|
PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE; SINGLE LAYER, SUTURED
|
Facility
|
OP
|
$10,352.58
|
|
|
Service Code
|
CPT 65779
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,971.29 |
| Max. Negotiated Rate |
$10,352.58 |
| Rate for Payer: Aetna Medicare |
$3,824.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,597.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,597.23
|
| Rate for Payer: BCBS Complete |
$2,069.85
|
| Rate for Payer: BCBS MAPPO |
$3,677.78
|
| Rate for Payer: BCN Medicare Advantage |
$3,677.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,677.78
|
| Rate for Payer: Mclaren Medicaid |
$1,971.29
|
| Rate for Payer: Mclaren Medicare |
$3,677.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,861.67
|
| Rate for Payer: Meridian Medicaid |
$2,069.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,229.45
|
| Rate for Payer: PACE Medicare |
$3,493.89
|
| Rate for Payer: PACE SWMI |
$3,677.78
|
| Rate for Payer: PHP Medicare Advantage |
$3,677.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,971.29
|
| Rate for Payer: Priority Health Medicare |
$3,677.78
|
| Rate for Payer: Railroad Medicare Medicare |
$3,677.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,352.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,677.78
|
| Rate for Payer: UHC Exchange |
$7,028.61
|
| Rate for Payer: UHC Medicare Advantage |
$3,677.78
|
| Rate for Payer: UHCCP Medicaid |
$1,971.29
|
| Rate for Payer: VA VA |
$3,677.78
|
|
|
PLACEMENT OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; INTERNAL-EXTERNAL
|
Facility
|
OP
|
$9,688.38
|
|
|
Service Code
|
CPT 47534
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,844.82 |
| Max. Negotiated Rate |
$9,688.38 |
| Rate for Payer: Aetna Medicare |
$3,579.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,302.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,302.27
|
| Rate for Payer: BCBS Complete |
$1,937.06
|
| Rate for Payer: BCBS MAPPO |
$3,441.82
|
| Rate for Payer: BCN Medicare Advantage |
$3,441.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,441.82
|
| Rate for Payer: Mclaren Medicaid |
$1,844.82
|
| Rate for Payer: Mclaren Medicare |
$3,441.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,613.91
|
| Rate for Payer: Meridian Medicaid |
$1,937.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,958.09
|
| Rate for Payer: PACE Medicare |
$3,269.73
|
| Rate for Payer: PACE SWMI |
$3,441.82
|
| Rate for Payer: PHP Medicare Advantage |
$3,441.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,844.82
|
| Rate for Payer: Priority Health Medicare |
$3,441.82
|
| Rate for Payer: Railroad Medicare Medicare |
$3,441.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,688.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,441.82
|
| Rate for Payer: UHC Exchange |
$6,577.66
|
| Rate for Payer: UHC Medicare Advantage |
$3,441.82
|
| Rate for Payer: UHCCP Medicaid |
$1,844.82
|
| Rate for Payer: VA VA |
$3,441.82
|
|
|
PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE
|
Facility
|
OP
|
$4,448.08
|
|
|
Service Code
|
CPT 19281
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$846.98 |
| Max. Negotiated Rate |
$4,448.08 |
| Rate for Payer: Aetna Medicare |
$1,643.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,975.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,975.24
|
| Rate for Payer: BCBS Complete |
$889.33
|
| Rate for Payer: BCBS MAPPO |
$1,580.19
|
| Rate for Payer: BCN Medicare Advantage |
$1,580.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,580.19
|
| Rate for Payer: Mclaren Medicaid |
$846.98
|
| Rate for Payer: Mclaren Medicare |
$1,580.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,659.20
|
| Rate for Payer: Meridian Medicaid |
$889.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,817.22
|
| Rate for Payer: PACE Medicare |
$1,501.18
|
| Rate for Payer: PACE SWMI |
$1,580.19
|
| Rate for Payer: PHP Medicare Advantage |
$1,580.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$846.98
|
| Rate for Payer: Priority Health Medicare |
$1,580.19
|
| Rate for Payer: Railroad Medicare Medicare |
$1,580.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,448.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,580.19
|
| Rate for Payer: UHC Exchange |
$3,019.90
|
| Rate for Payer: UHC Medicare Advantage |
$1,580.19
|
| Rate for Payer: UHCCP Medicaid |
$846.98
|
| Rate for Payer: VA VA |
$1,580.19
|
|
|
PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PERCUTANEOUS, INTRA-ABDOMINAL, INTRA-PELVIC (EXCEPT PROSTATE), AND/OR RETROPERITONEUM, SINGLE OR MULTIPLE
|
Facility
|
OP
|
$3,756.32
|
|
|
Service Code
|
CPT 49411
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$715.26 |
| Max. Negotiated Rate |
$3,756.32 |
| Rate for Payer: Aetna Medicare |
$1,387.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,668.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,668.05
|
| Rate for Payer: BCBS Complete |
$751.02
|
| Rate for Payer: BCBS MAPPO |
$1,334.44
|
| Rate for Payer: BCN Medicare Advantage |
$1,334.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,334.44
|
| Rate for Payer: Mclaren Medicaid |
$715.26
|
