|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$50.75
|
|
|
Service Code
|
NDC 00517083001
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.33 |
| Max. Negotiated Rate |
$45.67 |
| Rate for Payer: Aetna American Axle |
$32.99
|
| Rate for Payer: Aetna Commercial |
$43.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.99
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$35.52
|
| Rate for Payer: Cofinity Commercial |
$43.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$45.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: PHP Commercial |
$43.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: Priority Health SBD |
$31.97
|
| Rate for Payer: UMR Bronson Commercial |
$22.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.06
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$861.95
|
|
|
Service Code
|
NDC 00013830304
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$318.92 |
| Max. Negotiated Rate |
$775.75 |
| Rate for Payer: Aetna American Axle |
$560.27
|
| Rate for Payer: Aetna Commercial |
$732.66
|
| Rate for Payer: Aetna Medicare |
$430.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$560.27
|
| Rate for Payer: BCBS Complete |
$344.78
|
| Rate for Payer: Cash Price |
$689.56
|
| Rate for Payer: Cofinity Commercial |
$603.37
|
| Rate for Payer: Cofinity Commercial |
$741.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$603.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$689.56
|
| Rate for Payer: Healthscope Commercial |
$775.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$603.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$646.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$732.66
|
| Rate for Payer: PHP Commercial |
$732.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$560.27
|
| Rate for Payer: Priority Health SBD |
$543.03
|
| Rate for Payer: UMR Bronson Commercial |
$318.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$646.46
|
|
|
LATERAL RETINACULAR RELEASE, OPEN
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 27425
|
|
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
|
|
|
LAVAGE BY CANNULATION; MAXILLARY SINUS (ANTRUM PUNCTURE OR NATURAL OSTIUM)
|
Facility
|
OP
|
$637.52
|
|
|
Service Code
|
CPT 31000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$121.39 |
| Max. Negotiated Rate |
$637.52 |
| Rate for Payer: Aetna Medicare |
$235.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$283.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$283.10
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: BCBS MAPPO |
$226.48
|
| Rate for Payer: BCN Medicare Advantage |
$226.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$226.48
|
| Rate for Payer: Mclaren Medicaid |
$121.39
|
| Rate for Payer: Mclaren Medicare |
$226.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$237.80
|
| Rate for Payer: Meridian Medicaid |
$127.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.45
|
| Rate for Payer: PACE Medicare |
$215.16
|
| Rate for Payer: PACE SWMI |
$226.48
|
| Rate for Payer: PHP Medicare Advantage |
$226.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$121.39
|
| Rate for Payer: Priority Health Medicare |
$226.48
|
| Rate for Payer: Railroad Medicare Medicare |
$226.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$637.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$226.48
|
| Rate for Payer: UHC Exchange |
$432.83
|
| Rate for Payer: UHC Medicare Advantage |
$226.48
|
| Rate for Payer: UHCCP Medicaid |
$121.39
|
| Rate for Payer: VA VA |
$226.48
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 50268047811
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna American Axle |
$4.62
|
| Rate for Payer: Aetna Commercial |
$6.04
|
| Rate for Payer: Aetna Medicare |
$3.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.62
|
| Rate for Payer: BCBS Complete |
$2.84
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cofinity Commercial |
$4.98
|
| Rate for Payer: Cofinity Commercial |
$6.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.69
|
| Rate for Payer: Healthscope Commercial |
$6.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.04
|
| Rate for Payer: PHP Commercial |
$6.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.62
|
| Rate for Payer: Priority Health SBD |
$4.48
|
| Rate for Payer: UMR Bronson Commercial |
$2.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.33
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
OP
|
$355.20
|
|
|
Service Code
|
NDC 50268047815
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.42 |
| Max. Negotiated Rate |
$319.68 |
| Rate for Payer: Aetna American Axle |
$230.88
|
| Rate for Payer: Aetna Commercial |
$301.92
|
| Rate for Payer: Aetna Medicare |
$177.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.88
|
| Rate for Payer: BCBS Complete |
$142.08
|
| Rate for Payer: Cash Price |
$284.16
|
| Rate for Payer: Cofinity Commercial |
$248.64
|
| Rate for Payer: Cofinity Commercial |
$305.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.16
|
| Rate for Payer: Healthscope Commercial |
$319.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.92
|
| Rate for Payer: PHP Commercial |
$301.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.88
|
| Rate for Payer: Priority Health SBD |
$223.78
|
| Rate for Payer: UMR Bronson Commercial |
