|
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN
|
Facility
|
OP
|
$7,785.57
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
82228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$7,007.01 |
| Rate for Payer: Aetna Commercial |
$6,617.73
|
| Rate for Payer: Aetna Medicare |
$27.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,060.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33.39
|
| Rate for Payer: BCBS Complete |
$15.03
|
| Rate for Payer: BCBS MAPPO |
$26.71
|
| Rate for Payer: BCN Medicare Advantage |
$26.71
|
| Rate for Payer: Cash Price |
$6,228.46
|
| Rate for Payer: Cash Price |
$6,228.46
|
| Rate for Payer: Cofinity Commercial |
$6,695.59
|
| Rate for Payer: Cofinity Commercial |
$5,449.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,449.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,228.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26.71
|
| Rate for Payer: Healthscope Commercial |
$7,007.01
|
| Rate for Payer: Mclaren Medicaid |
$14.32
|
| Rate for Payer: Mclaren Medicare |
$26.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.05
|
| Rate for Payer: Meridian Medicaid |
$15.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,617.73
|
| Rate for Payer: PACE Medicare |
$25.37
|
| Rate for Payer: PACE SWMI |
$26.71
|
| Rate for Payer: PHP Commercial |
$6,617.73
|
| Rate for Payer: PHP Medicare Advantage |
$26.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,060.62
|
| Rate for Payer: Priority Health Medicare |
$26.71
|
| Rate for Payer: Priority Health SBD |
$4,904.91
|
| Rate for Payer: Railroad Medicare Medicare |
$26.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$26.71
|
| Rate for Payer: UHC Medicare Advantage |
$26.71
|
| Rate for Payer: UHCCP Medicaid |
$15.04
|
| Rate for Payer: VA VA |
$26.71
|
|
|
TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 26055
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$878.76
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 25310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29,932.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,857.40 |
| Max. Negotiated Rate |
$26,939.14 |
| Rate for Payer: Aetna Commercial |
$25,442.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,456.05
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cofinity Commercial |
$20,952.67
|
| Rate for Payer: Cofinity Commercial |
$25,741.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,952.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,945.90
|
| Rate for Payer: Healthscope Commercial |
$26,939.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,442.52
|
| Rate for Payer: PHP Commercial |
$25,442.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,456.05
|
| Rate for Payer: Priority Health SBD |
$18,857.40
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,932.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.31 |
| Max. Negotiated Rate |
$26,939.14 |
| Rate for Payer: Aetna Commercial |
$25,442.52
|
| Rate for Payer: Aetna Medicare |
$179.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,456.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$215.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$215.28
|
| Rate for Payer: BCBS Complete |
$96.93
|
| Rate for Payer: BCBS MAPPO |
$172.22
|
| Rate for Payer: BCN Medicare Advantage |
$172.22
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cofinity Commercial |
$20,952.67
|
| Rate for Payer: Cofinity Commercial |
$25,741.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,952.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,945.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$172.22
|
| Rate for Payer: Healthscope Commercial |
$26,939.14
|
| Rate for Payer: Mclaren Medicaid |
$92.31
|
| Rate for Payer: Mclaren Medicare |
$172.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$180.83
|
| Rate for Payer: Meridian Medicaid |
$96.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$198.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,442.52
|
| Rate for Payer: PACE Medicare |
$163.61
|
| Rate for Payer: PACE SWMI |
$172.22
|
| Rate for Payer: PHP Commercial |
$25,442.52
|
| Rate for Payer: PHP Medicare Advantage |
$172.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,456.05
|
| Rate for Payer: Priority Health Medicare |
$172.22
|
| Rate for Payer: Priority Health SBD |
$18,857.40
|
| Rate for Payer: Railroad Medicare Medicare |
$172.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$484.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$172.22
|
| Rate for Payer: UHC Medicare Advantage |
$172.22
|
| Rate for Payer: UHCCP Medicaid |
$96.96
|
| Rate for Payer: VA VA |
$172.22
|
|
|
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 24340
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,922.50
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
TENODESIS OF LONG TENDON OF BICEPS
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 23430
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,922.50
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 27680
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 24358
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 24359
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 28234
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$878.76
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 25290
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 28232
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$878.76
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$44,245.82
|
|
|
Service Code
|
HCPCS J3241
|
| Hospital Charge Code |
192660
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.53 |
| Max. Negotiated Rate |
$39,821.24 |
| Rate for Payer: Aetna Commercial |
$37,608.95
|
| Rate for Payer: Aetna Medicare |
$373.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28,759.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$448.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$448.99
|
