|
PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS
|
Facility
|
OP
|
$10,512.58
|
|
|
Service Code
|
CPT 19371
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,001.76 |
| Max. Negotiated Rate |
$10,512.58 |
| Rate for Payer: Aetna Medicare |
$3,884.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,668.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,668.27
|
| Rate for Payer: BCBS Complete |
$2,101.84
|
| Rate for Payer: BCBS MAPPO |
$3,734.62
|
| Rate for Payer: BCN Medicare Advantage |
$3,734.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,734.62
|
| Rate for Payer: Mclaren Medicaid |
$2,001.76
|
| Rate for Payer: Mclaren Medicare |
$3,734.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,921.35
|
| Rate for Payer: Meridian Medicaid |
$2,101.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,294.81
|
| Rate for Payer: PACE Medicare |
$3,547.89
|
| Rate for Payer: PACE SWMI |
$3,734.62
|
| Rate for Payer: PHP Medicare Advantage |
$3,734.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,001.76
|
| Rate for Payer: Priority Health Medicare |
$3,734.62
|
| Rate for Payer: Railroad Medicare Medicare |
$3,734.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,512.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,734.62
|
| Rate for Payer: UHC Exchange |
$7,137.23
|
| Rate for Payer: UHC Medicare Advantage |
$3,734.62
|
| Rate for Payer: UHCCP Medicaid |
$2,001.76
|
| Rate for Payer: VA VA |
$3,734.62
|
|
|
PERINDOPRIL ERBUMINE 4 MG TABLET
|
Facility
|
OP
|
$296.16
|
|
|
Service Code
|
NDC 00054011125
|
| Hospital Charge Code |
13160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.58 |
| Max. Negotiated Rate |
$266.54 |
| Rate for Payer: Aetna American Axle |
$192.50
|
| Rate for Payer: Aetna Commercial |
$251.74
|
| Rate for Payer: Aetna Medicare |
$148.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.50
|
| Rate for Payer: BCBS Complete |
$118.46
|
| Rate for Payer: Cash Price |
$236.93
|
| Rate for Payer: Cofinity Commercial |
$207.31
|
| Rate for Payer: Cofinity Commercial |
$254.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$207.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.93
|
| Rate for Payer: Healthscope Commercial |
$266.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$207.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$251.74
|
| Rate for Payer: PHP Commercial |
$251.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.50
|
| Rate for Payer: Priority Health SBD |
$186.58
|
| Rate for Payer: UMR Bronson Commercial |
$109.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.12
|
|
|
PERINDOPRIL ERBUMINE 4 MG TABLET
|
Facility
|
IP
|
$296.16
|
|
|
Service Code
|
NDC 00054011125
|
| Hospital Charge Code |
13160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.31 |
| Max. Negotiated Rate |
$266.54 |
| Rate for Payer: Aetna American Axle |
$192.50
|
| Rate for Payer: Aetna Commercial |
$251.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.50
|
| Rate for Payer: Cash Price |
$236.93
|
| Rate for Payer: Cofinity Commercial |
$207.31
|
| Rate for Payer: Cofinity Commercial |
$254.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$207.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.93
|
| Rate for Payer: Healthscope Commercial |
$266.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$207.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$251.74
|
| Rate for Payer: PHP Commercial |
$251.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.50
|
| Rate for Payer: Priority Health SBD |
$186.58
|
| Rate for Payer: UMR Bronson Commercial |
$130.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.12
|
|
|
PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 56810
|
|
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
|
|
|
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
IP
|
$118.65
|
|
|
Service Code
|
NDC 49230020694
|
| Hospital Charge Code |
27796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.21 |
| Max. Negotiated Rate |
$106.78 |
| Rate for Payer: Aetna American Axle |
$77.12
|
| Rate for Payer: Aetna Commercial |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.12
|
| Rate for Payer: Cash Price |
$94.92
|
| Rate for Payer: Cofinity Commercial |
$102.04
|
| Rate for Payer: Cofinity Commercial |
$83.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.92
|
| Rate for Payer: Healthscope Commercial |
$106.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.85
|
| Rate for Payer: PHP Commercial |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.12
|
| Rate for Payer: Priority Health SBD |
$74.75
|
| Rate for Payer: UMR Bronson Commercial |
$52.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.99
|
|
|
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
OP
|
$135.60
|
|
|
Service Code
|
NDC 49230020692
|
| Hospital Charge Code |
27796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.17 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna Medicare |
$67.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: BCBS Complete |
$54.24
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.14
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$50.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
IP
|
$135.60
|
|
