|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$13.13
|
|
|
Service Code
|
NDC 55150-165-05
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$11.82 |
| Rate for Payer: Aetna American Axle |
$8.53
|
| Rate for Payer: Aetna Commercial |
$11.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.53
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Cofinity Commercial |
$9.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.50
|
| Rate for Payer: Healthscope Commercial |
$11.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.16
|
| Rate for Payer: PHP Commercial |
$11.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.19
|
| Rate for Payer: Priority Health SBD |
$8.27
|
| Rate for Payer: UMR Bronson Commercial |
$5.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.85
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$28.42
|
|
|
Service Code
|
NDC 63323-495-04
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$25.58 |
| Rate for Payer: Aetna American Axle |
$18.47
|
| Rate for Payer: Aetna Commercial |
$24.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.47
|
| Rate for Payer: Cash Price |
$22.74
|
| Rate for Payer: Cofinity Commercial |
$19.89
|
| Rate for Payer: Cofinity Commercial |
$24.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.74
|
| Rate for Payer: Healthscope Commercial |
$25.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.16
|
| Rate for Payer: PHP Commercial |
$24.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.89
|
| Rate for Payer: Priority Health SBD |
$17.90
|
| Rate for Payer: UMR Bronson Commercial |
$12.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.32
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$19.64
|
|
|
Service Code
|
NDC 55150-164-02
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$17.68 |
| Rate for Payer: Aetna American Axle |
$12.77
|
| Rate for Payer: Aetna Commercial |
$16.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.77
|
| Rate for Payer: Cash Price |
$15.71
|
| Rate for Payer: Cofinity Commercial |
$13.75
|
| Rate for Payer: Cofinity Commercial |
$16.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.71
|
| Rate for Payer: Healthscope Commercial |
$17.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.69
|
| Rate for Payer: PHP Commercial |
$16.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.75
|
| Rate for Payer: Priority Health SBD |
$12.37
|
| Rate for Payer: UMR Bronson Commercial |
$8.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.73
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$28.66
|
|
|
Service Code
|
NDC 63323-496-03
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$25.79 |
| Rate for Payer: Aetna American Axle |
$18.63
|
| Rate for Payer: Aetna Commercial |
$24.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.63
|
| Rate for Payer: Cash Price |
$22.93
|
| Rate for Payer: Cofinity Commercial |
$20.06
|
| Rate for Payer: Cofinity Commercial |
$24.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.93
|
| Rate for Payer: Healthscope Commercial |
$25.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.36
|
| Rate for Payer: PHP Commercial |
$24.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.06
|
| Rate for Payer: Priority Health SBD |
$18.06
|
| Rate for Payer: UMR Bronson Commercial |
$12.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.50
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$27.99
|
|
|
Service Code
|
NDC 0409-4282-12
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Aetna American Axle |
$18.19
|
| Rate for Payer: Aetna Commercial |
$23.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.19
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Cofinity Commercial |
$19.59
|
| Rate for Payer: Cofinity Commercial |
$24.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$25.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.79
|
| Rate for Payer: PHP Commercial |
$23.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.59
|
| Rate for Payer: Priority Health SBD |
$17.63
|
| Rate for Payer: UMR Bronson Commercial |
$12.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.99
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.61
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
116451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$21.25 |
| Rate for Payer: Aetna American Axle |
$15.35
|
| Rate for Payer: Aetna Commercial |
$20.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.35
|
| Rate for Payer: Cash Price |
$18.89
|
| Rate for Payer: Cofinity Commercial |
$16.53
|
| Rate for Payer: Cofinity Commercial |
$20.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.89
|
| Rate for Payer: Healthscope Commercial |
$21.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.07
|
| Rate for Payer: PHP Commercial |