| Rate for Payer: Mclaren Medicare |
$1,334.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,401.16
|
| Rate for Payer: Meridian Medicaid |
$751.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,534.61
|
| Rate for Payer: PACE Medicare |
$1,267.72
|
| Rate for Payer: PACE SWMI |
$1,334.44
|
| Rate for Payer: PHP Medicare Advantage |
$1,334.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$715.26
|
| Rate for Payer: Priority Health Medicare |
$1,334.44
|
| Rate for Payer: Railroad Medicare Medicare |
$1,334.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,756.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,334.44
|
| Rate for Payer: UHC Exchange |
$2,550.25
|
| Rate for Payer: UHC Medicare Advantage |
$1,334.44
|
| Rate for Payer: UHCCP Medicaid |
$715.26
|
| Rate for Payer: VA VA |
$1,334.44
|
|
|
PLACEMENT OF NEPHROURETERAL CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, NEW ACCESS
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 50433
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.95 |
| Max. Negotiated Rate |
$9,468.51 |
| Rate for Payer: Aetna Medicare |
$3,498.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,204.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,204.64
|
| Rate for Payer: BCBS Complete |
$1,893.10
|
| Rate for Payer: BCBS MAPPO |
$3,363.71
|
| Rate for Payer: BCN Medicare Advantage |
$3,363.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,363.71
|
| Rate for Payer: Mclaren Medicaid |
$1,802.95
|
| Rate for Payer: Mclaren Medicare |
$3,363.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,531.90
|
| Rate for Payer: Meridian Medicaid |
$1,893.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,868.27
|
| Rate for Payer: PACE Medicare |
$3,195.52
|
| Rate for Payer: PACE SWMI |
$3,363.71
|
| Rate for Payer: PHP Medicare Advantage |
$3,363.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,802.95
|
| Rate for Payer: Priority Health Medicare |
$3,363.71
|
| Rate for Payer: Railroad Medicare Medicare |
$3,363.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,468.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,363.71
|
| Rate for Payer: UHC Exchange |
$6,428.39
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,802.95
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
PLACEMENT OF SETON
|
Facility
|
OP
|
$7,528.73
|
|
|
Service Code
|
CPT 46020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,433.59 |
| Max. Negotiated Rate |
$7,528.73 |
| Rate for Payer: Aetna Medicare |
$2,781.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,343.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,343.25
|
| Rate for Payer: BCBS Complete |
$1,505.26
|
| Rate for Payer: BCBS MAPPO |
$2,674.60
|
| Rate for Payer: BCN Medicare Advantage |
$2,674.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,674.60
|
| Rate for Payer: Mclaren Medicaid |
$1,433.59
|
| Rate for Payer: Mclaren Medicare |
$2,674.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,808.33
|
| Rate for Payer: Meridian Medicaid |
$1,505.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,075.79
|
| Rate for Payer: PACE Medicare |
$2,540.87
|
| Rate for Payer: PACE SWMI |
$2,674.60
|
| Rate for Payer: PHP Medicare Advantage |
$2,674.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,433.59
|
| Rate for Payer: Priority Health Medicare |
$2,674.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,674.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7,528.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,674.60
|
| Rate for Payer: UHC Exchange |
$5,111.43
|
| Rate for Payer: UHC Medicare Advantage |
$2,674.60
|
| Rate for Payer: UHCCP Medicaid |
$1,433.59
|
| Rate for Payer: VA VA |
$2,674.60
|
|
|
PLASMALYTE A 1 L/HEPARIN 30000UNIT IRRIGATION
|
Facility
|
OP
|
$35.43
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
500532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$31.89 |
| Rate for Payer: Aetna American Axle |
$23.03
|
| Rate for Payer: Aetna Commercial |
$30.12
|
| Rate for Payer: Aetna Medicare |
$17.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.03
|
| Rate for Payer: BCBS Complete |
$14.17
|
| Rate for Payer: Cash Price |
$28.34
|
| Rate for Payer: Cofinity Commercial |
$24.80
|
| Rate for Payer: Cofinity Commercial |
$30.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.34
|
| Rate for Payer: Healthscope Commercial |
$31.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.12
|
| Rate for Payer: PHP Commercial |
$30.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.03
|
| Rate for Payer: Priority Health SBD |
$22.32
|
| Rate for Payer: UMR Bronson Commercial |
$13.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.57
|
|
|
PLASMALYTE A 1 L/HEPARIN 30000UNIT IRRIGATION
|
Facility
|
IP
|
$35.43
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
500532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.59 |
| Max. Negotiated Rate |
$31.89 |
| Rate for Payer: Aetna American Axle |
$23.03
|
| Rate for Payer: Aetna Commercial |
$30.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.03
|
| Rate for Payer: Cash Price |
$28.34
|
| Rate for Payer: Cofinity Commercial |
$24.80
|
