|
ALENDRONATE 10 MG TABLET
|
Facility
IP
|
$227.95
|
|
|
Service Code
|
NDC 64980-340-01
|
| Hospital Charge Code |
15661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna American Axle |
$148.17
|
| Rate for Payer: Aetna Commercial |
$193.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.17
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Commercial |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.36
|
| Rate for Payer: Healthscope Commercial |
$205.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.76
|
| Rate for Payer: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.56
|
| Rate for Payer: Priority Health SBD |
$143.61
|
| Rate for Payer: UMR Bronson Commercial |
$100.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.96
|
|
|
ALENDRONATE 35 MG TABLET
|
Facility
IP
|
$18.62
|
|
|
Service Code
|
NDC 69097-223-16
|
| Hospital Charge Code |
29072
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna American Axle |
$12.10
|
| Rate for Payer: Aetna Commercial |
$15.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.10
|
| Rate for Payer: Cash Price |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$13.03
|
| Rate for Payer: Cofinity Commercial |
$16.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.90
|
| Rate for Payer: Healthscope Commercial |
$16.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.83
|
| Rate for Payer: PHP Commercial |
$15.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.03
|
| Rate for Payer: Priority Health SBD |
$11.73
|
| Rate for Payer: UMR Bronson Commercial |
$8.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.96
|
|
|
ALENDRONATE 35 MG TABLET
|
Facility
IP
|
$34.24
|
|
|
Service Code
|
NDC 65862-328-04
|
| Hospital Charge Code |
29072
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$30.82 |
| Rate for Payer: Aetna American Axle |
$22.26
|
| Rate for Payer: Aetna Commercial |
$29.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.26
|
| Rate for Payer: Cash Price |
$27.39
|
| Rate for Payer: Cofinity Commercial |
$29.45
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.39
|
| Rate for Payer: Healthscope Commercial |
$30.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.10
|
| Rate for Payer: PHP Commercial |
$29.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.97
|
| Rate for Payer: Priority Health SBD |
$21.57
|
| Rate for Payer: UMR Bronson Commercial |
$15.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.68
|
|
|
ALENDRONATE 70 MG/75 ML ORAL SOLUTION
|
Facility
IP
|
$165.39
|
|
|
Service Code
|
NDC 51224-301-10
|
| Hospital Charge Code |
37640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.77 |
| Max. Negotiated Rate |
$148.85 |
| Rate for Payer: Aetna American Axle |
$107.50
|
| Rate for Payer: Aetna Commercial |
$140.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.50
|
| Rate for Payer: Cash Price |
$132.31
|
| Rate for Payer: Cofinity Commercial |
$115.77
|
| Rate for Payer: Cofinity Commercial |
$142.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.31
|
| Rate for Payer: Healthscope Commercial |
$148.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$140.58
|
| Rate for Payer: PHP Commercial |
$140.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.77
|
| Rate for Payer: Priority Health SBD |
$104.20
|
| Rate for Payer: UMR Bronson Commercial |
$72.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.04
|
|
|
ALENDRONATE 70 MG TABLET
|
Facility
IP
|
$13.83
|
|
|
Service Code
|
NDC 41616-638-60
|
| Hospital Charge Code |
29048
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Aetna American Axle |
$8.99
|
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.99
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: Cofinity Commercial |
$9.68
|
| Rate for Payer: Cofinity Commercial |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.06
|
| Rate for Payer: Healthscope Commercial |
$12.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.76
|
| Rate for Payer: PHP Commercial |
$11.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.68
|
| Rate for Payer: Priority Health SBD |
$8.71
|
| Rate for Payer: UMR Bronson Commercial |
$6.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.37
|
|
|
ALENDRONATE 70 MG TABLET
|
Facility
IP
|
$170.65
|
|
|
Service Code
|
NDC 69543-131-20
|
| Hospital Charge Code |
29048
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.09 |
| Max. Negotiated Rate |
$153.58 |
| Rate for Payer: Aetna American Axle |
$110.92
|