| Rate for Payer: BCBS Complete |
$202.15
|
| Rate for Payer: BCBS MAPPO |
$359.19
|
| Rate for Payer: BCN Medicare Advantage |
$359.19
|
| Rate for Payer: Cash Price |
$35,396.66
|
| Rate for Payer: Cash Price |
$35,396.66
|
| Rate for Payer: Cofinity Commercial |
$38,051.41
|
| Rate for Payer: Cofinity Commercial |
$30,972.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$30,972.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35,396.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$359.19
|
| Rate for Payer: Healthscope Commercial |
$39,821.24
|
| Rate for Payer: Mclaren Medicaid |
$192.53
|
| Rate for Payer: Mclaren Medicare |
$359.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$377.15
|
| Rate for Payer: Meridian Medicaid |
$202.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$413.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37,608.95
|
| Rate for Payer: PACE Medicare |
$341.23
|
| Rate for Payer: PACE SWMI |
$359.19
|
| Rate for Payer: PHP Commercial |
$37,608.95
|
| Rate for Payer: PHP Medicare Advantage |
$359.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$192.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28,759.78
|
| Rate for Payer: Priority Health Medicare |
$359.19
|
| Rate for Payer: Priority Health SBD |
$27,874.87
|
| Rate for Payer: Railroad Medicare Medicare |
$359.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,011.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$359.19
|
| Rate for Payer: UHC Medicare Advantage |
$359.19
|
| Rate for Payer: UHCCP Medicaid |
$202.22
|
| Rate for Payer: VA VA |
$359.19
|
|
|
TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$44,245.82
|
|
|
Service Code
|
HCPCS J3241
|
| Hospital Charge Code |
192660
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27,874.87 |
| Max. Negotiated Rate |
$39,821.24 |
| Rate for Payer: Aetna Commercial |
$37,608.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28,759.78
|
| Rate for Payer: Cash Price |
$35,396.66
|
| Rate for Payer: Cofinity Commercial |
$30,972.07
|
| Rate for Payer: Cofinity Commercial |
$38,051.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$30,972.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35,396.66
|
| Rate for Payer: Healthscope Commercial |
$39,821.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37,608.95
|
| Rate for Payer: PHP Commercial |
$37,608.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28,759.78
|
| Rate for Payer: Priority Health SBD |
$27,874.87
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$21.32
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$19.19 |
| Rate for Payer: Aetna Commercial |
$18.12
|
| Rate for Payer: Aetna Commercial |
$14.37
|
| Rate for Payer: Aetna Medicare |
$8.46
|
| Rate for Payer: Aetna Medicare |
$10.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.99
|
| Rate for Payer: BCBS Complete |
$8.53
|
| Rate for Payer: BCBS Complete |
$6.76
|
| Rate for Payer: Cash Price |
$17.06
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$14.54
|
| Rate for Payer: Cofinity Commercial |
$14.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.06
|
| Rate for Payer: Healthscope Commercial |
$19.19
|
| Rate for Payer: Healthscope Commercial |
$15.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.37
|
| Rate for Payer: PHP Commercial |
$18.12
|
| Rate for Payer: PHP Commercial |
$14.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.86
|
| Rate for Payer: Priority Health SBD |
$10.65
|
| Rate for Payer: Priority Health SBD |
$13.43
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$16.91
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
11507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna Commercial |
$14.37
|
| Rate for Payer: Aetna Commercial |
$18.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.86
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cash Price |
$17.06
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$14.92
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$14.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.06
|
| Rate for Payer: Healthscope Commercial |
$15.22
|
| Rate for Payer: Healthscope Commercial |
$19.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.12
|
| Rate for Payer: PHP Commercial |
$14.37
|
| Rate for Payer: PHP Commercial |
$18.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.99
|
| Rate for Payer: Priority Health SBD |
$13.43
|
| Rate for Payer: Priority Health SBD |
$10.65
|
|
|
TERCONAZOLE 0.8 % VAGINAL CREAM
|
Facility
|
OP
|
$117.25
|
|
|
Service Code
|
NDC 51672130200
|
| Hospital Charge Code |
11511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.90 |
| Max. Negotiated Rate |
$105.53 |
| Rate for Payer: Aetna Commercial |
$99.66
|
| Rate for Payer: Aetna Medicare |
$58.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.21
|
| Rate for Payer: BCBS Complete |
$46.90
|
| Rate for Payer: Cash Price |
$93.80
|
| Rate for Payer: Cofinity Commercial |
$100.83
|
| Rate for Payer: Cofinity Commercial |
$82.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$82.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.80
|
| Rate for Payer: Healthscope Commercial |
$105.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.66
|
| Rate for Payer: PHP Commercial |
$99.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.21
|
| Rate for Payer: Priority Health SBD |
$73.87
|
|
|
TERCONAZOLE 0.8 % VAGINAL CREAM
|
Facility
|
IP
|
$117.25
|
|
|
Service Code
|
NDC 51672130200
|
| Hospital Charge Code |
11511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.87 |
| Max. Negotiated Rate |
$105.53 |
| Rate for Payer: Aetna Commercial |
$99.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.21
|
| Rate for Payer: Cash Price |
$93.80
|
| Rate for Payer: Cofinity Commercial |
$100.83
|
| Rate for Payer: Cofinity Commercial |
$82.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$82.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.80
|
| Rate for Payer: Healthscope Commercial |