| Rate for Payer: Cofinity Commercial |
$30.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.34
|
| Rate for Payer: Healthscope Commercial |
$31.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.12
|
| Rate for Payer: PHP Commercial |
$30.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.03
|
| Rate for Payer: Priority Health SBD |
$22.32
|
| Rate for Payer: UMR Bronson Commercial |
$15.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.57
|
|
|
PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 54300
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.95 |
| Max. Negotiated Rate |
$9,468.51 |
| Rate for Payer: Aetna Medicare |
$3,498.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,204.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,204.64
|
| Rate for Payer: BCBS Complete |
$1,893.10
|
| Rate for Payer: BCBS MAPPO |
$3,363.71
|
| Rate for Payer: BCN Medicare Advantage |
$3,363.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,363.71
|
| Rate for Payer: Mclaren Medicaid |
$1,802.95
|
| Rate for Payer: Mclaren Medicare |
$3,363.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,531.90
|
| Rate for Payer: Meridian Medicaid |
$1,893.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,868.27
|
| Rate for Payer: PACE Medicare |
$3,195.52
|
| Rate for Payer: PACE SWMI |
$3,363.71
|
| Rate for Payer: PHP Medicare Advantage |
$3,363.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,802.95
|
| Rate for Payer: Priority Health Medicare |
$3,363.71
|
| Rate for Payer: Railroad Medicare Medicare |
$3,363.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,468.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,363.71
|
| Rate for Payer: UHC Exchange |
$6,428.39
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,802.95
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR COMPLETE, UNILATERAL
|
Facility
|
OP
|
$16,240.34
|
|
|
Service Code
|
CPT 40700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,092.41 |
| Max. Negotiated Rate |
$16,240.34 |
| Rate for Payer: Aetna Medicare |
$6,000.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,211.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,211.77
|
| Rate for Payer: BCBS Complete |
$3,247.03
|
| Rate for Payer: BCBS MAPPO |
$5,769.42
|
| Rate for Payer: BCN Medicare Advantage |
$5,769.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,769.42
|
| Rate for Payer: Mclaren Medicaid |
$3,092.41
|
| Rate for Payer: Mclaren Medicare |
$5,769.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,057.89
|
| Rate for Payer: Meridian Medicaid |
$3,247.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,634.83
|
| Rate for Payer: PACE Medicare |
$5,480.95
|
| Rate for Payer: PACE SWMI |
$5,769.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,769.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,092.41
|
| Rate for Payer: Priority Health Medicare |
$5,769.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,769.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,240.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,769.42
|
| Rate for Payer: UHC Exchange |
$11,025.94
|
| Rate for Payer: UHC Medicare Advantage |
$5,769.42
|
| Rate for Payer: UHCCP Medicaid |
$3,092.41
|
| Rate for Payer: VA VA |
$5,769.42
|
|
|
PLASTIC REPAIR OF INTROITUS
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 56800
|
|
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
|
|
|
PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; PRIMARY OR SIMPLE
|
Facility
|
OP
|
$16,240.34
|
|
|
Service Code
|
CPT 42500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,092.41 |
| Max. Negotiated Rate |
$16,240.34 |
| Rate for Payer: Aetna Medicare |
$6,000.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,211.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,211.77
|
| Rate for Payer: BCBS Complete |
$3,247.03
|
| Rate for Payer: BCBS MAPPO |
$5,769.42
|
| Rate for Payer: BCN Medicare Advantage |
$5,769.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,769.42
|
| Rate for Payer: Mclaren Medicaid |
$3,092.41
|
| Rate for Payer: Mclaren Medicare |
$5,769.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,057.89
|
| Rate for Payer: Meridian Medicaid |
$3,247.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,634.83
|
| Rate for Payer: PACE Medicare |
$5,480.95
|
| Rate for Payer: PACE SWMI |
$5,769.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,769.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,092.41
|
| Rate for Payer: Priority Health Medicare |
$5,769.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,769.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,240.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,769.42
|
| Rate for Payer: UHC Exchange |
$11,025.94
|
| Rate for Payer: UHC Medicare Advantage |
$5,769.42
|
| Rate for Payer: UHCCP Medicaid |
$3,092.41
|
| Rate for Payer: VA VA |
$5,769.42
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
IP
|
$673.24
|
|
|
Service Code
|
HCPCS 90670
|
| Hospital Charge Code |
103895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$296.23 |
| Max. Negotiated Rate |
$605.92 |
| Rate for Payer: Aetna American Axle |
$437.61
|
