|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$31,453.30
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,839.45 |
| Max. Negotiated Rate |
$28,307.97 |
| Rate for Payer: Aetna American Axle |
$20,444.65
|
| Rate for Payer: Aetna Commercial |
$26,735.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20,444.65
|
| Rate for Payer: Cash Price |
$25,162.64
|
| Rate for Payer: Cofinity Commercial |
$22,017.31
|
| Rate for Payer: Cofinity Commercial |
$27,049.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$22,017.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,162.64
|
| Rate for Payer: Healthscope Commercial |
$28,307.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22,017.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23,589.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,735.31
|
| Rate for Payer: PHP Commercial |
$26,735.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,444.65
|
| Rate for Payer: Priority Health SBD |
$19,815.58
|
| Rate for Payer: UMR Bronson Commercial |
$13,839.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23,589.97
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$31,453.30
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$28,307.97 |
| Rate for Payer: Aetna American Axle |
$20,444.65
|
| Rate for Payer: Aetna Commercial |
$26,735.31
|
| Rate for Payer: Aetna Medicare |
$43.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20,444.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.48
|
| Rate for Payer: BCBS Complete |
$23.63
|
| Rate for Payer: BCBS MAPPO |
$41.98
|
| Rate for Payer: BCN Medicare Advantage |
$41.98
|
| Rate for Payer: Cash Price |
$25,162.64
|
| Rate for Payer: Cash Price |
$25,162.64
|
| Rate for Payer: Cofinity Commercial |
$27,049.84
|
| Rate for Payer: Cofinity Commercial |
$22,017.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$22,017.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,162.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.98
|
| Rate for Payer: Healthscope Commercial |
$28,307.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22,017.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23,589.97
|
| Rate for Payer: Mclaren Medicaid |
$22.50
|
| Rate for Payer: Mclaren Medicare |
$41.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.08
|
| Rate for Payer: Meridian Medicaid |
$23.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,735.31
|
| Rate for Payer: PACE Medicare |
$39.88
|
| Rate for Payer: PACE SWMI |
$41.98
|
| Rate for Payer: PHP Commercial |
$26,735.31
|
| Rate for Payer: PHP Medicare Advantage |
$41.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$22.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,444.65
|
| Rate for Payer: Priority Health Medicare |
$41.98
|
| Rate for Payer: Priority Health SBD |
$19,815.58
|
| Rate for Payer: Railroad Medicare Medicare |
$41.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$118.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.98
|
| Rate for Payer: UHC Exchange |
$80.23
|
| Rate for Payer: UHC Medicare Advantage |
$41.98
|
| Rate for Payer: UHCCP Medicaid |
$22.50
|
| Rate for Payer: UMR Bronson Commercial |
$11,637.72
|
| Rate for Payer: VA VA |
$41.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23,589.97
|
|
|
LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$11,655.36
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
10475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,128.36 |
| Max. Negotiated Rate |
$10,489.82 |
| Rate for Payer: Aetna American Axle |
$7,575.98
|
| Rate for Payer: Aetna Commercial |
$9,907.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,575.98
|
| Rate for Payer: Cash Price |
$9,324.29
|
| Rate for Payer: Cofinity Commercial |
$10,023.61
|
| Rate for Payer: Cofinity Commercial |
$8,158.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,158.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,324.29
|
| Rate for Payer: Healthscope Commercial |
$10,489.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,158.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,741.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,907.06
|
| Rate for Payer: PHP Commercial |
$9,907.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,575.98
|
| Rate for Payer: Priority Health SBD |
$7,342.88
|
| Rate for Payer: UMR Bronson Commercial |
$5,128.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,741.52
|
|
|
LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$11,655.36
|
|
|
Service Code
|
HCPCS J7504
|
| Hospital Charge Code |
10475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,752.41 |
| Max. Negotiated Rate |
$14,454.76 |
| Rate for Payer: Aetna American Axle |
$7,575.98
|
| Rate for Payer: Aetna Commercial |
$9,907.06
|
| Rate for Payer: Aetna Medicare |
$5,340.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,575.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,418.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,418.86
|
| Rate for Payer: BCBS Complete |
$2,890.03
|
| Rate for Payer: BCBS MAPPO |
$5,135.09
|
| Rate for Payer: BCN Medicare Advantage |
$5,135.09
|
| Rate for Payer: Cash Price |
$9,324.29
|
| Rate for Payer: Cash Price |
$9,324.29
|
| Rate for Payer: Cofinity Commercial |
$8,158.75
|
| Rate for Payer: Cofinity Commercial |
$10,023.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$8,158.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,324.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,135.09