$20.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.53
|
| Rate for Payer: Priority Health SBD |
$14.87
|
| Rate for Payer: UMR Bronson Commercial |
$10.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.71
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION
|
Facility
|
IP
|
$20.95
|
|
|
Service Code
|
NDC 0409-4283-01
|
| Hospital Charge Code |
4455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna American Axle |
$13.62
|
| Rate for Payer: Aetna Commercial |
$17.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.62
|
| Rate for Payer: Cash Price |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$14.66
|
| Rate for Payer: Cofinity Commercial |
$18.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.76
|
| Rate for Payer: Healthscope Commercial |
$18.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.81
|
| Rate for Payer: PHP Commercial |
$17.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.66
|
| Rate for Payer: Priority Health SBD |
$13.20
|
| Rate for Payer: UMR Bronson Commercial |
$9.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.71
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION
|
Facility
|
IP
|
$20.95
|
|
|
Service Code
|
NDC 0409-4283-11
|
| Hospital Charge Code |
4455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna American Axle |
$13.62
|
| Rate for Payer: Aetna Commercial |
$17.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.62
|
| Rate for Payer: Cash Price |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$14.66
|
| Rate for Payer: Cofinity Commercial |
$18.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.76
|
| Rate for Payer: Healthscope Commercial |
$18.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.81
|
| Rate for Payer: PHP Commercial |
$17.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.66
|
| Rate for Payer: Priority Health SBD |
$13.20
|
| Rate for Payer: UMR Bronson Commercial |
$9.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.71
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) NEBULIZED SOLUTION
|
Facility
|
IP
|
$20.95
|
|
|
Service Code
|
NDC 0409-4283-01
|
| Hospital Charge Code |
168979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna American Axle |
$13.62
|
| Rate for Payer: Aetna Commercial |
$17.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.62
|
| Rate for Payer: Cash Price |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$14.66
|
| Rate for Payer: Cofinity Commercial |
$18.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.76
|
| Rate for Payer: Healthscope Commercial |
$18.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.81
|
| Rate for Payer: PHP Commercial |
$17.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.66
|
| Rate for Payer: Priority Health SBD |
$13.20
|
| Rate for Payer: UMR Bronson Commercial |
$9.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.71
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$19.98 |
| Rate for Payer: Aetna American Axle |
$14.43
|
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$19.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Healthscope Commercial |
$19.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.87
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.54
|
| Rate for Payer: Priority Health SBD |
$13.99
|
| Rate for Payer: UMR Bronson Commercial |
$9.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.65
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION (ANES ANALGESIA)
|
Facility
|
IP
|
$22.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
301050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$19.98 |
| Rate for Payer: Aetna American Axle |
$14.43
|
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$19.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Healthscope Commercial |
$19.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.87
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.54
|
| Rate for Payer: Priority Health SBD |
$13.99
|
| Rate for Payer: UMR Bronson Commercial |
$9.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.65
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$134.85
|
|
|
Service Code
|
NDC 0409-9137-05
|
| Hospital Charge Code |
4457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.33 |
| Max. Negotiated Rate |
$121.36 |
| Rate for Payer: Aetna American Axle |
$87.65
|
| Rate for Payer: Aetna Commercial |
$114.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.65
|
| Rate for Payer: Cash Price |
$107.88
|
| Rate for Payer: Cofinity Commercial |
$115.97
|
| Rate for Payer: Cofinity Commercial |
$94.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.88
|
| Rate for Payer: Healthscope Commercial |
$121.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$114.62
|
| Rate for Payer: PHP Commercial |