| Rate for Payer: Aetna Commercial |
$572.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.61
|
| Rate for Payer: Cash Price |
$538.59
|
| Rate for Payer: Cofinity Commercial |
$471.27
|
| Rate for Payer: Cofinity Commercial |
$578.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$471.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$538.59
|
| Rate for Payer: Healthscope Commercial |
$605.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$471.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$504.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$572.25
|
| Rate for Payer: PHP Commercial |
$572.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$437.61
|
| Rate for Payer: Priority Health SBD |
$424.14
|
| Rate for Payer: UMR Bronson Commercial |
$296.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$504.93
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
OP
|
$673.24
|
|
|
Service Code
|
HCPCS 90670
|
| Hospital Charge Code |
103895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$249.10 |
| Max. Negotiated Rate |
$605.92 |
| Rate for Payer: Aetna American Axle |
$437.61
|
| Rate for Payer: Aetna American Axle |
$451.28
|
| Rate for Payer: Aetna Commercial |
$572.25
|
| Rate for Payer: Aetna Commercial |
$590.14
|
| Rate for Payer: Aetna Medicare |
$336.62
|
| Rate for Payer: Aetna Medicare |
$347.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$451.28
|
| Rate for Payer: BCBS Complete |
$269.30
|
| Rate for Payer: BCBS Complete |
$277.71
|
| Rate for Payer: Cash Price |
$538.59
|
| Rate for Payer: Cash Price |
$555.42
|
| Rate for Payer: Cofinity Commercial |
$578.99
|
| Rate for Payer: Cofinity Commercial |
$471.27
|
| Rate for Payer: Cofinity Commercial |
$597.08
|
| Rate for Payer: Cofinity Commercial |
$486.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$471.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$486.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$555.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$538.59
|
| Rate for Payer: Healthscope Commercial |
$605.92
|
| Rate for Payer: Healthscope Commercial |
$624.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$471.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$486.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$520.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$504.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$590.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$572.25
|
| Rate for Payer: PHP Commercial |
$590.14
|
| Rate for Payer: PHP Commercial |
$572.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$437.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$451.28
|
| Rate for Payer: Priority Health SBD |
$437.40
|
| Rate for Payer: Priority Health SBD |
$424.14
|
| Rate for Payer: UMR Bronson Commercial |
$249.10
|
| Rate for Payer: UMR Bronson Commercial |
$256.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$504.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$520.71
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
OP
|
$777.63
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
197781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$287.72 |
| Max. Negotiated Rate |
$699.87 |
| Rate for Payer: Aetna American Axle |
$505.46
|
| Rate for Payer: Aetna American Axle |
$521.29
|
| Rate for Payer: Aetna Commercial |
$660.99
|
| Rate for Payer: Aetna Commercial |
$681.69
|
| Rate for Payer: Aetna Medicare |
$388.81
|
| Rate for Payer: Aetna Medicare |
$401.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$521.29
|
| Rate for Payer: BCBS Complete |
$320.80
|
| Rate for Payer: BCBS Complete |
$311.05
|
| Rate for Payer: Cash Price |
$622.10
|
| Rate for Payer: Cash Price |
$641.59
|
| Rate for Payer: Cofinity Commercial |
$668.76
|
| Rate for Payer: Cofinity Commercial |
$544.34
|
| Rate for Payer: Cofinity Commercial |
$561.39
|
| Rate for Payer: Cofinity Commercial |
$689.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$561.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$544.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$641.59
|
| Rate for Payer: Healthscope Commercial |
$721.79
|
| Rate for Payer: Healthscope Commercial |
$699.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$561.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$601.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$660.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$681.69
|
| Rate for Payer: PHP Commercial |
$681.69
|
| Rate for Payer: PHP Commercial |
$660.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$505.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$521.29
|
| Rate for Payer: Priority Health SBD |
$505.25
|
| Rate for Payer: Priority Health SBD |
$489.91
|
| Rate for Payer: UMR Bronson Commercial |
$287.72
|
| Rate for Payer: UMR Bronson Commercial |
$296.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$601.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.22
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
IP
|
$777.63
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
197781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$342.16 |
| Max. Negotiated Rate |