| Rate for Payer: Aetna Commercial |
$145.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.92
|
| Rate for Payer: Cash Price |
$136.52
|
| Rate for Payer: Cofinity Commercial |
$146.76
|
| Rate for Payer: Cofinity Commercial |
$119.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.52
|
| Rate for Payer: Healthscope Commercial |
$153.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$145.05
|
| Rate for Payer: PHP Commercial |
$145.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.46
|
| Rate for Payer: Priority Health SBD |
$107.51
|
| Rate for Payer: UMR Bronson Commercial |
$75.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.99
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
IP
|
$309.70
|
|
|
Service Code
|
NDC 69097-844-07
|
| Hospital Charge Code |
36982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.27 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna American Axle |
$201.30
|
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.79
|
| Rate for Payer: Priority Health SBD |
$195.11
|
| Rate for Payer: UMR Bronson Commercial |
$136.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.28
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
IP
|
$309.70
|
|
|
Service Code
|
NDC 29300-155-01
|
| Hospital Charge Code |
36982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.27 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna American Axle |
$201.30
|
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.79
|
| Rate for Payer: Priority Health SBD |
$195.11
|
| Rate for Payer: UMR Bronson Commercial |
$136.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.28
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
IP
|
$200.93
|
|
|
Service Code
|
NDC 57237-114-90
|
| Hospital Charge Code |
36982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.41 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna American Axle |
$130.60
|
| Rate for Payer: Aetna Commercial |
$170.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.60
|
| Rate for Payer: Cash Price |
$160.74
|
| Rate for Payer: Cofinity Commercial |
$140.65
|
| Rate for Payer: Cofinity Commercial |
$172.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.74
|
| Rate for Payer: Healthscope Commercial |
$180.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.79
|
| Rate for Payer: PHP Commercial |
$170.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.65
|
| Rate for Payer: Priority Health SBD |
$126.59
|
| Rate for Payer: UMR Bronson Commercial |
$88.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.70
|
|
|
ALGLUCOSIDASE ALFA 50 MG INTRAVENOUS SOLUTION
|
Facility
OP
|
$2,690.05
|
|
|
Service Code
|
HCPCS J0221
|
| Hospital Charge Code |
76353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.91 |
| Max. Negotiated Rate |
$2,421.04 |
| Rate for Payer: Aetna American Axle |
$1,748.53
|
| Rate for Payer: Aetna Commercial |
$2,286.54
|
| Rate for Payer: Aetna Medicare |
$205.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,748.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$246.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$246.60
|
| Rate for Payer: BCBS Complete |
$113.32
|
| Rate for Payer: BCBS MAPPO |
$197.28
|
| Rate for Payer: BCBS Trust/PPO |
$637.51
|
| Rate for Payer: BCN Medicare Advantage |
$197.28
|
| Rate for Payer: Cash Price |
$2,152.04
|
| Rate for Payer: Cash Price |
$2,152.04
|
| Rate for Payer: Cofinity Commercial |
$2,313.44
|
| Rate for Payer: Cofinity Commercial |
$1,883.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,152.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$197.28
|
| Rate for Payer: Healthscope Commercial |
$2,421.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,883.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,017.54
|
| Rate for Payer: Mclaren Medicaid |
$107.91
|
| Rate for Payer: Mclaren Medicare |
$197.28
|
| Rate for Payer: Meridian Medicaid |
$113.32
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$207.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$226.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,286.54
|
| Rate for Payer: PACE Medicare |
$187.41
|
| Rate for Payer: PACE SWMI |
$197.28
|
| Rate for Payer: PHP Commercial |
$2,286.54
|
| Rate for Payer: PHP Medicare Advantage |
$197.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$107.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,883.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$578.78
|
| Rate for Payer: Priority Health Medicare |