|
| Rate for Payer: Healthscope Commercial |
$10,489.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,158.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,741.52
|
| Rate for Payer: Mclaren Medicaid |
$2,752.41
|
| Rate for Payer: Mclaren Medicare |
$5,135.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,391.84
|
| Rate for Payer: Meridian Medicaid |
$2,890.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,905.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,907.06
|
| Rate for Payer: PACE Medicare |
$4,878.34
|
| Rate for Payer: PACE SWMI |
$5,135.09
|
| Rate for Payer: PHP Commercial |
$9,907.06
|
| Rate for Payer: PHP Medicare Advantage |
$5,135.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,752.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,575.98
|
| Rate for Payer: Priority Health Medicare |
$5,135.09
|
| Rate for Payer: Priority Health SBD |
$7,342.88
|
| Rate for Payer: Railroad Medicare Medicare |
$5,135.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,454.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,135.09
|
| Rate for Payer: UHC Exchange |
$9,813.67
|
| Rate for Payer: UHC Medicare Advantage |
$5,135.09
|
| Rate for Payer: UHCCP Medicaid |
$2,752.41
|
| Rate for Payer: UMR Bronson Commercial |
$4,312.48
|
| Rate for Payer: VA VA |
$5,135.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,741.52
|
|
|
LYSIS INTRANASAL SYNECHIA
|
Facility
|
OP
|
$1,398.05
|
|
|
Service Code
|
CPT 30560
|
|
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
|
|
|
LYSIS OF LABIAL ADHESIONS
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 56441
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Exchange |
$5,926.19
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,662.10
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS
|
Facility
|
OP
|
$5,623.80
|
|
|
Service Code
|
CPT 54162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,070.86 |
| Max. Negotiated Rate |
$5,623.80 |
| Rate for Payer: Aetna Medicare |
$2,077.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,497.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,497.34
|
| Rate for Payer: BCBS Complete |
$1,124.40
|
| Rate for Payer: BCBS MAPPO |
$1,997.87
|
| Rate for Payer: BCN Medicare Advantage |
$1,997.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,997.87
|
| Rate for Payer: Mclaren Medicaid |
$1,070.86
|
| Rate for Payer: Mclaren Medicare |
$1,997.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,097.76
|
| Rate for Payer: Meridian Medicaid |
$1,124.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,297.55
|
| Rate for Payer: PACE Medicare |
$1,897.98
|
| Rate for Payer: PACE SWMI |
$1,997.87
|
| Rate for Payer: PHP Medicare Advantage |
$1,997.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,070.86
|
| Rate for Payer: Priority Health Medicare |
$1,997.87
|
| Rate for Payer: Railroad Medicare Medicare |
$1,997.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,623.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,997.87
|
| Rate for Payer: UHC Exchange |
$3,818.13
|
| Rate for Payer: UHC Medicare Advantage |
$1,997.87
|
| Rate for Payer: UHCCP Medicaid |
$1,070.86
|
| Rate for Payer: VA VA |
$1,997.87
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
OP
|
$753.46
|
|
|
Service Code
|
NDC 51079062484
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.78 |
| Max. Negotiated Rate |
$678.11 |
| Rate for Payer: Aetna American Axle |
$489.75
|
| Rate for Payer: Aetna Commercial |
$640.44
|
| Rate for Payer: Aetna Medicare |
$376.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.75
|
| Rate for Payer: BCBS Complete |
$301.38
|
| Rate for Payer: Cash Price |
$602.77
|
| Rate for Payer: Cofinity Commercial |
$527.42
|
| Rate for Payer: Cofinity Commercial |
$647.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$527.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.77
|
| Rate for Payer: Healthscope Commercial |
$678.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$527.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$565.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$640.44
|
| Rate for Payer: PHP Commercial |
$640.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$489.75
|
| Rate for Payer: Priority Health SBD |
$474.68
|
| Rate for Payer: UMR Bronson Commercial |
$278.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$565.10
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$3,767.30
|
|
|
Service Code
|
NDC 51079062485
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,657.61 |
| Max. Negotiated Rate |
$3,390.57 |
| Rate for Payer: Aetna American Axle |
$2,448.74
|
| Rate for Payer: Aetna Commercial |
$3,202.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,448.74
|
| Rate for Payer: Cash Price |
$3,013.84
|
| Rate for Payer: Cofinity Commercial |
$2,637.11
|
| Rate for Payer: Cofinity Commercial |
$3,239.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,637.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,013.84
|
| Rate for Payer: Healthscope Commercial |
$3,390.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,637.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,825.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,202.20
|
| Rate for Payer: PHP Commercial |
$3,202.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,448.74