|
Service Code
|
NDC 49230020692
|
| Hospital Charge Code |
27796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.66 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.14
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$59.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
OP
|
$118.65
|
|
|
Service Code
|
NDC 49230020694
|
| Hospital Charge Code |
27796
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.90 |
| Max. Negotiated Rate |
$106.78 |
| Rate for Payer: Aetna American Axle |
$77.12
|
| Rate for Payer: Aetna Commercial |
$100.85
|
| Rate for Payer: Aetna Medicare |
$59.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.12
|
| Rate for Payer: BCBS Complete |
$47.46
|
| Rate for Payer: Cash Price |
$94.92
|
| Rate for Payer: Cofinity Commercial |
$102.04
|
| Rate for Payer: Cofinity Commercial |
$83.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.92
|
| Rate for Payer: Healthscope Commercial |
$106.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.85
|
| Rate for Payer: PHP Commercial |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.12
|
| Rate for Payer: Priority Health SBD |
$74.75
|
| Rate for Payer: UMR Bronson Commercial |
$43.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.99
|
|
|
PERITONEAL DIALYSIS DRAINAGE BAG (EMPTY BAG)
|
Facility
|
IP
|
$13.51
|
|
|
Service Code
|
NDC 09900001008
|
| Hospital Charge Code |
200025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$12.16 |
| Rate for Payer: Aetna American Axle |
$8.78
|
| Rate for Payer: Aetna Commercial |
$11.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: Cofinity Commercial |
$11.62
|
| Rate for Payer: Cofinity Commercial |
$9.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.81
|
| Rate for Payer: Healthscope Commercial |
$12.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.48
|
| Rate for Payer: PHP Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.13
|
|
|
PERITONEAL DIALYSIS DRAINAGE BAG (EMPTY BAG)
|
Facility
|
OP
|
$13.51
|
|
|
Service Code
|
NDC 09900001008
|
| Hospital Charge Code |
200025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$12.16 |
| Rate for Payer: Aetna American Axle |
$8.78
|
| Rate for Payer: Aetna Commercial |
$11.48
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: Cofinity Commercial |
$11.62
|
| Rate for Payer: Cofinity Commercial |
$9.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.81
|
| Rate for Payer: Healthscope Commercial |
$12.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.48
|
| Rate for Payer: PHP Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$5.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.13
|
|
|
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
OP
|
$118.65
|
|
|
Service Code
|
NDC 49230020994
|
| Hospital Charge Code |
27800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.90 |
| Max. Negotiated Rate |
$106.78 |
| Rate for Payer: Aetna American Axle |
$77.12
|
| Rate for Payer: Aetna Commercial |
$100.85
|
| Rate for Payer: Aetna Medicare |
$59.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.12
|
| Rate for Payer: BCBS Complete |
$47.46
|
| Rate for Payer: Cash Price |
$94.92
|
| Rate for Payer: Cofinity Commercial |
$102.04
|
| Rate for Payer: Cofinity Commercial |
$83.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.92
|
| Rate for Payer: Healthscope Commercial |
$106.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.85
|
| Rate for Payer: PHP Commercial |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.12
|
| Rate for Payer: Priority Health SBD |
$74.75
|
| Rate for Payer: UMR Bronson Commercial |
$43.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.99
|
|
|
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
IP
|
$135.60
|
|
|
Service Code
|
NDC 49230020992
|
| Hospital Charge Code |
27800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.66 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.14
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$59.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
OP
|
$135.60
|
|
|
Service Code
|
NDC 49230020992
|
| Hospital Charge Code |
27800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.17 |
| Max. Negotiated Rate |
$122.04 |
| Rate for Payer: Aetna American Axle |
$88.14
|
| Rate for Payer: Aetna Commercial |
$115.26
|
| Rate for Payer: Aetna Medicare |
$67.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.14
|
| Rate for Payer: BCBS Complete |
$54.24
|
| Rate for Payer: Cash Price |
$108.48
|
| Rate for Payer: Cofinity Commercial |
$116.62
|
| Rate for Payer: Cofinity Commercial |
$94.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.48
|
| Rate for Payer: Healthscope Commercial |
$122.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.26
|
| Rate for Payer: PHP Commercial |
$115.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.14
|
| Rate for Payer: Priority Health SBD |
$85.43
|
| Rate for Payer: UMR Bronson Commercial |
$50.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.70
|
|
|
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L
|
Facility
|
IP
|
$118.65
|
|
|
Service Code
|
NDC 49230020994
|
| Hospital Charge Code |
27800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.21 |
| Max. Negotiated Rate |
$106.78 |