$114.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.40
|
| Rate for Payer: Priority Health SBD |
$84.96
|
| Rate for Payer: UMR Bronson Commercial |
$59.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.14
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$101.53
|
|
|
Service Code
|
NDC 0409-4904-34
|
| Hospital Charge Code |
4457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.67 |
| Max. Negotiated Rate |
$91.38 |
| Rate for Payer: Aetna American Axle |
$65.99
|
| Rate for Payer: Aetna Commercial |
$86.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.99
|
| Rate for Payer: Cash Price |
$81.22
|
| Rate for Payer: Cofinity Commercial |
$71.07
|
| Rate for Payer: Cofinity Commercial |
$87.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.22
|
| Rate for Payer: Healthscope Commercial |
$91.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$71.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.30
|
| Rate for Payer: PHP Commercial |
$86.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.07
|
| Rate for Payer: Priority Health SBD |
$63.96
|
| Rate for Payer: UMR Bronson Commercial |
$44.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.15
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Aetna American Axle |
$10.10
|
| Rate for Payer: Aetna American Axle |
$37.02
|
| Rate for Payer: Aetna Commercial |
$48.42
|
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$10.88
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Cofinity Commercial |
$48.99
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Healthscope Commercial |
$51.26
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.42
|
| Rate for Payer: PHP Commercial |
$48.42
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.88
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: Priority Health SBD |
$35.88
|
| Rate for Payer: UMR Bronson Commercial |
$6.84
|
| Rate for Payer: UMR Bronson Commercial |
$25.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.66
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$10.40
|
|
|
Service Code
|
NDC 0496-0882-05
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Aetna American Axle |
$6.76
|
| Rate for Payer: Aetna Commercial |
$8.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.76
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cofinity Commercial |
$7.28
|
| Rate for Payer: Cofinity Commercial |
$8.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.32
|
| Rate for Payer: Healthscope Commercial |
$9.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.84
|
| Rate for Payer: PHP Commercial |
$8.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health SBD |
$6.55
|
| Rate for Payer: UMR Bronson Commercial |
$4.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.80
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$9.55
|
|
|
Service Code
|
NDC 24357-701-06
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$8.60 |
| Rate for Payer: Aetna American Axle |
$6.21
|
| Rate for Payer: Aetna Commercial |
$8.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.21
|
| Rate for Payer: Cash Price |
$7.64
|
| Rate for Payer: Cofinity Commercial |
$6.68
|
| Rate for Payer: Cofinity Commercial |
$8.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.64
|
| Rate for Payer: Healthscope Commercial |
$8.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.12
|
| Rate for Payer: PHP Commercial |
$8.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.68
|
| Rate for Payer: Priority Health SBD |
$6.02
|
| Rate for Payer: UMR Bronson Commercial |
$4.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.16
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$9.55
|
|
|
Service Code
|
NDC 24357-701-05
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$8.60 |
| Rate for Payer: Aetna American Axle |
$6.21
|
| Rate for Payer: Aetna Commercial |
$8.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.21
|
| Rate for Payer: Cash Price |
$7.64
|
| Rate for Payer: Cofinity Commercial |
$6.68
|
| Rate for Payer: Cofinity Commercial |
$8.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.64
|
| Rate for Payer: Healthscope Commercial |
$8.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.12
|
| Rate for Payer: PHP Commercial |
$8.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.68
|
| Rate for Payer: Priority Health SBD |
$6.02
|
| Rate for Payer: UMR Bronson Commercial |
$4.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.16
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$14.18
|
|
|
Service Code
|
NDC 0496-0882-07
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$12.76 |
| Rate for Payer: Aetna American Axle |
$9.22
|
| Rate for Payer: Aetna Commercial |
$12.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.22