$197.28
|
| Rate for Payer: Priority Health Narrow Network |
$463.02
|
| Rate for Payer: Priority Health SBD |
$1,694.73
|
| Rate for Payer: Railroad Medicare Medicare |
$197.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$197.28
|
| Rate for Payer: UHC Medicare Advantage |
$203.20
|
| Rate for Payer: UMR Bronson Commercial |
$995.32
|
| Rate for Payer: VA VA |
$197.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,017.54
|
|
|
ALGLUCOSIDASE ALFA 50 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$2,690.05
|
|
|
Service Code
|
HCPCS J0221
|
| Hospital Charge Code |
76353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,183.62 |
| Max. Negotiated Rate |
$2,421.04 |
| Rate for Payer: Aetna American Axle |
$1,748.53
|
| Rate for Payer: Aetna Commercial |
$2,286.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,748.53
|
| Rate for Payer: Cash Price |
$2,152.04
|
| Rate for Payer: Cofinity Commercial |
$1,883.04
|
| Rate for Payer: Cofinity Commercial |
$2,313.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,152.04
|
| Rate for Payer: Healthscope Commercial |
$2,421.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,883.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,017.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,286.54
|
| Rate for Payer: PHP Commercial |
$2,286.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,883.04
|
| Rate for Payer: Priority Health SBD |
$1,694.73
|
| Rate for Payer: UMR Bronson Commercial |
$1,183.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,017.54
|
|
|
ALISKIREN 150 MG TABLET
|
Facility
IP
|
$917.53
|
|
|
Service Code
|
NDC 70839-150-30
|
| Hospital Charge Code |
78653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$403.71 |
| Max. Negotiated Rate |
$825.78 |
| Rate for Payer: Aetna American Axle |
$596.39
|
| Rate for Payer: Aetna Commercial |
$779.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$596.39
|
| Rate for Payer: Cash Price |
$734.02
|
| Rate for Payer: Cofinity Commercial |
$789.08
|
| Rate for Payer: Cofinity Commercial |
$642.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$734.02
|
| Rate for Payer: Healthscope Commercial |
$825.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$642.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$688.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$779.90
|
| Rate for Payer: PHP Commercial |
$779.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$642.27
|
| Rate for Payer: Priority Health SBD |
$578.04
|
| Rate for Payer: UMR Bronson Commercial |
$403.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$688.15
|
|
|
ALLERGIC REACTIONS WITH MCC
|
Facility
IP
|
$32,496.82
|
|
|
Service Code
|
MS-DRG 915
|
| Min. Negotiated Rate |
$13,473.70 |
| Max. Negotiated Rate |
$32,496.82 |
| Rate for Payer: Aetna Medicare |
$14,750.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,728.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,728.55
|
| Rate for Payer: BCBS MAPPO |
$14,182.84
|
| Rate for Payer: BCBS Trust/PPO |
$32,496.82
|
| Rate for Payer: BCN Medicare Advantage |
$14,182.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,182.84
|
| Rate for Payer: Mclaren Medicare |
$14,182.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,891.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,310.27
|
| Rate for Payer: PACE Medicare |
$13,473.70
|
| Rate for Payer: PACE SWMI |
$14,182.84
|
| Rate for Payer: PHP Medicare Advantage |
$14,182.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25,456.76
|
| Rate for Payer: Priority Health Medicare |
$14,182.84
|
| Rate for Payer: Priority Health Narrow Network |
$20,365.41
|
| Rate for Payer: Railroad Medicare Medicare |
$14,182.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27,060.60
|
| Rate for Payer: UHC Core |
$22,189.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$14,182.84
|
| Rate for Payer: UHC Exchange |
$17,640.66
|
| Rate for Payer: UHC Medicare Advantage |
$14,608.33
|
| Rate for Payer: VA VA |
$14,182.84
|
|
|
ALLERGIC REACTIONS WITHOUT MCC
|
Facility
IP
|
$11,571.90
|
|
|
Service Code
|
MS-DRG 916
|
| Min. Negotiated Rate |
$5,309.64 |
| Max. Negotiated Rate |
$11,571.90 |
| Rate for Payer: Aetna Medicare |
$5,812.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,986.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,986.36
|
| Rate for Payer: BCBS MAPPO |
$5,589.09
|
| Rate for Payer: BCBS Trust/PPO |
$11,571.90
|
| Rate for Payer: BCN Medicare Advantage |