|
| Rate for Payer: Priority Health SBD |
$2,373.40
|
| Rate for Payer: UMR Bronson Commercial |
$1,657.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,825.47
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
OP
|
$462.07
|
|
|
Service Code
|
NDC 49884090252
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.97 |
| Max. Negotiated Rate |
$415.86 |
| Rate for Payer: Aetna American Axle |
$300.35
|
| Rate for Payer: Aetna Commercial |
$392.76
|
| Rate for Payer: Aetna Medicare |
$231.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$300.35
|
| Rate for Payer: BCBS Complete |
$184.83
|
| Rate for Payer: Cash Price |
$369.66
|
| Rate for Payer: Cofinity Commercial |
$323.45
|
| Rate for Payer: Cofinity Commercial |
$397.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$323.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$369.66
|
| Rate for Payer: Healthscope Commercial |
$415.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$323.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$346.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$392.76
|
| Rate for Payer: PHP Commercial |
$392.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$300.35
|
| Rate for Payer: Priority Health SBD |
$291.10
|
| Rate for Payer: UMR Bronson Commercial |
$170.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$346.55
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$2,310.34
|
|
|
Service Code
|
NDC 49884090278
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,016.55 |
| Max. Negotiated Rate |
$2,079.31 |
| Rate for Payer: Aetna American Axle |
$1,501.72
|
| Rate for Payer: Aetna Commercial |
$1,963.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,501.72
|
| Rate for Payer: Cash Price |
$1,848.27
|
| Rate for Payer: Cofinity Commercial |
$1,617.24
|
| Rate for Payer: Cofinity Commercial |
$1,986.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,617.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,848.27
|
| Rate for Payer: Healthscope Commercial |
$2,079.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,617.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,732.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,963.79
|
| Rate for Payer: PHP Commercial |
$1,963.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,501.72
|
| Rate for Payer: Priority Health SBD |
$1,455.51
|
| Rate for Payer: UMR Bronson Commercial |
$1,016.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,732.76
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
OP
|
$2,310.34
|
|
|
Service Code
|
NDC 49884090278
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$854.83 |
| Max. Negotiated Rate |
$2,079.31 |
| Rate for Payer: Aetna American Axle |
$1,501.72
|
| Rate for Payer: Aetna Commercial |
$1,963.79
|
| Rate for Payer: Aetna Medicare |
$1,155.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,501.72
|
| Rate for Payer: BCBS Complete |
$924.14
|
| Rate for Payer: Cash Price |
$1,848.27
|
| Rate for Payer: Cofinity Commercial |
$1,617.24
|
| Rate for Payer: Cofinity Commercial |
$1,986.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,617.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,848.27
|
| Rate for Payer: Healthscope Commercial |
$2,079.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,617.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,732.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,963.79
|
| Rate for Payer: PHP Commercial |
$1,963.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,501.72
|
| Rate for Payer: Priority Health SBD |
$1,455.51
|
| Rate for Payer: UMR Bronson Commercial |
$854.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,732.76
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$753.46
|
|
|
Service Code
|
NDC 51079062484
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.52 |
| Max. Negotiated Rate |
$678.11 |
| Rate for Payer: Aetna American Axle |
$489.75
|
| Rate for Payer: Aetna Commercial |
$640.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.75
|
| Rate for Payer: Cash Price |
$602.77
|
| Rate for Payer: Cofinity Commercial |
$527.42
|
| Rate for Payer: Cofinity Commercial |
$647.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$527.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.77
|
| Rate for Payer: Healthscope Commercial |
$678.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$527.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$565.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$640.44
|
| Rate for Payer: PHP Commercial |
$640.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$489.75
|
| Rate for Payer: Priority Health SBD |
$474.68
|
| Rate for Payer: UMR Bronson Commercial |
$331.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$565.10
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
OP
|
$3,767.30
|
|
|
Service Code
|
NDC 51079062485
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,393.90 |
| Max. Negotiated Rate |
$3,390.57 |
| Rate for Payer: Aetna American Axle |
$2,448.74
|
| Rate for Payer: Aetna Commercial |
$3,202.20
|
| Rate for Payer: Aetna Medicare |
$1,883.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,448.74
|
| Rate for Payer: BCBS Complete |
$1,506.92
|
| Rate for Payer: Cash Price |
$3,013.84
|
| Rate for Payer: Cofinity Commercial |
$2,637.11
|
| Rate for Payer: Cofinity Commercial |