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$12.19
|
| Rate for Payer: Cofinity Commercial |
$9.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.34
|
| Rate for Payer: Healthscope Commercial |
$12.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.05
|
| Rate for Payer: PHP Commercial |
$12.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.93
|
| Rate for Payer: Priority Health SBD |
$8.93
|
| Rate for Payer: UMR Bronson Commercial |
$6.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.64
|
|
|
LIDOCAINE WITH EPINEPHRINE IN NS 50 ML
|
Facility
|
IP
|
$3.75
|
|
|
Service Code
|
NDC 9900-0002-02
|
| Hospital Charge Code |
158459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna American Axle |
$2.44
|
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.44
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.00
|
| Rate for Payer: Healthscope Commercial |
$3.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.19
|
| Rate for Payer: PHP Commercial |
$3.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.62
|
| Rate for Payer: Priority Health SBD |
$2.36
|
| Rate for Payer: UMR Bronson Commercial |
$1.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.81
|
|
|
LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR
|
Facility
|
OP
|
$20,018.71
|
|
|
Service Code
|
CPT 27427
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$705.64 |
| Max. Negotiated Rate |
$20,018.71 |
| Rate for Payer: Aetna Medicare |
$6,613.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,948.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,948.86
|
| Rate for Payer: BCBS Complete |
$3,652.66
|
| Rate for Payer: BCBS MAPPO |
$6,359.09
|
| Rate for Payer: BCBS Trust/PPO |
$6,673.93
|
| Rate for Payer: BCN Medicare Advantage |
$6,359.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,359.09
|
| Rate for Payer: Mclaren Medicaid |
$3,478.42
|
| Rate for Payer: Mclaren Medicare |
$6,359.09
|
| Rate for Payer: Meridian Medicaid |
$3,652.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,677.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,312.95
|
| Rate for Payer: PACE Medicare |
$6,041.14
|
| Rate for Payer: PACE SWMI |
$6,359.09
|
| Rate for Payer: PHP Medicare Advantage |
$6,359.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,478.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,018.71
|
| Rate for Payer: Priority Health Medicare |
$6,359.09
|
| Rate for Payer: Priority Health Narrow Network |
$16,014.97
|
| Rate for Payer: Railroad Medicare Medicare |
$6,359.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$776.20
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,359.09
|
| Rate for Payer: UHC Exchange |
$705.64
|
| Rate for Payer: UHC Medicare Advantage |
$6,549.86
|
| Rate for Payer: VA VA |
$6,359.09
|
|
|
LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS
|
Facility
|
OP
|
$8,919.33
|
|
|
Service Code
|
CPT 37700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$237.72 |
| Max. Negotiated Rate |
$8,919.33 |
| Rate for Payer: Aetna Medicare |
$2,946.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,541.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,541.61
|
| Rate for Payer: BCBS Complete |
$1,627.44
|
| Rate for Payer: BCBS MAPPO |
$2,833.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,894.36
|
| Rate for Payer: BCN Medicare Advantage |
$2,833.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,833.29
|
| Rate for Payer: Mclaren Medicaid |
$1,549.81
|
| Rate for Payer: Mclaren Medicare |
$2,833.29
|
| Rate for Payer: Meridian Medicaid |
$1,627.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,974.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,258.28
|
| Rate for Payer: PACE Medicare |
$2,691.63
|
| Rate for Payer: PACE SWMI |
$2,833.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,833.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,549.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,919.33
|
| Rate for Payer: Priority Health Medicare |
$2,833.29
|
| Rate for Payer: Priority Health Narrow Network |
$7,135.46
|
| Rate for Payer: Railroad Medicare Medicare |
$2,833.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.49
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,833.29
|
| Rate for Payer: UHC Exchange |
$237.72
|
| Rate for Payer: UHC Medicare Advantage |
$2,918.29
|
| Rate for Payer: VA VA |
$2,833.29
|
|
|
LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,919.33
|
|
|
Service Code
|
CPT 37780
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$229.54 |
| Max. Negotiated Rate |
$8,919.33 |
| Rate for Payer: Aetna Medicare |
$2,946.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,541.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,541.61
|
| Rate for Payer: BCBS Complete |
