|
PR EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG
|
Professional
|
Both
|
$417.00
|
|
|
Service Code
|
HCPCS 95720
|
| Min. Negotiated Rate |
$130.14 |
| Max. Negotiated Rate |
$399.39 |
| Rate for Payer: Aetna Commercial |
$226.36
|
| Rate for Payer: BCBS Complete |
$136.65
|
| Rate for Payer: BCBS Trust/PPO |
$399.39
|
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Cash Price |
$333.60
|
| Rate for Payer: Meridian Medicaid |
$136.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$130.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$270.83
|
| Rate for Payer: Priority Health Narrow Network |
$270.83
|
| Rate for Payer: Priority Health SBD |
$270.83
|
| Rate for Payer: UMR Bronson Commercial |
$191.82
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
IP
|
$154.40
|
|
|
Service Code
|
NDC 69238-1313-9
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.94 |
| Max. Negotiated Rate |
$138.96 |
| Rate for Payer: Aetna American Axle |
$100.36
|
| Rate for Payer: Aetna Commercial |
$131.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.36
|
| Rate for Payer: Cash Price |
$123.52
|
| Rate for Payer: Cofinity Commercial |
$108.08
|
| Rate for Payer: Cofinity Commercial |
$132.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.52
|
| Rate for Payer: Healthscope Commercial |
$138.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.24
|
| Rate for Payer: PHP Commercial |
$131.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.08
|
| Rate for Payer: Priority Health SBD |
$97.27
|
| Rate for Payer: UMR Bronson Commercial |
$67.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.80
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
IP
|
$3,647.83
|
|
|
Service Code
|
NDC 0071-1015-41
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,605.05 |
| Max. Negotiated Rate |
$3,283.05 |
| Rate for Payer: Aetna American Axle |
$2,371.09
|
| Rate for Payer: Aetna Commercial |
$3,100.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,371.09
|
| Rate for Payer: Cash Price |
$2,918.26
|
| Rate for Payer: Cofinity Commercial |
$2,553.48
|
| Rate for Payer: Cofinity Commercial |
$3,137.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,918.26
|
| Rate for Payer: Healthscope Commercial |
$3,283.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,553.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,735.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,100.66
|
| Rate for Payer: PHP Commercial |
$3,100.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,553.48
|
| Rate for Payer: Priority Health SBD |
$2,298.13
|
| Rate for Payer: UMR Bronson Commercial |
$1,605.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,735.87
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
IP
|
$272.84
|
|
|
Service Code
|
NDC 0228-2859-09
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$245.56 |
| Rate for Payer: Aetna American Axle |
$177.35
|
| Rate for Payer: Aetna Commercial |
$231.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.35
|
| Rate for Payer: Cash Price |
$218.27
|
| Rate for Payer: Cofinity Commercial |
$190.99
|
| Rate for Payer: Cofinity Commercial |
$234.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.27
|
| Rate for Payer: Healthscope Commercial |
$245.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$231.91
|
| Rate for Payer: PHP Commercial |
$231.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.99
|
| Rate for Payer: Priority Health SBD |
$171.89
|
| Rate for Payer: UMR Bronson Commercial |
$120.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.63
|
|
|
PREGABALIN 25 MG CAPSULE
|
Facility
|
IP
|
$2,984.68
|
|
|
Service Code
|
NDC 0071-1012-68
|
| Hospital Charge Code |
42162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,313.26 |
| Max. Negotiated Rate |
$2,686.21 |
| Rate for Payer: Aetna American Axle |
$1,940.04
|
| Rate for Payer: Aetna Commercial |
$2,536.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,940.04
|
| Rate for Payer: Cash Price |
$2,387.74
|
| Rate for Payer: Cofinity Commercial |
$2,089.28
|
| Rate for Payer: Cofinity Commercial |
$2,566.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,387.74
|
| Rate for Payer: Healthscope Commercial |
$2,686.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,089.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,238.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,536.98
|
| Rate for Payer: PHP Commercial |
$2,536.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,089.28
|
| Rate for Payer: Priority Health SBD |
$1,880.35
|
| Rate for Payer: UMR Bronson Commercial |