$5,589.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,589.09
|
| Rate for Payer: Mclaren Medicare |
$5,589.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,868.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,427.45
|
| Rate for Payer: PACE Medicare |
$5,309.64
|
| Rate for Payer: PACE SWMI |
$5,589.09
|
| Rate for Payer: PHP Medicare Advantage |
$5,589.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,453.73
|
| Rate for Payer: Priority Health Medicare |
$5,589.09
|
| Rate for Payer: Priority Health Narrow Network |
$7,562.98
|
| Rate for Payer: Railroad Medicare Medicare |
$5,589.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,049.34
|
| Rate for Payer: UHC Core |
$8,240.27
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,589.09
|
| Rate for Payer: UHC Exchange |
$6,551.11
|
| Rate for Payer: UHC Medicare Advantage |
$5,756.76
|
| Rate for Payer: VA VA |
$5,589.09
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
IP
|
$351,436.60
|
|
|
Service Code
|
MS-DRG 014
|
| Min. Negotiated Rate |
$84,388.91 |
| Max. Negotiated Rate |
$351,436.60 |
| Rate for Payer: Aetna Medicare |
$92,383.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$111,038.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$111,038.04
|
| Rate for Payer: BCBS MAPPO |
$88,830.43
|
| Rate for Payer: BCBS Trust/PPO |
$351,436.60
|
| Rate for Payer: BCN Medicare Advantage |
$88,830.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$88,830.43
|
| Rate for Payer: Mclaren Medicare |
$88,830.43
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$93,271.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102,154.99
|
| Rate for Payer: PACE Medicare |
$84,388.91
|
| Rate for Payer: PACE SWMI |
$88,830.43
|
| Rate for Payer: PHP Medicare Advantage |
$88,830.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$164,463.00
|
| Rate for Payer: Priority Health Medicare |
$88,830.43
|
| Rate for Payer: Priority Health Narrow Network |
$131,570.40
|
| Rate for Payer: Railroad Medicare Medicare |
$88,830.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$174,824.57
|
| Rate for Payer: UHC Core |
$143,352.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$88,830.43
|
| Rate for Payer: UHC Exchange |
$113,967.19
|
| Rate for Payer: UHC Medicare Advantage |
$91,495.34
|
| Rate for Payer: VA VA |
$88,830.43
|
|
|
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$700.00
|
|
|
Service Code
|
CPT 20930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$302.66 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$302.66
|
| Rate for Payer: UHC Core |
$700.00
|
|
|
ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$32,116.94
|
|
|
Service Code
|
CPT 20931
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$108.06 |
| Max. Negotiated Rate |
$32,116.94 |
| Rate for Payer: BCBS Trust/PPO |
$32,116.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$118.87
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$108.06
|
|
|
ALLOPURINOL 100 MG TABLET
|
Facility
IP
|
$2.78
|
|
|
Service Code
|
NDC 51079-205-01
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna American Axle |
$1.81
|
| Rate for Payer: Aetna Commercial |
$2.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.81
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cofinity Commercial |
$1.95
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.22
|
| Rate for Payer: Healthscope Commercial |
$2.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.36
|
| Rate for Payer: PHP Commercial |
$2.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.95
|
| Rate for Payer: Priority Health SBD |
$1.75
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.08
|
|
|
ALLOPURINOL 100 MG TABLET
|
Facility
IP
|
$3.65
|
|
|
Service Code
|
NDC 62584-988-11
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna American Axle |
$2.37
|
| Rate for Payer: Aetna Commercial |
$3.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.37
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cofinity Commercial |
$2.56
|
| Rate for Payer: Cofinity Commercial |
$3.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.92
|
| Rate for Payer: Healthscope Commercial |
$3.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.10
|
| Rate for Payer: PHP Commercial |
$3.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.56
|
| Rate for Payer: Priority Health SBD |
$2.30
|
| Rate for Payer: UMR Bronson Commercial |
$1.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.74