$699.87 |
| Rate for Payer: Aetna American Axle |
$505.46
|
| Rate for Payer: Aetna American Axle |
$521.29
|
| Rate for Payer: Aetna Commercial |
$660.99
|
| Rate for Payer: Aetna Commercial |
$681.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$521.29
|
| Rate for Payer: Cash Price |
$622.10
|
| Rate for Payer: Cash Price |
$641.59
|
| Rate for Payer: Cofinity Commercial |
$689.71
|
| Rate for Payer: Cofinity Commercial |
$561.39
|
| Rate for Payer: Cofinity Commercial |
$544.34
|
| Rate for Payer: Cofinity Commercial |
$668.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$544.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$561.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$641.59
|
| Rate for Payer: Healthscope Commercial |
$699.87
|
| Rate for Payer: Healthscope Commercial |
$721.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$561.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$601.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$681.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$660.99
|
| Rate for Payer: PHP Commercial |
$681.69
|
| Rate for Payer: PHP Commercial |
$660.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$505.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$521.29
|
| Rate for Payer: Priority Health SBD |
$489.91
|
| Rate for Payer: Priority Health SBD |
$505.25
|
| Rate for Payer: UMR Bronson Commercial |
$342.16
|
| Rate for Payer: UMR Bronson Commercial |
$352.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$601.49
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$83,565.24
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
190691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.26 |
| Max. Negotiated Rate |
$75,208.72 |
| Rate for Payer: Aetna American Axle |
$54,317.41
|
| Rate for Payer: Aetna Commercial |
$71,030.45
|
| Rate for Payer: Aetna Medicare |
$142.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54,317.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$170.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$170.84
|
| Rate for Payer: BCBS Complete |
$76.92
|
| Rate for Payer: BCBS MAPPO |
$136.67
|
| Rate for Payer: BCN Medicare Advantage |
$136.67
|
| Rate for Payer: Cash Price |
$66,852.19
|
| Rate for Payer: Cash Price |
$66,852.19
|
| Rate for Payer: Cofinity Commercial |
$71,866.11
|
| Rate for Payer: Cofinity Commercial |
$58,495.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$58,495.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66,852.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$136.67
|
| Rate for Payer: Healthscope Commercial |
$75,208.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58,495.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62,673.93
|
| Rate for Payer: Mclaren Medicaid |
$73.26
|
| Rate for Payer: Mclaren Medicare |
$136.67
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$143.50
|
| Rate for Payer: Meridian Medicaid |
$76.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71,030.45
|
| Rate for Payer: PACE Medicare |
$129.84
|
| Rate for Payer: PACE SWMI |
$136.67
|
| Rate for Payer: PHP Commercial |
$71,030.45
|
| Rate for Payer: PHP Medicare Advantage |
$136.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$73.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54,317.41
|
| Rate for Payer: Priority Health Medicare |
$136.67
|
| Rate for Payer: Priority Health SBD |
$52,646.10
|
| Rate for Payer: Railroad Medicare Medicare |
$136.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$384.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$136.67
|
| Rate for Payer: UHC Exchange |
$261.19
|
| Rate for Payer: UHC Medicare Advantage |
$136.67
|
| Rate for Payer: UHCCP Medicaid |
$73.26
|
| Rate for Payer: UMR Bronson Commercial |
$30,919.14
|
| Rate for Payer: VA VA |
$136.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62,673.93
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$83,565.24
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
190691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36,768.71 |
| Max. Negotiated Rate |
$75,208.72 |
| Rate for Payer: Aetna American Axle |
$54,317.41
|
| Rate for Payer: Aetna Commercial |
$71,030.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54,317.41
|
| Rate for Payer: Cash Price |
$66,852.19
|
| Rate for Payer: Cofinity Commercial |
$58,495.67
|
| Rate for Payer: Cofinity Commercial |
$71,866.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$58,495.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66,852.19
|
| Rate for Payer: Healthscope Commercial |
$75,208.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$58,495.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62,673.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71,030.45
|
| Rate for Payer: PHP Commercial |
$71,030.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54,317.41
|
| Rate for Payer: Priority Health SBD |
$52,646.10
|
| Rate for Payer: UMR Bronson Commercial |
$36,768.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62,673.93
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$17,906.89
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.26 |