$131.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.40
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 50268047811
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna American Axle |
$4.62
|
| Rate for Payer: Aetna Commercial |
$6.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.62
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cofinity Commercial |
$4.98
|
| Rate for Payer: Cofinity Commercial |
$6.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.69
|
| Rate for Payer: Healthscope Commercial |
$6.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.04
|
| Rate for Payer: PHP Commercial |
$6.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.62
|
| Rate for Payer: Priority Health SBD |
$4.48
|
| Rate for Payer: UMR Bronson Commercial |
$3.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.33
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
IP
|
$355.20
|
|
|
Service Code
|
NDC 50268047815
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.29 |
| Max. Negotiated Rate |
$319.68 |
| Rate for Payer: Aetna American Axle |
$230.88
|
| Rate for Payer: Aetna Commercial |
$301.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.88
|
| Rate for Payer: Cash Price |
$284.16
|
| Rate for Payer: Cofinity Commercial |
$248.64
|
| Rate for Payer: Cofinity Commercial |
$305.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$248.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$284.16
|
| Rate for Payer: Healthscope Commercial |
$319.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.92
|
| Rate for Payer: PHP Commercial |
$301.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.88
|
| Rate for Payer: Priority Health SBD |
$223.78
|
| Rate for Payer: UMR Bronson Commercial |
$156.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.40
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
IP
|
$527.25
|
|
|
Service Code
|
NDC 00955173730
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.99 |
| Max. Negotiated Rate |
$474.52 |
| Rate for Payer: Aetna American Axle |
$342.71
|
| Rate for Payer: Aetna Commercial |
$448.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$342.71
|
| Rate for Payer: Cash Price |
$421.80
|
| Rate for Payer: Cofinity Commercial |
$369.07
|
| Rate for Payer: Cofinity Commercial |
$453.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$369.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$421.80
|
| Rate for Payer: Healthscope Commercial |
$474.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$369.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$395.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$448.16
|
| Rate for Payer: PHP Commercial |
$448.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$342.71
|
| Rate for Payer: Priority Health SBD |
$332.17
|
| Rate for Payer: UMR Bronson Commercial |
$231.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$395.44
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
OP
|
$93.46
|
|
|
Service Code
|
NDC 23155004403
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.58 |
| Max. Negotiated Rate |
$84.11 |
| Rate for Payer: Aetna American Axle |
$60.75
|
| Rate for Payer: Aetna Commercial |
$79.44
|
| Rate for Payer: Aetna Medicare |
$46.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.75
|
| Rate for Payer: BCBS Complete |
$37.38
|
| Rate for Payer: Cash Price |
$74.77
|
| Rate for Payer: Cofinity Commercial |
$65.42
|
| Rate for Payer: Cofinity Commercial |
$80.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.77
|
| Rate for Payer: Healthscope Commercial |
$84.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.44
|
| Rate for Payer: PHP Commercial |
$79.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.75
|
| Rate for Payer: Priority Health SBD |
$58.88
|
| Rate for Payer: UMR Bronson Commercial |
$34.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.09
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
IP
|
$93.46
|
|
|
Service Code
|
NDC 23155004403
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.12 |
| Max. Negotiated Rate |
$84.11 |
| Rate for Payer: Aetna American Axle |
$60.75
|
| Rate for Payer: Aetna Commercial |
$79.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.75
|
| Rate for Payer: Cash Price |
$74.77
|
| Rate for Payer: Cofinity Commercial |
$65.42
|
| Rate for Payer: Cofinity Commercial |
$80.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.77
|
| Rate for Payer: Healthscope Commercial |
$84.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.44
|
| Rate for Payer: PHP Commercial |
$79.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.75
|
| Rate for Payer: Priority Health SBD |
$58.88
|
| Rate for Payer: UMR Bronson Commercial |
$41.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.09
|
|
|
LEFLUNOMIDE 20 MG TABLET
|
Facility
|
OP
|
$527.25
|
|
|
Service Code
|
NDC 00955173730
|
| Hospital Charge Code |
23873
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.08 |
| Max. Negotiated Rate |
$474.52 |
| Rate for Payer: Aetna American Axle |
$342.71
|
| Rate for Payer: Aetna Commercial |
$448.16
|
| Rate for Payer: Aetna Medicare |
$263.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$342.71
|
| Rate for Payer: BCBS Complete |
$210.90
|
| Rate for Payer: Cash Price |
$421.80
|
| Rate for Payer: Cofinity Commercial |