$1,313.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,238.51
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$179.78
|
|
|
Service Code
|
NDC 69238-1311-9
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$161.80 |
| Rate for Payer: Aetna American Axle |
$116.86
|
| Rate for Payer: Aetna Commercial |
$152.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.86
|
| Rate for Payer: Cash Price |
$143.82
|
| Rate for Payer: Cofinity Commercial |
$125.85
|
| Rate for Payer: Cofinity Commercial |
$154.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.82
|
| Rate for Payer: Healthscope Commercial |
$161.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$152.81
|
| Rate for Payer: PHP Commercial |
$152.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.85
|
| Rate for Payer: Priority Health SBD |
$113.26
|
| Rate for Payer: UMR Bronson Commercial |
$79.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.84
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$3.99
|
|
|
Service Code
|
NDC 60687-484-11
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$3.59 |
| Rate for Payer: Aetna American Axle |
$2.59
|
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.59
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$3.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.19
|
| Rate for Payer: Healthscope Commercial |
$3.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.79
|
| Rate for Payer: Priority Health SBD |
$2.51
|
| Rate for Payer: UMR Bronson Commercial |
$1.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.99
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$131.13
|
|
|
Service Code
|
NDC 72205-012-90
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.70 |
| Max. Negotiated Rate |
$118.02 |
| Rate for Payer: Aetna American Axle |
$85.23
|
| Rate for Payer: Aetna Commercial |
$111.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.23
|
| Rate for Payer: Cash Price |
$104.90
|
| Rate for Payer: Cofinity Commercial |
$112.77
|
| Rate for Payer: Cofinity Commercial |
$91.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.90
|
| Rate for Payer: Healthscope Commercial |
$118.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.46
|
| Rate for Payer: PHP Commercial |
$111.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.79
|
| Rate for Payer: Priority Health SBD |
$82.61
|
| Rate for Payer: UMR Bronson Commercial |
$57.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.35
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$2,984.68
|
|
|
Service Code
|
NDC 0071-1013-68
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,313.26 |
| Max. Negotiated Rate |
$2,686.21 |
| Rate for Payer: Aetna American Axle |
$1,940.04
|
| Rate for Payer: Aetna Commercial |
$2,536.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,940.04
|
| Rate for Payer: Cash Price |
$2,387.74
|
| Rate for Payer: Cofinity Commercial |
$2,089.28
|
| Rate for Payer: Cofinity Commercial |
$2,566.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,387.74
|
| Rate for Payer: Healthscope Commercial |
$2,686.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,089.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,238.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,536.98
|
| Rate for Payer: PHP Commercial |
$2,536.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,089.28
|
| Rate for Payer: Priority Health SBD |
$1,880.35
|
| Rate for Payer: UMR Bronson Commercial |
$1,313.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,238.51
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$398.88
|
|
|
Service Code
|
NDC 60687-484-01
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.51 |
| Max. Negotiated Rate |
$358.99 |
| Rate for Payer: Aetna American Axle |
$259.27
|
| Rate for Payer: Aetna Commercial |
$339.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.27
|
| Rate for Payer: Cash Price |
$319.10
|
| Rate for Payer: Cofinity Commercial |
$279.22
|
| Rate for Payer: Cofinity Commercial |
$343.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.10
|
| Rate for Payer: Healthscope Commercial |
$358.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$279.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$299.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.05
|
| Rate for Payer: PHP Commercial |
$339.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.22
|
| Rate for Payer: Priority Health SBD |
$251.29
|
| Rate for Payer: UMR Bronson Commercial |
$175.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$299.16
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$143.82
|
|
|
Service Code