|
|
|
ALLOPURINOL 100 MG TABLET
|
Facility
IP
|
$277.40
|
|
|
Service Code
|
NDC 51079-205-20
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.06 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna American Axle |
$180.31
|
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Cofinity Commercial |
$194.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.79
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.18
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UMR Bronson Commercial |
$122.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
ALLOPURINOL 100 MG TABLET
|
Facility
IP
|
$446.50
|
|
|
Service Code
|
NDC 0904-7041-61
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.46 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna American Axle |
$290.22
|
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.22
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$312.55
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$312.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$379.52
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.55
|
| Rate for Payer: Priority Health SBD |
$281.30
|
| Rate for Payer: UMR Bronson Commercial |
$196.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.88
|
|
|
ALLOPURINOL 100 MG TABLET
|
Facility
IP
|
$283.10
|
|
|
Service Code
|
NDC 0603-2115-21
|
| Hospital Charge Code |
310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.56 |
| Max. Negotiated Rate |
$254.79 |
| Rate for Payer: Aetna American Axle |
$184.02
|
| Rate for Payer: Aetna Commercial |
$240.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.02
|
| Rate for Payer: Cash Price |
$226.48
|
| Rate for Payer: Cofinity Commercial |
$198.17
|
| Rate for Payer: Cofinity Commercial |
$243.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.48
|
| Rate for Payer: Healthscope Commercial |
$254.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$212.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$240.64
|
| Rate for Payer: PHP Commercial |
$240.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.17
|
| Rate for Payer: Priority Health SBD |
$178.35
|
| Rate for Payer: UMR Bronson Commercial |
$124.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$212.32
|
|
|
ALLOPURINOL 100 MG TABLET
|
Facility
IP
|
$246.75
|
|
|
Service Code
|
NDC 23155-693-01
|
| Hospital Charge Code |
310
|
|
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: 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 Multiplan/Beech St/PHCS |
$209.74
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.72
|
| 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
|
|
|
ALLOPURINOL 300 MG TABLET
|
Facility
IP
|
$325.85
|
|
|
Service Code
|
NDC 0904-6572-61
|
| Hospital Charge Code |
311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.37 |
| Max. Negotiated Rate |
$293.26 |
| Rate for Payer: Aetna American Axle |
$211.80
|
| Rate for Payer: Aetna Commercial |
$276.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.80
|
| Rate for Payer: Cash Price |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$228.10
|
| Rate for Payer: Cofinity Commercial |
$280.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.68
|
| Rate for Payer: Healthscope Commercial |
$293.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.97
|
| Rate for Payer: PHP Commercial |
$276.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.10
|
| Rate for Payer: Priority Health SBD |
$205.29
|
| Rate for Payer: UMR Bronson Commercial |
$143.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.39
|
|
|
ALLOPURINOL 300 MG TABLET
|
Facility
IP
|
$276.96
|
|
|
Service Code
|
NDC 51079-206-20
|
| Hospital Charge Code |
311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.86 |
| Max. Negotiated Rate |
$249.26 |
| Rate for Payer: Aetna American Axle |
$180.02
|
| Rate for Payer: Aetna Commercial |
$235.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.02
|
| Rate for Payer: Cash Price |
$221.57
|
| Rate for Payer: Cofinity Commercial |
$193.87
|
| Rate for Payer: Cofinity Commercial |
$238.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.57
|
| Rate for Payer: Healthscope Commercial |
$249.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.42
|
| Rate for Payer: PHP Commercial |
$235.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.87
|
| Rate for Payer: Priority Health SBD |
$174.48
|
| Rate for Payer: UMR Bronson Commercial |
$121.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.72
|
|