$369.07
|
| Rate for Payer: Cofinity Commercial |
$453.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$369.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$421.80
|
| Rate for Payer: Healthscope Commercial |
$474.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$369.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$395.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$448.16
|
| Rate for Payer: PHP Commercial |
$448.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$342.71
|
| Rate for Payer: Priority Health SBD |
$332.17
|
| Rate for Payer: UMR Bronson Commercial |
$195.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$395.44
|
|
|
LENGTHENING OF HAMSTRING TENDON; SINGLE TENDON
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 27393
|
|
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
|
|
|
LENGTHENING OF PALATE, AND PHARYNGEAL FLAP
|
Facility
|
OP
|
$16,240.34
|
|
|
Service Code
|
CPT 42226
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,092.41 |
| Max. Negotiated Rate |
$16,240.34 |
| Rate for Payer: Aetna Medicare |
$6,000.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,211.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,211.77
|
| Rate for Payer: BCBS Complete |
$3,247.03
|
| Rate for Payer: BCBS MAPPO |
$5,769.42
|
| Rate for Payer: BCN Medicare Advantage |
$5,769.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,769.42
|
| Rate for Payer: Mclaren Medicaid |
$3,092.41
|
| Rate for Payer: Mclaren Medicare |
$5,769.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,057.89
|
| Rate for Payer: Meridian Medicaid |
$3,247.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,634.83
|
| Rate for Payer: PACE Medicare |
$5,480.95
|
| Rate for Payer: PACE SWMI |
$5,769.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,769.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,092.41
|
| Rate for Payer: Priority Health Medicare |
$5,769.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,769.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,240.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,769.42
|
| Rate for Payer: UHC Exchange |
$11,025.94
|
| Rate for Payer: UHC Medicare Advantage |
$5,769.42
|
| Rate for Payer: UHCCP Medicaid |
$3,092.41
|
| Rate for Payer: VA VA |
$5,769.42
|
|
|
LENGTHENING OF TENDON, FLEXOR, HAND OR FINGER, EACH TENDON
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 26478
|
|
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
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE TENDONS (THROUGH SAME INCISION), EACH
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 27686
|
|
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
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 27685
|
|
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
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
OP
|
$185.73
|
|
|
Service Code
|
NDC 50268047615
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.72 |
| Max. Negotiated Rate |
$167.16 |
| Rate for Payer: Aetna American Axle |
$120.72
|
| Rate for Payer: Aetna Commercial |
$157.87
|
| Rate for Payer: Aetna Medicare |
$92.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.72
|
| Rate for Payer: BCBS Complete |
$74.29
|
| Rate for Payer: Cash Price |
$148.58
|
| Rate for Payer: Cofinity Commercial |
$130.01
|
| Rate for Payer: Cofinity Commercial |
$159.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.58
|
| Rate for Payer: Healthscope Commercial |
$167.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$130.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.87
|
| Rate for Payer: PHP Commercial |
$157.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.72
|
| Rate for Payer: Priority Health SBD |
$117.01
|
| Rate for Payer: UMR Bronson Commercial |
$68.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.30
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
OP
|
$79.52
|
|
|
Service Code
|
NDC 00093762056
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.42 |
| Max. Negotiated Rate |
$71.57 |
| Rate for Payer: Aetna American Axle |
$51.69
|
| Rate for Payer: Aetna Commercial |
$67.59
|
| Rate for Payer: Aetna Medicare |
$39.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.69
|
| Rate for Payer: BCBS Complete |
$31.81
|
| Rate for Payer: Cash Price |
$63.62
|
| Rate for Payer: Cofinity Commercial |
$55.66
|
| Rate for Payer: Cofinity Commercial |
$68.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.62
|
| Rate for Payer: Healthscope Commercial |
$71.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.59
|
| Rate for Payer: PHP Commercial |
$67.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.69
|
| Rate for Payer: Priority Health SBD |
$50.10
|
| Rate for Payer: UMR Bronson Commercial |
$29.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.64
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
IP
|
$109.28
|
|
|
Service Code
|
NDC 51991075933
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.08 |
| Max. Negotiated Rate |
$98.35 |
| Rate for Payer: Aetna American Axle |
$71.03
|
| Rate for Payer: Aetna Commercial |
$92.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.03
|
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cofinity Commercial |
$76.50
|
| Rate for Payer: Cofinity Commercial |