|
NDC 69097-678-05
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.28 |
| Max. Negotiated Rate |
$129.44 |
| Rate for Payer: Aetna American Axle |
$93.48
|
| Rate for Payer: Aetna Commercial |
$122.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.48
|
| Rate for Payer: Cash Price |
$115.06
|
| Rate for Payer: Cofinity Commercial |
$100.67
|
| Rate for Payer: Cofinity Commercial |
$123.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.06
|
| Rate for Payer: Healthscope Commercial |
$129.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$100.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$122.25
|
| Rate for Payer: PHP Commercial |
$122.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.67
|
| Rate for Payer: Priority Health SBD |
$90.61
|
| Rate for Payer: UMR Bronson Commercial |
$63.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.86
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$3,258.59
|
|
|
Service Code
|
NDC 0071-1013-41
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,433.78 |
| Max. Negotiated Rate |
$2,932.73 |
| Rate for Payer: Aetna American Axle |
$2,118.08
|
| Rate for Payer: Aetna Commercial |
$2,769.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,118.08
|
| Rate for Payer: Cash Price |
$2,606.87
|
| Rate for Payer: Cofinity Commercial |
$2,281.01
|
| Rate for Payer: Cofinity Commercial |
$2,802.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,606.87
|
| Rate for Payer: Healthscope Commercial |
$2,932.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,281.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,443.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,769.80
|
| Rate for Payer: PHP Commercial |
$2,769.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,281.01
|
| Rate for Payer: Priority Health SBD |
$2,052.91
|
| Rate for Payer: UMR Bronson Commercial |
$1,433.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,443.94
|
|
|
PREGABALIN 75 MG CAPSULE
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 69238-1312-9
|
| Hospital Charge Code |
42164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
PREGABALIN 75 MG CAPSULE
|
Facility
|
IP
|
$387.60
|
|
|
Service Code
|
NDC 0904-7000-61
|
| Hospital Charge Code |
42164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.54 |
| Max. Negotiated Rate |
$348.84 |
| Rate for Payer: Aetna American Axle |
$251.94
|
| Rate for Payer: Aetna Commercial |
$329.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.94
|
| Rate for Payer: Cash Price |
$310.08
|
| Rate for Payer: Cofinity Commercial |
$271.32
|
| Rate for Payer: Cofinity Commercial |
$333.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.08
|
| Rate for Payer: Healthscope Commercial |
$348.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$271.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$329.46
|
| Rate for Payer: PHP Commercial |
$329.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.32
|
| Rate for Payer: Priority Health SBD |
$244.19
|
| Rate for Payer: UMR Bronson Commercial |
$170.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.70
|
|
|
PREGABALIN 75 MG CAPSULE
|
Facility
|
IP
|
$3,647.83
|
|
|
Service Code
|
NDC 0071-1014-41
|
| Hospital Charge Code |
42164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,605.05 |
| Max. Negotiated Rate |
$3,283.05 |
| Rate for Payer: Aetna American Axle |
$2,371.09
|
| Rate for Payer: Aetna Commercial |
$3,100.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,371.09
|
| Rate for Payer: Cash Price |
$2,918.26
|
| Rate for Payer: Cofinity Commercial |
$2,553.48
|
| Rate for Payer: Cofinity Commercial |
$3,137.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,918.26
|
| Rate for Payer: Healthscope Commercial |
$3,283.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,553.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,735.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,100.66
|
| Rate for Payer: PHP Commercial |
$3,100.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,553.48
|
| Rate for Payer: Priority Health SBD |
$2,298.13
|
| Rate for Payer: UMR Bronson Commercial |
$1,605.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,735.87
|
|
|
PR EGD ABLATE TUMOR POLYP/LESION W/DILATION& WIRE
|
Professional
|
Both
|
$1,385.00
|
|
|
Service Code
|
HCPCS 43270
|
| Min. Negotiated Rate |
$140.79 |
| Max. Negotiated Rate |
$969.50 |
| Rate for Payer: Aetna Commercial |
$298.44
|
| Rate for Payer: BCBS Complete |
$147.83
|
| Rate for Payer: BCBS Trust/PPO |
$724.83
|
| Rate for Payer: Cash Price |
$1,108.00
|
| Rate for Payer: Cash Price |
$1,108.00
|
