|
PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$13,605.01
|
|
|
Service Code
|
CPT 22515
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$210.92 |
| Max. Negotiated Rate |
$13,605.01 |
| Rate for Payer: BCBS Trust/PPO |
$13,605.01
|
| Rate for Payer: BCN Commercial |
$13,605.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$232.01
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$210.92
|
|
|
PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR
|
Facility
|
OP
|
$21,998.64
|
|
|
Service Code
|
CPT 22514
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$459.14 |
| Max. Negotiated Rate |
$21,998.64 |
| Rate for Payer: Aetna Medicare |
$7,279.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,749.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,749.10
|
| Rate for Payer: BCBS Complete |
$3,939.19
|
| Rate for Payer: BCBS MAPPO |
$6,999.28
|
| Rate for Payer: BCBS Trust/PPO |
$6,636.14
|
| Rate for Payer: BCN Commercial |
$6,636.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,999.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,999.28
|
| Rate for Payer: Mclaren Medicaid |
$3,751.61
|
| Rate for Payer: Mclaren Medicare |
$6,999.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,349.24
|
| Rate for Payer: Meridian Medicaid |
$3,939.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,049.17
|
| Rate for Payer: Nomi Health Commercial |
$14,698.49
|
| Rate for Payer: PACE Medicare |
$6,649.32
|
| Rate for Payer: PACE SWMI |
$6,999.28
|
| Rate for Payer: PHP Medicare Advantage |
$6,999.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,751.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,998.64
|
| Rate for Payer: Priority Health Medicare |
$6,999.28
|
| Rate for Payer: Priority Health Narrow Network |
$17,598.91
|
| Rate for Payer: Railroad Medicare Medicare |
$6,999.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$505.05
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,999.28
|
| Rate for Payer: UHC Exchange |
$459.14
|
| Rate for Payer: UHC Medicare Advantage |
$6,999.28
|
| Rate for Payer: UHCCP Medicaid |
$3,751.61
|
| Rate for Payer: VA VA |
$6,999.28
|
|
|
PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC
|
Facility
|
OP
|
$21,998.64
|
|
|
Service Code
|
CPT 22513
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.91 |
| Max. Negotiated Rate |
$21,998.64 |
| Rate for Payer: Aetna Medicare |
$7,279.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,749.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,749.10
|
| Rate for Payer: BCBS Complete |
$3,939.19
|
| Rate for Payer: BCBS MAPPO |
$6,999.28
|
| Rate for Payer: BCBS Trust/PPO |
$6,551.85
|
| Rate for Payer: BCN Commercial |
$6,551.85
|
| Rate for Payer: BCN Medicare Advantage |
$6,999.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,999.28
|
| Rate for Payer: Mclaren Medicaid |
$3,751.61
|
| Rate for Payer: Mclaren Medicare |
$6,999.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,349.24
|
| Rate for Payer: Meridian Medicaid |
$3,939.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,049.17
|
| Rate for Payer: Nomi Health Commercial |
$14,698.49
|
| Rate for Payer: PACE Medicare |
$6,649.32
|
| Rate for Payer: PACE SWMI |
$6,999.28
|
| Rate for Payer: PHP Medicare Advantage |
$6,999.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,751.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,998.64
|
| Rate for Payer: Priority Health Medicare |
$6,999.28
|
| Rate for Payer: Priority Health Narrow Network |
$17,598.91
|
| Rate for Payer: Railroad Medicare Medicare |
$6,999.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$542.20
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,999.28
|
| Rate for Payer: UHC Exchange |
$492.91
|
| Rate for Payer: UHC Medicare Advantage |
$6,999.28
|
| Rate for Payer: UHCCP Medicaid |
$3,751.61
|
| Rate for Payer: VA VA |
$6,999.28
|
|
|
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION
|
Facility
|
OP
|
$54.70
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
31270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.70 |
| Max. Negotiated Rate |
$54.70 |
| Rate for Payer: BCBS Trust/PPO |
$54.70
|
| Rate for Payer: BCN Commercial |
$54.70
|
|
|
PERFLUTREN LIPID MICROSPHERES (DILUTED) INTRAVENOUS SUSP
|
Facility
|
OP
|
$54.70
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
180013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.70 |
| Max. Negotiated Rate |
$54.70 |
| Rate for Payer: BCBS Trust/PPO |
$54.70
|
| Rate for Payer: BCN Commercial |
$54.70
|
|
|
PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS
|
Facility
|
OP
|
$11,792.02
|
|
|
Service Code
|
CPT 19371
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$684.30 |
| Max. Negotiated Rate |
$11,792.02 |
| Rate for Payer: Aetna Medicare |
$3,901.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,689.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,689.81
|
| Rate for Payer: BCBS Complete |
$2,111.54
|
| Rate for Payer: BCBS MAPPO |
$3,751.85
|
| Rate for Payer: BCBS Trust/PPO |
$5,355.21
|
| Rate for Payer: BCN Commercial |
$5,355.21
|
| Rate for Payer: BCN Medicare Advantage |
$3,751.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,751.85
|
| Rate for Payer: Mclaren Medicaid |
$2,010.99
|
| Rate for Payer: Mclaren Medicare |
$3,751.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,939.44
|
| Rate for Payer: Meridian Medicaid |
$2,111.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,314.63
|
| Rate for Payer: Nomi Health Commercial |
$7,878.88
|
| Rate for Payer: PACE Medicare |
$3,564.26
|
| Rate for Payer: PACE SWMI |
$3,751.85
|
| Rate for Payer: PHP Medicare Advantage |
$3,751.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,010.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,792.02
|
| Rate for Payer: Priority Health Medicare |
$3,751.85
|
| Rate for Payer: Priority Health Narrow Network |
$9,433.62
|
| Rate for Payer: Railroad Medicare Medicare |
$3,751.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$752.73
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,751.85
|
| Rate for Payer: UHC Exchange |
$684.30
|
| Rate for Payer: UHC Medicare Advantage |
$3,751.85
|
| Rate for Payer: UHCCP Medicaid |
$2,010.99
|
| Rate for Payer: VA VA |
$3,751.85
|
|
|
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
|
$9,791.14
|
|
|
Service Code
|
CPT 56810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$264.99 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,660.74
|
| Rate for Payer: BCN Commercial |
$1,660.74
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$291.49
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$264.99
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,669.77
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
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
|
$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 |
$59.32
|
| 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
|
|
|
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
|
$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: 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: 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: 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 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 |
$6.76
|
| 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 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 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
|
|
|
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 |
$59.32
|
| 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
|
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
|
$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
|
|
|
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 |
$35.68 |
| 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 |
$27.76
|
| Rate for Payer: Cofinity Commercial |
$34.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.72
|
| Rate for Payer: Healthscope Commercial |
$35.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.76
|
| 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 |
$35.68 |
| 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 |
$27.76
|
| Rate for Payer: Cofinity Commercial |
$34.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.72
|
| Rate for Payer: Healthscope Commercial |
$35.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.76
|
| 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
|
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 |
$225.64
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.64
|
| 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 |
$225.64
|
| 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
|
$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 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 |
$225.64
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.64
|
| 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 |
$225.64
|
| 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
|
|