$93.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$76.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.42
|
| Rate for Payer: Healthscope Commercial |
$98.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.89
|
| Rate for Payer: PHP Commercial |
$92.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.03
|
| Rate for Payer: Priority Health SBD |
$68.85
|
| Rate for Payer: UMR Bronson Commercial |
$48.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.96
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
IP
|
$65.55
|
|
|
Service Code
|
NDC 62756051183
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.84 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna American Axle |
$42.61
|
| Rate for Payer: Aetna Commercial |
$55.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.61
|
| Rate for Payer: Cash Price |
$52.44
|
| Rate for Payer: Cofinity Commercial |
$45.88
|
| Rate for Payer: Cofinity Commercial |
$56.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.44
|
| Rate for Payer: Healthscope Commercial |
$58.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.72
|
| Rate for Payer: PHP Commercial |
$55.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.61
|
| Rate for Payer: Priority Health SBD |
$41.30
|
| Rate for Payer: UMR Bronson Commercial |
$28.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.16
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
OP
|
$2,867.02
|
|
|
Service Code
|
NDC 00078024915
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,060.80 |
| Max. Negotiated Rate |
$2,580.32 |
| Rate for Payer: Aetna American Axle |
$1,863.56
|
| Rate for Payer: Aetna Commercial |
$2,436.97
|
| Rate for Payer: Aetna Medicare |
$1,433.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,863.56
|
| Rate for Payer: BCBS Complete |
$1,146.81
|
| Rate for Payer: Cash Price |
$2,293.62
|
| Rate for Payer: Cofinity Commercial |
$2,006.91
|
| Rate for Payer: Cofinity Commercial |
$2,465.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,006.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,293.62
|
| Rate for Payer: Healthscope Commercial |
$2,580.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,006.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,150.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,436.97
|
| Rate for Payer: PHP Commercial |
$2,436.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,863.56
|
| Rate for Payer: Priority Health SBD |
$1,806.22
|
| Rate for Payer: UMR Bronson Commercial |
$1,060.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,150.26
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
IP
|
$2,867.02
|
|
|
Service Code
|
NDC 00078024915
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,261.49 |
| Max. Negotiated Rate |
$2,580.32 |
| Rate for Payer: Aetna American Axle |
$1,863.56
|
| Rate for Payer: Aetna Commercial |
$2,436.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,863.56
|
| Rate for Payer: Cash Price |
$2,293.62
|
| Rate for Payer: Cofinity Commercial |
$2,006.91
|
| Rate for Payer: Cofinity Commercial |
$2,465.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,006.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,293.62
|
| Rate for Payer: Healthscope Commercial |
$2,580.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,006.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,150.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,436.97
|
| Rate for Payer: PHP Commercial |
$2,436.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,863.56
|
| Rate for Payer: Priority Health SBD |
$1,806.22
|
| Rate for Payer: UMR Bronson Commercial |
$1,261.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,150.26
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
IP
|
$79.52
|
|
|
Service Code
|
NDC 00093762056
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.99 |
| Max. Negotiated Rate |
$71.57 |
| Rate for Payer: Aetna American Axle |
$51.69
|
| Rate for Payer: Aetna Commercial |
$67.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.69
|
| Rate for Payer: Cash Price |
$63.62
|
| Rate for Payer: Cofinity Commercial |
$55.66
|
| Rate for Payer: Cofinity Commercial |
$68.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.62
|
| Rate for Payer: Healthscope Commercial |
$71.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.59
|
| Rate for Payer: PHP Commercial |
$67.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.69
|
| Rate for Payer: Priority Health SBD |
$50.10
|
| Rate for Payer: UMR Bronson Commercial |
$34.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.64
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
NDC 50268047611
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna American Axle |
$2.42
|
| Rate for Payer: Aetna Commercial |
$3.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.42
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$2.60
|
| Rate for Payer: Cofinity Commercial |
$3.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.98
|
| Rate for Payer: Healthscope Commercial |
$3.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.16
|
| Rate for Payer: PHP Commercial |
$3.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: Priority Health SBD |
$2.34
|
| Rate for Payer: UMR Bronson Commercial |
$1.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.79
|
|