| Rate for Payer: Meridian Medicaid |
$147.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$140.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$969.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$386.30
|
| Rate for Payer: Priority Health Narrow Network |
$386.30
|
| Rate for Payer: Priority Health SBD |
$386.30
|
| Rate for Payer: UMR Bronson Commercial |
$637.10
|
|
|
PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM
|
Facility
|
IP
|
$1,767.00
|
|
|
Service Code
|
CPT 43249
|
| Hospital Charge Code |
43249
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$777.48 |
| Max. Negotiated Rate |
$1,590.30 |
| Rate for Payer: Aetna American Axle |
$1,148.55
|
| Rate for Payer: Aetna Commercial |
$1,501.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,148.55
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cofinity Commercial |
$1,236.90
|
| Rate for Payer: Cofinity Commercial |
$1,519.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,413.60
|
| Rate for Payer: Healthscope Commercial |
$1,590.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,236.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,325.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,501.95
|
| Rate for Payer: PHP Commercial |
$1,501.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,236.90
|
| Rate for Payer: Priority Health SBD |
$1,113.21
|
| Rate for Payer: UMR Bronson Commercial |
$777.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,325.25
|
|
|
PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM
|
Professional
|
Both
|
$1,767.00
|
|
|
Service Code
|
HCPCS 43249
|
| Hospital Charge Code |
43249
|
| Min. Negotiated Rate |
$96.70 |
| Max. Negotiated Rate |
$1,236.90 |
| Rate for Payer: Aetna Commercial |
$204.01
|
| Rate for Payer: BCBS Complete |
$101.54
|
| Rate for Payer: BCBS Trust/PPO |
$845.81
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Meridian Medicaid |
$101.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,236.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.17
|
| Rate for Payer: Priority Health Narrow Network |
$265.17
|
| Rate for Payer: Priority Health SBD |
$265.17
|
| Rate for Payer: UMR Bronson Commercial |
$812.82
|
|
|
PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM
|
Facility
|
OP
|
$1,767.00
|
|
|
Service Code
|
CPT 43249
|
| Hospital Charge Code |
43249
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$148.66 |
| Max. Negotiated Rate |
$5,324.53 |
| Rate for Payer: Aetna American Axle |
$1,148.55
|
| Rate for Payer: Aetna Commercial |
$1,501.95
|
| Rate for Payer: Aetna Medicare |
$1,759.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,148.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,114.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,114.21
|
| Rate for Payer: BCBS Complete |
$971.52
|
| Rate for Payer: BCBS MAPPO |
$1,691.37
|
| Rate for Payer: BCBS Trust/PPO |
$1,053.72
|
| Rate for Payer: BCN Medicare Advantage |
$1,691.37
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cofinity Commercial |
$1,236.90
|
| Rate for Payer: Cofinity Commercial |
$1,519.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,413.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,691.37
|
| Rate for Payer: Healthscope Commercial |
$1,590.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,236.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,325.25
|
| Rate for Payer: Mclaren Medicaid |
$925.18
|
| Rate for Payer: Mclaren Medicare |
$1,691.37
|
| Rate for Payer: Meridian Medicaid |
$971.52
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,775.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,945.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,501.95
|
| Rate for Payer: PACE Medicare |
$1,606.80
|
| Rate for Payer: PACE SWMI |
$1,691.37
|
| Rate for Payer: PHP Commercial |
$1,501.95
|
| Rate for Payer: PHP Medicare Advantage |
$1,691.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$925.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,236.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,324.53
|
| Rate for Payer: Priority Health Medicare |
$1,691.37
|
| Rate for Payer: Priority Health Narrow Network |
$4,259.62
|
| Rate for Payer: Priority Health SBD |
$1,113.21
|
| Rate for Payer: Railroad Medicare Medicare |
$1,691.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,691.37
|
| Rate for Payer: UHC Exchange |
$148.66
|
| Rate for Payer: UHC Medicare Advantage |
$1,742.11
|
| Rate for Payer: UMR Bronson Commercial |
$653.79
|
| Rate for Payer: VA VA |
$1,691.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,325.25
