Rate for Payer: PHP Commercial |
$5,299.21
|
| Rate for Payer: PHP Medicare Advantage |
$10.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$5.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,052.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.95
|
| Rate for Payer: Priority Health Medicare |
$10.54
|
| Rate for Payer: Priority Health Narrow Network |
$25.56
|
| Rate for Payer: Priority Health SBD |
$3,927.65
|
| Rate for Payer: Railroad Medicare Medicare |
$10.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.54
|
| Rate for Payer: UHC Exchange |
$20.14
|
| Rate for Payer: UHC Medicare Advantage |
$10.54
|
| Rate for Payer: UHCCP Medicaid |
$5.65
|
| Rate for Payer: UMR Bronson Commercial |
$2,306.72
|
| Rate for Payer: VA VA |
$10.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,675.78
|
|
|
GONIOTOMY
|
Facility
|
OP
|
$12,388.13
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$764.00 |
| Max. Negotiated Rate |
$12,388.13 |
| Rate for Payer: Aetna Medicare |
$4,099.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,926.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,926.90
|
| Rate for Payer: BCBS Complete |
$2,218.29
|
| Rate for Payer: BCBS MAPPO |
$3,941.52
|
| Rate for Payer: BCBS Trust/PPO |
$2,327.05
|
| Rate for Payer: BCN Commercial |
$2,327.05
|
| Rate for Payer: BCN Medicare Advantage |
$3,941.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,941.52
|
| Rate for Payer: Mclaren Medicaid |
$2,112.65
|
| Rate for Payer: Mclaren Medicare |
$3,941.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4,138.60
|
| Rate for Payer: Meridian Medicaid |
$2,218.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,532.75
|
| Rate for Payer: Nomi Health Commercial |
$8,277.19
|
| Rate for Payer: PACE Medicare |
$3,744.44
|
| Rate for Payer: PACE SWMI |
$3,941.52
|
| Rate for Payer: PHP Medicare Advantage |
$3,941.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,112.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,388.13
|
| Rate for Payer: Priority Health Medicare |
$3,941.52
|
| Rate for Payer: Priority Health Narrow Network |
$9,910.50
|
| Rate for Payer: Railroad Medicare Medicare |
$3,941.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$840.40
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,941.52
|
| Rate for Payer: UHC Exchange |
$764.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,941.52
|
| Rate for Payer: UHCCP Medicaid |
$2,112.65
|
| Rate for Payer: VA VA |
$3,941.52
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT
|
Facility
|
OP
|
$10,804.08
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
16254
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.84 |
| Max. Negotiated Rate |
$9,723.67 |
| Rate for Payer: Aetna American Axle |
$7,022.65
|
| Rate for Payer: Aetna Commercial |
$9,183.47
|
| Rate for Payer: Aetna Medicare |
$731.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,022.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$878.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$878.82
|
| Rate for Payer: BCBS Complete |
$395.68
|
| Rate for Payer: BCBS MAPPO |
$703.06
|
| Rate for Payer: BCBS Trust/PPO |
$1,785.71
|
| Rate for Payer: BCN Commercial |
$1,785.71
|
| Rate for Payer: BCN Medicare Advantage |
$703.06
|
| Rate for Payer: Cash Price |
$8,643.26
|
| Rate for Payer: Cash Price |
$8,643.26
|
| Rate for Payer: Cofinity Commercial |
$9,291.51
|
| Rate for Payer: Cofinity Commercial |
$7,562.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,562.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,643.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$703.06
|
| Rate for Payer: Healthscope Commercial |
$9,723.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,562.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,103.06
|
| Rate for Payer: Mclaren Medicaid |
$376.84
|
| Rate for Payer: Mclaren Medicare |
$703.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$738.21
|
| Rate for Payer: Meridian Medicaid |
$395.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$808.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,183.47
|
| Rate for Payer: Nomi Health Commercial |
$2,109.18
|
| Rate for Payer: PACE Medicare |
$667.91
|
| Rate for Payer: PACE SWMI |
$703.06
|
| Rate for Payer: PHP Commercial |
$9,183.47
|
| Rate for Payer: PHP Medicare Advantage |
$703.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$376.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,022.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,942.00
|
| Rate for Payer: Priority Health Medicare |
$703.06
|
| Rate for Payer: Priority Health Narrow Network |
$1,553.60
|
| Rate for Payer: Priority Health SBD |
$6,806.57
|
| Rate for Payer: Railroad Medicare Medicare |
$703.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,979.04
|
| Rate for Payer: UHC Dual Complete DSNP |
$703.06
|
| Rate for Payer: UHC Exchange |
$1,343.62
|
| Rate for Payer: UHC Medicare Advantage |
$703.06
|
| Rate for Payer: UHCCP Medicaid |
$376.84
|
| Rate for Payer: UMR Bronson Commercial |
$3,997.51
|
| Rate for Payer: VA VA |
$703.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,103.06
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT
|
Facility
|
OP
|
$3,364.48
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
10137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$376.84 |
| Max. Negotiated Rate |
$3,028.03 |
| Rate for Payer: Aetna American Axle |
$2,186.91
|
| Rate for Payer: Aetna Commercial |
$2,859.81
|
| Rate for Payer: Aetna Medicare |
$731.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,186.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$878.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$878.82
|
| Rate for Payer: BCBS Complete |
$395.68
|
| Rate for Payer: BCBS MAPPO |
$703.06
|
| Rate for Payer: BCBS Trust/PPO |
$1,785.71
|
| Rate for Payer: BCN Commercial |
$1,785.71
|
| Rate for Payer: BCN Medicare Advantage |
$703.06
|
| Rate for Payer: Cash Price |
$2,691.58
|
| Rate for Payer: Cash Price |
$2,691.58
|
| Rate for Payer: Cofinity Commercial |
$2,893.45
|