| Rate for Payer: Aetna American Axle |
$77.12
|
| Rate for Payer: Aetna Commercial |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.12
|
| Rate for Payer: Cash Price |
$94.92
|
| Rate for Payer: Cofinity Commercial |
$102.04
|
| Rate for Payer: Cofinity Commercial |
$83.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.92
|
| Rate for Payer: Healthscope Commercial |
$106.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.85
|
| Rate for Payer: PHP Commercial |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.12
|
| Rate for Payer: Priority Health SBD |
$74.75
|
| Rate for Payer: UMR Bronson Commercial |
$52.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.99
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID
|
Facility
|
OP
|
$39.65
|
|
|
Service Code
|
NDC 63736012002
|
| Hospital Charge Code |
10918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$35.69 |
| Rate for Payer: Aetna American Axle |
$25.77
|
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Medicare |
$19.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.77
|
| Rate for Payer: BCBS Complete |
$15.86
|
| Rate for Payer: Cash Price |
$31.72
|
| Rate for Payer: Cofinity Commercial |
$27.75
|
| Rate for Payer: Cofinity Commercial |
$34.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.72
|
| Rate for Payer: Healthscope Commercial |
$35.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.70
|
| Rate for Payer: PHP Commercial |
$33.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.77
|
| Rate for Payer: Priority Health SBD |
$24.98
|
| Rate for Payer: UMR Bronson Commercial |
$14.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.74
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID
|
Facility
|
IP
|
$39.65
|
|
|
Service Code
|
NDC 63736012002
|
| Hospital Charge Code |
10918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.45 |
| Max. Negotiated Rate |
$35.69 |
| Rate for Payer: Aetna American Axle |
$25.77
|
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.77
|
| Rate for Payer: Cash Price |
$31.72
|
| Rate for Payer: Cofinity Commercial |
$27.75
|
| Rate for Payer: Cofinity Commercial |
$34.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.72
|
| Rate for Payer: Healthscope Commercial |
$35.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.70
|
| Rate for Payer: PHP Commercial |
$33.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.77
|
| Rate for Payer: Priority Health SBD |
$24.98
|
| Rate for Payer: UMR Bronson Commercial |
$17.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.74
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
IP
|
$83.16
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.59 |
| Max. Negotiated Rate |
$74.84 |
| Rate for Payer: Aetna American Axle |
$54.05
|
| Rate for Payer: Aetna Commercial |
$70.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.05
|
| Rate for Payer: Cash Price |
$66.53
|
| Rate for Payer: Cofinity Commercial |
$58.21
|
| Rate for Payer: Cofinity Commercial |
$71.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$58.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.53
|
| Rate for Payer: Healthscope Commercial |
$74.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.69
|
| Rate for Payer: PHP Commercial |
$70.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.05
|
| Rate for Payer: Priority Health SBD |
$52.39
|
| Rate for Payer: UMR Bronson Commercial |
$36.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.37
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
IP
|
$322.35
|
|
|
Service Code
|
NDC 00472024260
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.83 |
| Max. Negotiated Rate |
$290.12 |
| Rate for Payer: Aetna American Axle |
$209.53
|
| Rate for Payer: Aetna Commercial |
$274.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.53
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$225.65
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$290.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: PHP Commercial |
$274.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: Priority Health SBD |
$203.08
|
| Rate for Payer: UMR Bronson Commercial |
$141.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.76
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
OP
|
$83.16
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.77 |
| Max. Negotiated Rate |
$74.84 |
| Rate for Payer: Aetna American Axle |
$54.05
|
| Rate for Payer: Aetna Commercial |
$70.69
|
| Rate for Payer: Aetna Medicare |
$41.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.05
|
| Rate for Payer: BCBS Complete |
$33.26
|
| Rate for Payer: Cash Price |
$66.53
|
| Rate for Payer: Cofinity Commercial |
$58.21
|
| Rate for Payer: Cofinity Commercial |
$71.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$58.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.53
|
| Rate for Payer: Healthscope Commercial |
$74.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.69
|
| Rate for Payer: PHP Commercial |
$70.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.05
|
| Rate for Payer: Priority Health SBD |
$52.39
|
| Rate for Payer: UMR Bronson Commercial |
$30.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.37