|
|
|
PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM
|
Professional
|
Both
|
$1,767.00
|
|
|
Service Code
|
HCPCS 43249
|
| Min. Negotiated Rate |
$96.70 |
| Max. Negotiated Rate |
$1,236.90 |
| Rate for Payer: Aetna Commercial |
$204.01
|
| Rate for Payer: BCBS Complete |
$101.54
|
| Rate for Payer: BCBS Trust/PPO |
$845.81
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Cash Price |
$1,413.60
|
| Rate for Payer: Meridian Medicaid |
$101.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,236.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.17
|
| Rate for Payer: Priority Health Narrow Network |
$265.17
|
| Rate for Payer: Priority Health SBD |
$265.17
|
| Rate for Payer: UMR Bronson Commercial |
$812.82
|
|
|
PR EGD BAND LIGATION ESOPHGEAL/GASTRIC VARICES
|
Professional
|
Both
|
$1,115.00
|
|
|
Service Code
|
HCPCS 43244
|
| Min. Negotiated Rate |
$129.43 |
| Max. Negotiated Rate |
$780.50 |
| Rate for Payer: Aetna Commercial |
$325.46
|
| Rate for Payer: BCBS Complete |
$161.48
|
| Rate for Payer: BCBS Trust/PPO |
$129.43
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Meridian Medicaid |
$161.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$153.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$780.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$422.16
|
| Rate for Payer: Priority Health Narrow Network |
$422.16
|
| Rate for Payer: Priority Health SBD |
$422.16
|
| Rate for Payer: UMR Bronson Commercial |
$512.90
|
|
|
PR EGD DELIVER THERMAL ENERGY SPHNCTR/CARDIA GERD
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 43257
|
| Min. Negotiated Rate |
$147.18 |
| Max. Negotiated Rate |
$850.03 |
| Rate for Payer: Aetna Commercial |
$308.63
|
| Rate for Payer: BCBS Complete |
$154.54
|
| Rate for Payer: BCBS Trust/PPO |
$850.03
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Meridian Medicaid |
$154.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$147.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$402.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$400.41
|
| Rate for Payer: Priority Health Narrow Network |
$400.41
|
| Rate for Payer: Priority Health SBD |
$400.41
|
| Rate for Payer: UMR Bronson Commercial |
$264.50
|
|
|
PR EGD DILATION GASTRIC/DUODENAL STRICTURE
|
Professional
|
Both
|
$993.00
|
|
|
Service Code
|
HCPCS 43245
|
| Min. Negotiated Rate |
$68.68 |
| Max. Negotiated Rate |
$695.10 |
| Rate for Payer: Aetna Commercial |
$234.83
|
| Rate for Payer: BCBS Complete |
$116.08
|
| Rate for Payer: BCBS Trust/PPO |
$68.68
|
| Rate for Payer: Cash Price |
$794.40
|
| Rate for Payer: Cash Price |
$794.40
|
| Rate for Payer: Meridian Medicaid |
$116.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$110.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$695.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$303.40
|
| Rate for Payer: Priority Health Narrow Network |
$303.40
|
| Rate for Payer: Priority Health SBD |
$303.40
|
| Rate for Payer: UMR Bronson Commercial |
$456.78
|
|
|
PR EGD ENDOSCOPIC STENT PLACEMENT W/WIRE& DILATION
|
Professional
|
Both
|
$677.00
|
|
|
Service Code
|
HCPCS 43266
|
| Min. Negotiated Rate |
$136.75 |
| Max. Negotiated Rate |
$1,452.30 |
| Rate for Payer: Aetna Commercial |
$289.61
|
| Rate for Payer: BCBS Complete |
$143.59
|
| Rate for Payer: BCBS Trust/PPO |
$1,452.30
|
| Rate for Payer: Cash Price |
$541.60
|
| Rate for Payer: Cash Price |
$541.60
|
| Rate for Payer: Meridian Medicaid |
$143.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$136.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$473.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$375.13
|
| Rate for Payer: Priority Health Narrow Network |
$375.13
|
| Rate for Payer: Priority Health SBD |
$375.13
|
| Rate for Payer: UMR Bronson Commercial |
$311.42
|
|
|
PR EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER
|
Professional
|
Both
|
$1,019.00
|
|
|
Service Code
|
HCPCS 43233
|
| Min. Negotiated Rate |
$77.66 |
| Max. Negotiated Rate |
$713.30 |
| Rate for Payer: Aetna Commercial |
$306.04
|
| Rate for Payer: BCBS Complete |
$151.41
|
| Rate for Payer: BCBS Trust/PPO |
$77.66
|
| Rate for Payer: Cash Price |
$815.20
|
| Rate for Payer: Cash Price |
$815.20
|
| Rate for Payer: Meridian Medicaid |
$151.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$144.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$713.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$394.52
|
| Rate for Payer: Priority Health Narrow Network |
$394.52
|
| Rate for Payer: Priority Health SBD |
$394.52
|
| Rate for Payer: UMR Bronson Commercial |
$468.74
|
|
