|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE
|
Facility
|
OP
|
$1,096.83
|
|
|
Service Code
|
CPT 10120
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$208.85 |
| Max. Negotiated Rate |
$1,096.83 |
| Rate for Payer: Aetna Medicare |
$405.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$487.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$487.06
|
| Rate for Payer: BCBS Complete |
$219.30
|
| Rate for Payer: BCBS MAPPO |
$389.65
|
| Rate for Payer: BCN Medicare Advantage |
$389.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$389.65
|
| Rate for Payer: Mclaren Medicaid |
$208.85
|
| Rate for Payer: Mclaren Medicare |
$389.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$409.13
|
| Rate for Payer: Meridian Medicaid |
$219.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$448.10
|
| Rate for Payer: PACE Medicare |
$370.17
|
| Rate for Payer: PACE SWMI |
$389.65
|
| Rate for Payer: PHP Medicare Advantage |
$389.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$208.85
|
| Rate for Payer: Priority Health Medicare |
$389.65
|
| Rate for Payer: Railroad Medicare Medicare |
$389.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,096.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$389.65
|
| Rate for Payer: UHC Exchange |
$744.66
|
| Rate for Payer: UHC Medicare Advantage |
$389.65
|
| Rate for Payer: UHCCP Medicaid |
$208.85
|
| Rate for Payer: VA VA |
$389.65
|
|
|
INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), FOOT
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 28005
|
|
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
|
|
|
INCISION, DEEP, BONE CORTEX, FOREARM AND/OR WRIST (EG, OSTEOMYELITIS OR BONE ABSCESS)
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 25035
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Exchange |
$13,314.90
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,734.39
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), HUMERUS OR ELBOW
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 23935
|
|
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
|
|
|
INCISION (EG, OSTEOMYELITIS OR BONE ABSCESS), LEG OR ANKLE
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 27607
|
|
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
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Exchange |
$2,982.94
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$836.62
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
INCISION, FLEXOR TENDON SHEATH, WRIST (EG, FLEXOR CARPI RADIALIS)
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 25001
|
|
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
|
|
|
INCISION OF LABIAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$1,398.05
|
|
|
Service Code
|
CPT 40806
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$266.21 |
| Max. Negotiated Rate |
$1,398.05 |
| Rate for Payer: Aetna Medicare |
$516.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$620.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$620.83
|
| Rate for Payer: BCBS Complete |
$279.52
|
| Rate for Payer: BCBS MAPPO |
$496.66
|
| Rate for Payer: BCN Medicare Advantage |
$496.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$496.66
|
| Rate for Payer: Mclaren Medicaid |
$266.21
|
| Rate for Payer: Mclaren Medicare |
$496.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$521.49
|
| Rate for Payer: Meridian Medicaid |
$279.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$571.16
|
| Rate for Payer: PACE Medicare |
$471.83
|
| Rate for Payer: PACE SWMI |
$496.66
|
| Rate for Payer: PHP Medicare Advantage |
$496.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$266.21
|
| Rate for Payer: Priority Health Medicare |
$496.66
|
| Rate for Payer: Railroad Medicare Medicare |
$496.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,398.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$496.66
|
| Rate for Payer: UHC Exchange |
$949.17
|
| Rate for Payer: UHC Medicare Advantage |
$496.66
|
| Rate for Payer: UHCCP Medicaid |
$266.21
|
| Rate for Payer: VA VA |
$496.66
|
|
|
INCISION OF LINGUAL FRENUM (FRENOTOMY)
|
Facility
|
OP
|
$4,066.57
|
|
|
Service Code
|
CPT 41010
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$774.34 |
| Max. Negotiated Rate |
$4,066.57 |
| Rate for Payer: Aetna Medicare |
$1,502.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,805.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,805.83
|
| Rate for Payer: BCBS Complete |
$813.05
|
| Rate for Payer: BCBS MAPPO |
$1,444.66
|
| Rate for Payer: BCN Medicare Advantage |
$1,444.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,444.66
|
| Rate for Payer: Mclaren Medicaid |
$774.34
|
| Rate for Payer: Mclaren Medicare |
$1,444.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,516.89
|
| Rate for Payer: Meridian Medicaid |
$813.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,661.36
|
| Rate for Payer: PACE Medicare |
$1,372.43
|
| Rate for Payer: PACE SWMI |
$1,444.66
|
| Rate for Payer: PHP Medicare Advantage |
$1,444.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$774.34
|
| Rate for Payer: Priority Health Medicare |
$1,444.66
|
| Rate for Payer: Railroad Medicare Medicare |
$1,444.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,066.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,444.66
|
| Rate for Payer: UHC Exchange |
$2,760.89
|
| Rate for Payer: UHC Medicare Advantage |
$1,444.66
|
| Rate for Payer: UHCCP Medicaid |
$774.34
|
| Rate for Payer: VA VA |
$1,444.66
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$8,791.70
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$7,912.53 |
| Rate for Payer: Aetna American Axle |
$5,714.60
|
| Rate for Payer: Aetna Commercial |
$7,472.94
|
| Rate for Payer: Aetna Medicare |
$12.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,714.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.40
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: BCBS MAPPO |
$12.32
|
| Rate for Payer: BCN Medicare Advantage |
$12.32
|
| Rate for Payer: Cash Price |
$7,033.36
|
| Rate for Payer: Cash Price |
$7,033.36
|
| Rate for Payer: Cofinity Commercial |
$7,560.86
|
| Rate for Payer: Cofinity Commercial |
$6,154.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,154.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,033.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.32