$3,239.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,637.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,013.84
|
| Rate for Payer: Healthscope Commercial |
$3,390.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,637.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,825.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,202.20
|
| Rate for Payer: PHP Commercial |
$3,202.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,448.74
|
| Rate for Payer: Priority Health SBD |
$2,373.40
|
| Rate for Payer: UMR Bronson Commercial |
$1,393.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,825.47
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET
|
Facility
|
IP
|
$462.07
|
|
|
Service Code
|
NDC 49884090252
|
| Hospital Charge Code |
23233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.31 |
| Max. Negotiated Rate |
$415.86 |
| Rate for Payer: Aetna American Axle |
$300.35
|
| Rate for Payer: Aetna Commercial |
$392.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$300.35
|
| Rate for Payer: Cash Price |
$369.66
|
| Rate for Payer: Cofinity Commercial |
$323.45
|
| Rate for Payer: Cofinity Commercial |
$397.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$323.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$369.66
|
| Rate for Payer: Healthscope Commercial |
$415.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$323.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$346.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$392.76
|
| Rate for Payer: PHP Commercial |
$392.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$300.35
|
| Rate for Payer: Priority Health SBD |
$291.10
|
| Rate for Payer: UMR Bronson Commercial |
$203.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$346.55
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
OP
|
$1,703.50
|
|
|
Service Code
|
NDC 16571072348
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$630.29 |
| Max. Negotiated Rate |
$1,533.15 |
| Rate for Payer: Aetna American Axle |
$1,107.28
|
| Rate for Payer: Aetna Commercial |
$1,447.97
|
| Rate for Payer: Aetna Medicare |
$851.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,107.28
|
| Rate for Payer: BCBS Complete |
$681.40
|
| Rate for Payer: Cash Price |
$1,362.80
|
| Rate for Payer: Cofinity Commercial |
$1,192.45
|
| Rate for Payer: Cofinity Commercial |
$1,465.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,192.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,362.80
|
| Rate for Payer: Healthscope Commercial |
$1,533.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,192.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,277.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,447.97
|
| Rate for Payer: PHP Commercial |
$1,447.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,107.28
|
| Rate for Payer: Priority Health SBD |
$1,073.20
|
| Rate for Payer: UMR Bronson Commercial |
$630.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,277.62
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$1,703.50
|
|
|
Service Code
|
NDC 16571072348
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$749.54 |
| Max. Negotiated Rate |
$1,533.15 |
| Rate for Payer: Aetna American Axle |
$1,107.28
|
| Rate for Payer: Aetna Commercial |
$1,447.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,107.28
|
| Rate for Payer: Cash Price |
$1,362.80
|
| Rate for Payer: Cofinity Commercial |
$1,192.45
|
| Rate for Payer: Cofinity Commercial |
$1,465.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,192.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,362.80
|
| Rate for Payer: Healthscope Commercial |
$1,533.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,192.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,277.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,447.97
|
| Rate for Payer: PHP Commercial |
$1,447.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,107.28
|
| Rate for Payer: Priority Health SBD |
$1,073.20
|
| Rate for Payer: UMR Bronson Commercial |
$749.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,277.62
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$1,362.17
|
|
|
Service Code
|
NDC 51079062383
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$599.35 |
| Max. Negotiated Rate |
$1,225.95 |
| Rate for Payer: Aetna American Axle |
$885.41
|
| Rate for Payer: Aetna Commercial |
$1,157.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$885.41
|
| Rate for Payer: Cash Price |
$1,089.74
|
| Rate for Payer: Cofinity Commercial |
$1,171.47
|
| Rate for Payer: Cofinity Commercial |
$953.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$953.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,089.74
|
| Rate for Payer: Healthscope Commercial |
$1,225.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$953.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,021.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,157.84
|
| Rate for Payer: PHP Commercial |
$1,157.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$885.41
|
| Rate for Payer: Priority Health SBD |
$858.17
|
| Rate for Payer: UMR Bronson Commercial |
$599.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,021.63
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$247.27
|
|
|
Service Code
|
NDC 16571072360
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.80 |
| Max. Negotiated Rate |
$222.54 |
| Rate for Payer: Aetna American Axle |
$160.73
|
| Rate for Payer: Aetna Commercial |