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
OP
|
$322.35
|
|
|
Service Code
|
NDC 00472024260
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.27 |
| Max. Negotiated Rate |
$290.12 |
| Rate for Payer: Aetna American Axle |
$209.53
|
| Rate for Payer: Aetna Commercial |
$274.00
|
| Rate for Payer: Aetna Medicare |
$161.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.53
|
| Rate for Payer: BCBS Complete |
$128.94
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$225.65
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$290.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: PHP Commercial |
$274.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: Priority Health SBD |
$203.08
|
| Rate for Payer: UMR Bronson Commercial |
$119.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.76
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
OP
|
$322.35
|
|
|
Service Code
|
NDC 45802026937
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.27 |
| Max. Negotiated Rate |
$290.12 |
| Rate for Payer: Aetna American Axle |
$209.53
|
| Rate for Payer: Aetna Commercial |
$274.00
|
| Rate for Payer: Aetna Medicare |
$161.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.53
|
| Rate for Payer: BCBS Complete |
$128.94
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$225.65
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$290.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: PHP Commercial |
$274.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: Priority Health SBD |
$203.08
|
| Rate for Payer: UMR Bronson Commercial |
$119.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.76
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
IP
|
$322.35
|
|
|
Service Code
|
NDC 45802026937
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.83 |
| Max. Negotiated Rate |
$290.12 |
| Rate for Payer: Aetna American Axle |
$209.53
|
| Rate for Payer: Aetna Commercial |
$274.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.53
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$225.65
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$290.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: PHP Commercial |
$274.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: Priority Health SBD |
$203.08
|
| Rate for Payer: UMR Bronson Commercial |
$141.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.76
|
|
|
PERPHENAZINE 2 MG TABLET
|
Facility
|
OP
|
$301.15
|
|
|
Service Code
|
NDC 52536016201
|
| Hospital Charge Code |
6157
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.43 |
| Max. Negotiated Rate |
$271.04 |
| Rate for Payer: Aetna American Axle |
$195.75
|
| Rate for Payer: Aetna Commercial |
$255.98
|
| Rate for Payer: Aetna Medicare |
$150.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.75
|
| Rate for Payer: BCBS Complete |
$120.46
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Commercial |
$210.81
|
| Rate for Payer: Cofinity Commercial |
$258.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.92
|
| Rate for Payer: Healthscope Commercial |
$271.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: PHP Commercial |
$255.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.75
|
| Rate for Payer: Priority Health SBD |
$189.72
|
| Rate for Payer: UMR Bronson Commercial |
$111.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.86
|
|
|
PERPHENAZINE 2 MG TABLET
|
Facility
|
IP
|
$301.15
|
|
|
Service Code
|
NDC 52536016201
|
| Hospital Charge Code |
6157
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.51 |
| Max. Negotiated Rate |
$271.04 |
| Rate for Payer: Aetna American Axle |
$195.75
|
| Rate for Payer: Aetna Commercial |
$255.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.75
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Commercial |
$210.81
|
| Rate for Payer: Cofinity Commercial |
$258.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.92
|
| Rate for Payer: Healthscope Commercial |
$271.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: PHP Commercial |
$255.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.75
|
| Rate for Payer: Priority Health SBD |
$189.72
|
| Rate for Payer: UMR Bronson Commercial |
$132.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.86
|
|
|
PERPHENAZINE 2 MG TABLET
|
Facility
|
OP
|
$201.40
|
|
|
Service Code
|
NDC 00603506021
|
| Hospital Charge Code |
6157
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.52 |
| Max. Negotiated Rate |
$181.26 |
| Rate for Payer: Aetna American Axle |
$130.91
|
| Rate for Payer: Aetna Commercial |
$171.19
|
| Rate for Payer: Aetna Medicare |
$100.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.91
|
| Rate for Payer: BCBS Complete |
$80.56
|
| Rate for Payer: Cash Price |
$161.12
|
| Rate for Payer: Cofinity Commercial |
$140.98
|
| Rate for Payer: Cofinity Commercial |
$173.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.12
|
| Rate for Payer: Healthscope Commercial |
$181.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$171.19
|
| Rate for Payer: PHP Commercial |
$171.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.91
|
| Rate for Payer: Priority Health SBD |
$126.88
|
| Rate for Payer: UMR Bronson Commercial |
$74.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.05
|
|