|
| Rate for Payer: Healthscope Commercial |
$7,912.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,154.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,593.77
|
| Rate for Payer: Mclaren Medicaid |
$6.60
|
| Rate for Payer: Mclaren Medicare |
$12.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.94
|
| Rate for Payer: Meridian Medicaid |
$6.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,472.94
|
| Rate for Payer: PACE Medicare |
$11.70
|
| Rate for Payer: PACE SWMI |
$12.32
|
| Rate for Payer: PHP Commercial |
$7,472.94
|
| Rate for Payer: PHP Medicare Advantage |
$12.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,714.60
|
| Rate for Payer: Priority Health Medicare |
$12.32
|
| Rate for Payer: Priority Health SBD |
$5,538.77
|
| Rate for Payer: Railroad Medicare Medicare |
$12.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.32
|
| Rate for Payer: UHC Exchange |
$23.54
|
| Rate for Payer: UHC Medicare Advantage |
$12.32
|
| Rate for Payer: UHCCP Medicaid |
$6.60
|
| Rate for Payer: UMR Bronson Commercial |
$3,252.93
|
| Rate for Payer: VA VA |
$12.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,593.77
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$8,791.70
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
198874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,868.35 |
| Max. Negotiated Rate |
$7,912.53 |
| Rate for Payer: Aetna American Axle |
$5,714.60
|
| Rate for Payer: Aetna Commercial |
$7,472.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,714.60
|
| Rate for Payer: Cash Price |
$7,033.36
|
| Rate for Payer: Cofinity Commercial |
$6,154.19
|
| Rate for Payer: Cofinity Commercial |
$7,560.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,154.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,033.36
|
| Rate for Payer: Healthscope Commercial |
$7,912.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,154.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,593.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,472.94
|
| Rate for Payer: PHP Commercial |
$7,472.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,714.60
|
| Rate for Payer: Priority Health SBD |
$5,538.77
|
| Rate for Payer: UMR Bronson Commercial |
$3,868.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,593.77
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
IP
|
$253.80
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.67 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna American Axle |
$164.97
|
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.97
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Cofinity Commercial |
$218.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$228.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: PHP Commercial |
$215.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: Priority Health SBD |
$159.89
|
| Rate for Payer: UMR Bronson Commercial |
$111.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.35
|
|
|
INDAPAMIDE 2.5 MG TABLET
|
Facility
|
OP
|
$253.80
|
|
|
Service Code
|
NDC 62559051101
|
| Hospital Charge Code |
3879
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.91 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna American Axle |
$164.97
|
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna Medicare |
$126.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.97
|
| Rate for Payer: BCBS Complete |
$101.52
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Cofinity Commercial |
$218.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$228.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: PHP Commercial |
$215.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: Priority Health SBD |
$159.89
|
| Rate for Payer: UMR Bronson Commercial |
$93.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.35
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$175.81 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$237.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: BCBS Complete |
$190.07
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: UMR Bronson Commercial |
$175.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
NDC 00517037510
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$209.07 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Commercial |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$332.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.86
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: UMR Bronson Commercial |
$209.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031500
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
NDC 81284031505
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$374.38 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$505.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: BCBS Complete |
$404.74
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Commercial |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$708.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$657.70
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$232.38
|
|
|
Service Code
|
NDC 17238042406
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.98 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna Medicare |
$116.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: BCBS Complete |
$92.95
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$85.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$232.38
|
|
|
Service Code
|
NDC 17238042425
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.25 |
| Max. Negotiated Rate |
$209.14 |
| Rate for Payer: Aetna American Axle |
$151.05
|
| Rate for Payer: Aetna Commercial |
$197.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.05
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cofinity Commercial |
$162.67
|
| Rate for Payer: Cofinity Commercial |
$199.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.90
|
| Rate for Payer: Healthscope Commercial |
$209.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.52
|
| Rate for Payer: PHP Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.05
|
| Rate for Payer: Priority Health SBD |
$146.40
|
| Rate for Payer: UMR Bronson Commercial |
$102.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.28
|
|