$210.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.73
|
| Rate for Payer: Cash Price |
$197.82
|
| Rate for Payer: Cofinity Commercial |
$173.09
|
| Rate for Payer: Cofinity Commercial |
$212.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.82
|
| Rate for Payer: Healthscope Commercial |
$222.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.18
|
| Rate for Payer: PHP Commercial |
$210.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.73
|
| Rate for Payer: Priority Health SBD |
$155.78
|
| Rate for Payer: UMR Bronson Commercial |
$108.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.45
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
OP
|
$1,362.17
|
|
|
Service Code
|
NDC 51079062383
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,225.95 |
| Rate for Payer: Aetna American Axle |
$885.41
|
| Rate for Payer: Aetna Commercial |
$1,157.84
|
| Rate for Payer: Aetna Medicare |
$681.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$885.41
|
| Rate for Payer: BCBS Complete |
$544.87
|
| Rate for Payer: Cash Price |
$1,089.74
|
| Rate for Payer: Cofinity Commercial |
$1,171.47
|
| Rate for Payer: Cofinity Commercial |
$953.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$953.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,089.74
|
| Rate for Payer: Healthscope Commercial |
$1,225.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$953.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,021.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,157.84
|
| Rate for Payer: PHP Commercial |
$1,157.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$885.41
|
| Rate for Payer: Priority Health SBD |
$858.17
|
| Rate for Payer: UMR Bronson Commercial |
$504.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,021.63
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
OP
|
$247.27
|
|
|
Service Code
|
NDC 16571072360
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.49 |
| Max. Negotiated Rate |
$222.54 |
| Rate for Payer: Aetna American Axle |
$160.73
|
| Rate for Payer: Aetna Commercial |
$210.18
|
| Rate for Payer: Aetna Medicare |
$123.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.73
|
| Rate for Payer: BCBS Complete |
$98.91
|
| Rate for Payer: Cash Price |
$197.82
|
| Rate for Payer: Cofinity Commercial |
$173.09
|
| Rate for Payer: Cofinity Commercial |
$212.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.82
|
| Rate for Payer: Healthscope Commercial |
$222.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.18
|
| Rate for Payer: PHP Commercial |
$210.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.73
|
| Rate for Payer: Priority Health SBD |
$155.78
|
| Rate for Payer: UMR Bronson Commercial |
$91.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.45
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
OP
|
$197.66
|
|
|
Service Code
|
NDC 51079062381
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.13 |
| Max. Negotiated Rate |
$177.89 |
| Rate for Payer: Aetna American Axle |
$128.48
|
| Rate for Payer: Aetna Commercial |
$168.01
|
| Rate for Payer: Aetna Medicare |
$98.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.48
|
| Rate for Payer: BCBS Complete |
$79.06
|
| Rate for Payer: Cash Price |
$158.13
|
| Rate for Payer: Cofinity Commercial |
$138.36
|
| Rate for Payer: Cofinity Commercial |
$169.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.13
|
| Rate for Payer: Healthscope Commercial |
$177.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$168.01
|
| Rate for Payer: PHP Commercial |
$168.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.48
|
| Rate for Payer: Priority Health SBD |
$124.53
|
| Rate for Payer: UMR Bronson Commercial |
$73.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.25
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM
|
Facility
|
IP
|
$197.66
|
|
|
Service Code
|
NDC 51079062381
|
| Hospital Charge Code |
10478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.97 |
| Max. Negotiated Rate |
$177.89 |
| Rate for Payer: Aetna American Axle |
$128.48
|
| Rate for Payer: Aetna Commercial |
$168.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.48
|
| Rate for Payer: Cash Price |
$158.13
|
| Rate for Payer: Cofinity Commercial |
$138.36
|
| Rate for Payer: Cofinity Commercial |
$169.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.13
|
| Rate for Payer: Healthscope Commercial |
$177.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$168.01
|
| Rate for Payer: PHP Commercial |
$168.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.48
|
| Rate for Payer: Priority Health SBD |
$124.53
|
| Rate for Payer: UMR Bronson Commercial |
$86.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.25
|
|
|
MAGIC PERICREAM
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 09900000714
|
| Hospital Charge Code |
150680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna Medicare |
$5.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: BCBS Complete |
$4.10
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.67
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
|
MAGIC PERICREAM
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 09900000714
|
| Hospital Charge Code |
150680
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna American Axle |
$6.67
|
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.67
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.70
|
|