| Max. Negotiated Rate |
$16,116.20 |
| Rate for Payer: Aetna American Axle |
$11,639.48
|
| Rate for Payer: Aetna Commercial |
$15,220.86
|
| Rate for Payer: Aetna Medicare |
$142.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,639.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$170.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$170.84
|
| Rate for Payer: BCBS Complete |
$76.92
|
| Rate for Payer: BCBS MAPPO |
$136.67
|
| Rate for Payer: BCN Medicare Advantage |
$136.67
|
| Rate for Payer: Cash Price |
$14,325.51
|
| Rate for Payer: Cash Price |
$14,325.51
|
| Rate for Payer: Cofinity Commercial |
$15,399.93
|
| Rate for Payer: Cofinity Commercial |
$12,534.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,534.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,325.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$136.67
|
| Rate for Payer: Healthscope Commercial |
$16,116.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,534.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,430.17
|
| Rate for Payer: Mclaren Medicaid |
$73.26
|
| Rate for Payer: Mclaren Medicare |
$136.67
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$143.50
|
| Rate for Payer: Meridian Medicaid |
$76.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,220.86
|
| Rate for Payer: PACE Medicare |
$129.84
|
| Rate for Payer: PACE SWMI |
$136.67
|
| Rate for Payer: PHP Commercial |
$15,220.86
|
| Rate for Payer: PHP Medicare Advantage |
$136.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$73.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,639.48
|
| Rate for Payer: Priority Health Medicare |
$136.67
|
| Rate for Payer: Priority Health SBD |
$11,281.34
|
| Rate for Payer: Railroad Medicare Medicare |
$136.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$384.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$136.67
|
| Rate for Payer: UHC Exchange |
$261.19
|
| Rate for Payer: UHC Medicare Advantage |
$136.67
|
| Rate for Payer: UHCCP Medicaid |
$73.26
|
| Rate for Payer: UMR Bronson Commercial |
$6,625.55
|
| Rate for Payer: VA VA |
$136.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,430.17
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$17,906.89
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,879.03 |
| Max. Negotiated Rate |
$16,116.20 |
| Rate for Payer: Aetna American Axle |
$11,639.48
|
| Rate for Payer: Aetna Commercial |
$15,220.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,639.48
|
| Rate for Payer: Cash Price |
$14,325.51
|
| Rate for Payer: Cofinity Commercial |
$12,534.82
|
| Rate for Payer: Cofinity Commercial |
$15,399.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,534.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,325.51
|
| Rate for Payer: Healthscope Commercial |
$16,116.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,534.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13,430.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,220.86
|
| Rate for Payer: PHP Commercial |
$15,220.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,639.48
|
| Rate for Payer: Priority Health SBD |
$11,281.34
|
| Rate for Payer: UMR Bronson Commercial |
$7,879.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13,430.17
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$81.54
|
|
|
Service Code
|
NDC 67850014005
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$35.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$81.54
|
|
|
Service Code
|
NDC 67850014005
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: BCBS Complete |
$32.62
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$30.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$81.54
|
|
|
Service Code
|
NDC 67850014000
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: BCBS Complete |
$32.62
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$30.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 0.5 % (10 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$81.54
|
|
|
Service Code
|
NDC 67850014000
|
| Hospital Charge Code |
155486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$73.39 |
| Rate for Payer: Aetna American Axle |
$53.00
|
| Rate for Payer: Aetna Commercial |
$69.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.00
|
| Rate for Payer: Cash Price |
$65.23
|
| Rate for Payer: Cofinity Commercial |
$57.08
|
| Rate for Payer: Cofinity Commercial |
$70.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.23
|
| Rate for Payer: Healthscope Commercial |
$73.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.31
|
| Rate for Payer: PHP Commercial |
$69.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.00
|
| Rate for Payer: Priority Health SBD |
$51.37
|
| Rate for Payer: UMR Bronson Commercial |
$35.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.16
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna American Axle |
$60.80
|
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Commercial |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.80
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UMR Bronson Commercial |
$41.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.16
|
|