| Rate for Payer: Cofinity Commercial |
$2,355.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,355.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,691.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$703.06
|
| Rate for Payer: Healthscope Commercial |
$3,028.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,355.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,523.36
|
| Rate for Payer: Mclaren Medicaid |
$376.84
|
| Rate for Payer: Mclaren Medicare |
$703.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$738.21
|
| Rate for Payer: Meridian Medicaid |
$395.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$808.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,859.81
|
| Rate for Payer: Nomi Health Commercial |
$2,109.18
|
| Rate for Payer: PACE Medicare |
$667.91
|
| Rate for Payer: PACE SWMI |
$703.06
|
| Rate for Payer: PHP Commercial |
$2,859.81
|
| Rate for Payer: PHP Medicare Advantage |
$703.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$376.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,186.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,942.00
|
| Rate for Payer: Priority Health Medicare |
$703.06
|
| Rate for Payer: Priority Health Narrow Network |
$1,553.60
|
| Rate for Payer: Priority Health SBD |
$2,119.62
|
| Rate for Payer: Railroad Medicare Medicare |
$703.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,979.04
|
| Rate for Payer: UHC Dual Complete DSNP |
$703.06
|
| Rate for Payer: UHC Exchange |
$1,343.62
|
| Rate for Payer: UHC Medicare Advantage |
$703.06
|
| Rate for Payer: UHCCP Medicaid |
$376.84
|
| Rate for Payer: UMR Bronson Commercial |
$1,244.86
|
| Rate for Payer: VA VA |
$703.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,523.36
|
|
|
GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 21215
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$750.90 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$2,845.58
|
| Rate for Payer: BCN Commercial |
$2,845.58
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$825.99
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$750.90
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,106.68
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 21210
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$722.35 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$2,845.58
|
| Rate for Payer: BCN Commercial |
$2,845.58
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$794.58
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$722.35
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,106.68
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
GRAFT; DERMA-FAT-FASCIA
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15770
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$644.40 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$2,108.09
|
| Rate for Payer: BCN Commercial |
$2,108.09
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$708.84
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$644.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 21235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$545.22 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$5,462.86
|
| Rate for Payer: BCN Commercial |
$5,462.86
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$599.74
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$545.22
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,106.68
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15771
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$490.91 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$4,550.62
|
| Rate for Payer: BCN Commercial |
$4,550.62
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$540.00
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$490.91
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$142.78 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$641.02
|
| Rate for Payer: BCN Commercial |
$641.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.06
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$142.78
|
|
|
GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15769
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$462.21 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$2,603.00
|
| Rate for Payer: BCN Commercial |
$2,603.00
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.43
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$462.21
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
GRANISETRON HCL 1 MG/ML (1 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$27.09
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
117977
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$24.38 |
| Rate for Payer: Aetna American Axle |
$17.61
|
| Rate for Payer: Aetna American Axle |
$11.65
|
| Rate for Payer: Aetna Commercial |
$15.24
|
| Rate for Payer: Aetna Commercial |
$23.03
|
| Rate for Payer: Aetna Medicare |
$13.54
|
| Rate for Payer: Aetna Medicare |
$8.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.61
|
| Rate for Payer: BCBS Complete |
$10.84
|
| Rate for Payer: BCBS Complete |
$7.17
|
| Rate for Payer: BCBS Trust/PPO |
$0.74
|
| Rate for Payer: BCBS Trust/PPO |
$0.74
|
| Rate for Payer: BCN Commercial |
$0.74
|
| Rate for Payer: BCN Commercial |
$0.74
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cash Price |
$21.67
|
| Rate for Payer: Cash Price |
$21.67
|
| Rate for Payer: Cofinity Commercial |
$12.55
|
| Rate for Payer: Cofinity Commercial |
$15.42
|
| Rate for Payer: Cofinity Commercial |
$23.30
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.34
|
| Rate for Payer: Healthscope Commercial |
$16.14
|
| Rate for Payer: Healthscope Commercial |
$24.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.24
|
| Rate for Payer: PHP Commercial |
$23.03
|
| Rate for Payer: PHP Commercial |
$15.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.61
|
| Rate for Payer: Priority Health SBD |
$17.07
|
| Rate for Payer: Priority Health SBD |
$11.30
|
| Rate for Payer: UMR Bronson Commercial |
$6.63
|
| Rate for Payer: UMR Bronson Commercial |
$10.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.32
|
|