$1,627.44
|
| Rate for Payer: BCBS MAPPO |
$2,833.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,678.65
|
| Rate for Payer: BCN Medicare Advantage |
$2,833.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,833.29
|
| Rate for Payer: Mclaren Medicaid |
$1,549.81
|
| Rate for Payer: Mclaren Medicare |
$2,833.29
|
| Rate for Payer: Meridian Medicaid |
$1,627.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,974.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,258.28
|
| Rate for Payer: PACE Medicare |
$2,691.63
|
| Rate for Payer: PACE SWMI |
$2,833.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,833.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,549.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,919.33
|
| Rate for Payer: Priority Health Medicare |
$2,833.29
|
| Rate for Payer: Priority Health Narrow Network |
$7,135.46
|
| Rate for Payer: Railroad Medicare Medicare |
$2,833.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.49
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,833.29
|
| Rate for Payer: UHC Exchange |
$229.54
|
| Rate for Payer: UHC Medicare Advantage |
$2,918.29
|
| Rate for Payer: VA VA |
$2,833.29
|
|
|
LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG
|
Facility
|
OP
|
$8,919.33
|
|
|
Service Code
|
CPT 37785
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$248.20 |
| Max. Negotiated Rate |
$8,919.33 |
| Rate for Payer: Aetna Medicare |
$2,946.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,541.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,541.61
|
| Rate for Payer: BCBS Complete |
$1,627.44
|
| Rate for Payer: BCBS MAPPO |
$2,833.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,894.36
|
| Rate for Payer: BCN Medicare Advantage |
$2,833.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,833.29
|
| Rate for Payer: Mclaren Medicaid |
$1,549.81
|
| Rate for Payer: Mclaren Medicare |
$2,833.29
|
| Rate for Payer: Meridian Medicaid |
$1,627.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,974.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,258.28
|
| Rate for Payer: PACE Medicare |
$2,691.63
|
| Rate for Payer: PACE SWMI |
$2,833.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,833.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,549.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,919.33
|
| Rate for Payer: Priority Health Medicare |
$2,833.29
|
| Rate for Payer: Priority Health Narrow Network |
$7,135.46
|
| Rate for Payer: Railroad Medicare Medicare |
$2,833.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.02
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,833.29
|
| Rate for Payer: UHC Exchange |
$248.20
|
| Rate for Payer: UHC Medicare Advantage |
$2,918.29
|
| Rate for Payer: VA VA |
$2,833.29
|
|
|
LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW
|
Facility
|
OP
|
$8,919.33
|
|
|
Service Code
|
CPT 37722
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$446.30 |
| Max. Negotiated Rate |
$8,919.33 |
| Rate for Payer: Aetna Medicare |
$2,946.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,541.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,541.61
|
| Rate for Payer: BCBS Complete |
$1,627.44
|
| Rate for Payer: BCBS MAPPO |
$2,833.29
|
| Rate for Payer: BCBS Trust/PPO |
$2,210.06
|
| Rate for Payer: BCN Medicare Advantage |
$2,833.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,833.29
|
| Rate for Payer: Mclaren Medicaid |
$1,549.81
|
| Rate for Payer: Mclaren Medicare |
$2,833.29
|
| Rate for Payer: Meridian Medicaid |
$1,627.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,974.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,258.28
|
| Rate for Payer: PACE Medicare |
$2,691.63
|
| Rate for Payer: PACE SWMI |
$2,833.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,833.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,549.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,919.33
|
| Rate for Payer: Priority Health Medicare |
$2,833.29
|
| Rate for Payer: Priority Health Narrow Network |
$7,135.46
|
| Rate for Payer: Railroad Medicare Medicare |
$2,833.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$490.93
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,833.29
|
| Rate for Payer: UHC Exchange |
$446.30
|
| Rate for Payer: UHC Medicare Advantage |
$2,918.29
|
| Rate for Payer: VA VA |
$2,833.29
|
|
|
LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY
|
Facility
|
OP
|
$1,879.00
|
|
|
Service Code
|
CPT 37618
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$384.09 |
| Max. Negotiated Rate |
$1,879.00 |
| Rate for Payer: BCBS Trust/PPO |
$1,342.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$422.50
|
| Rate for Payer: UHC Core |
$1,879.00
|
| Rate for Payer: UHC Exchange |
$384.09
|
|