$105.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.66
|
| Rate for Payer: PHP Commercial |
$99.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.21
|
| Rate for Payer: Priority Health SBD |
$73.87
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$88.05
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.47 |
| Max. Negotiated Rate |
$79.25 |
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna Commercial |
$93.84
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.47
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cofinity Commercial |
$77.28
|
| Rate for Payer: Cofinity Commercial |
$94.94
|
| Rate for Payer: Cofinity Commercial |
$61.63
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Commercial |
$68.36
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Healthscope Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$79.25
|
| Rate for Payer: Healthscope Commercial |
$87.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: PHP Commercial |
$93.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health SBD |
$61.52
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: Priority Health SBD |
$69.55
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$110.40
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.16 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$93.84
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna Medicare |
$48.83
|
| Rate for Payer: Aetna Medicare |
$55.20
|
| Rate for Payer: Aetna Medicare |
$44.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: BCBS Complete |
$35.22
|
| Rate for Payer: BCBS Complete |
$44.16
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Cofinity Commercial |
$94.94
|
| Rate for Payer: Cofinity Commercial |
$77.28
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Commercial |
$61.63
|
| Rate for Payer: Cofinity Commercial |
$68.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Healthscope Commercial |
$79.25
|
| Rate for Payer: Healthscope Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$87.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: PHP Commercial |
$93.84
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.23
|
| Rate for Payer: Priority Health SBD |
$61.52
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: Priority Health SBD |
$69.55
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$1,678.15
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,057.23 |
| Max. Negotiated Rate |
$1,510.34 |
| Rate for Payer: Aetna Commercial |
$1,426.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,090.80
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,174.70
|
| Rate for Payer: Cofinity Commercial |
$1,443.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,174.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.52
|
| Rate for Payer: Healthscope Commercial |
$1,510.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.43
|
| Rate for Payer: PHP Commercial |
$1,426.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.80
|
| Rate for Payer: Priority Health SBD |
$1,057.23
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$1,678.15
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.85 |
| Max. Negotiated Rate |
$1,669.24 |
| Rate for Payer: Aetna Commercial |
$1,426.43
|
| Rate for Payer: Aetna Medicare |
$616.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,090.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$741.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$741.25
|
| Rate for Payer: BCBS Complete |
$333.74
|
| Rate for Payer: BCBS MAPPO |
$593.00
|
| Rate for Payer: BCN Medicare Advantage |
$593.00
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,443.21
|
| Rate for Payer: Cofinity Commercial |
$1,174.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,174.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$593.00
|
| Rate for Payer: Healthscope Commercial |
$1,510.34
|
| Rate for Payer: Mclaren Medicaid |
$317.85
|
| Rate for Payer: Mclaren Medicare |
$593.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$622.65
|
| Rate for Payer: Meridian Medicaid |
$333.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$681.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.43
|
| Rate for Payer: PACE Medicare |
$563.35
|
| Rate for Payer: PACE SWMI |
$593.00
|
| Rate for Payer: PHP Commercial |
$1,426.43
|
| Rate for Payer: PHP Medicare Advantage |
$593.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$317.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.80
|
| Rate for Payer: Priority Health Medicare |
$593.00
|
| Rate for Payer: Priority Health SBD |
$1,057.23
|
| Rate for Payer: Railroad Medicare Medicare |
$593.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,669.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$593.00
|
| Rate for Payer: UHC Medicare Advantage |
$593.00
|
| Rate for Payer: UHCCP Medicaid |
$333.86
|
| Rate for Payer: VA VA |
$593.00
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
OP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$34.42 |
| Rate for Payer: Aetna Commercial |
$32.51
|
| Rate for Payer: Aetna Medicare |
$19.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.86
|
| Rate for Payer: BCBS Complete |
$15.30
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Cofinity Commercial |
$26.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$34.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: PHP Commercial |
$32.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health SBD |
$24.10
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
IP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$34.42 |
| Rate for Payer: Aetna Commercial |
$32.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.86
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$26.77
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$34.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: PHP Commercial |
$32.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health SBD |
$24.10
|
|
