|
UNLISTED PROCEDURE, FOREARM OR WRIST
|
Facility
|
OP
|
$658.55
|
|
|
Service Code
|
CPT 25999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$658.55 |
| Rate for Payer: Aetna Medicare |
$243.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$292.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$292.44
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: BCBS MAPPO |
$233.95
|
| Rate for Payer: BCN Medicare Advantage |
$233.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$233.95
|
| Rate for Payer: Mclaren Medicaid |
$125.40
|
| Rate for Payer: Mclaren Medicare |
$233.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$245.65
|
| Rate for Payer: Meridian Medicaid |
$131.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: PACE Medicare |
$222.25
|
| Rate for Payer: PACE SWMI |
$233.95
|
| Rate for Payer: PHP Medicare Advantage |
$233.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$125.40
|
| Rate for Payer: Priority Health Medicare |
$233.95
|
| Rate for Payer: Railroad Medicare Medicare |
$233.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$658.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$233.95
|
| Rate for Payer: UHC Medicare Advantage |
$233.95
|
| Rate for Payer: UHCCP Medicaid |
$131.71
|
| Rate for Payer: VA VA |
$233.95
|
|
|
UNLISTED PROCEDURE, LEG OR ANKLE
|
Facility
|
OP
|
$658.55
|
|
|
Service Code
|
CPT 27899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$658.55 |
| Rate for Payer: Aetna Medicare |
$243.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$292.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$292.44
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: BCBS MAPPO |
$233.95
|
| Rate for Payer: BCN Medicare Advantage |
$233.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$233.95
|
| Rate for Payer: Mclaren Medicaid |
$125.40
|
| Rate for Payer: Mclaren Medicare |
$233.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$245.65
|
| Rate for Payer: Meridian Medicaid |
$131.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: PACE Medicare |
$222.25
|
| Rate for Payer: PACE SWMI |
$233.95
|
| Rate for Payer: PHP Medicare Advantage |
$233.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$125.40
|
| Rate for Payer: Priority Health Medicare |
$233.95
|
| Rate for Payer: Railroad Medicare Medicare |
$233.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$658.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$233.95
|
| Rate for Payer: UHC Medicare Advantage |
$233.95
|
| Rate for Payer: UHCCP Medicaid |
$131.71
|
| Rate for Payer: VA VA |
$233.95
|
|
|
UNLISTED PROCEDURE, MALE GENITAL SYSTEM
|
Facility
|
OP
|
$667.69
|
|
|
Service Code
|
CPT 55899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$127.14 |
| Max. Negotiated Rate |
$667.69 |
| Rate for Payer: Aetna Medicare |
$246.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$296.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$296.50
|
| Rate for Payer: BCBS Complete |
$133.50
|
| Rate for Payer: BCBS MAPPO |
$237.20
|
| Rate for Payer: BCN Medicare Advantage |
$237.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$237.20
|
| Rate for Payer: Mclaren Medicaid |
$127.14
|
| Rate for Payer: Mclaren Medicare |
$237.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$249.06
|
| Rate for Payer: Meridian Medicaid |
$133.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$272.78
|
| Rate for Payer: PACE Medicare |
$225.34
|
| Rate for Payer: PACE SWMI |
$237.20
|
| Rate for Payer: PHP Medicare Advantage |
$237.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$127.14
|
| Rate for Payer: Priority Health Medicare |
$237.20
|
| Rate for Payer: Railroad Medicare Medicare |
$237.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$667.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$237.20
|
| Rate for Payer: UHC Medicare Advantage |
$237.20
|
| Rate for Payer: UHCCP Medicaid |
$133.54
|
| Rate for Payer: VA VA |
$237.20
|
|
|
UNLISTED PROCEDURE, NERVOUS SYSTEM
|
Facility
|
OP
|
$810.38
|
|
|
Service Code
|
CPT 64999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$154.31 |
| Max. Negotiated Rate |
$810.38 |
| Rate for Payer: Aetna Medicare |
$299.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$359.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$359.86
|
| Rate for Payer: BCBS Complete |
$162.02
|
| Rate for Payer: BCBS MAPPO |
$287.89
|
| Rate for Payer: BCN Medicare Advantage |
$287.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$287.89
|
| Rate for Payer: Mclaren Medicaid |
$154.31
|
| Rate for Payer: Mclaren Medicare |
$287.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$302.28
|
| Rate for Payer: Meridian Medicaid |
$162.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$331.07
|
| Rate for Payer: PACE Medicare |
$273.50
|
| Rate for Payer: PACE SWMI |
$287.89
|
| Rate for Payer: PHP Medicare Advantage |
$287.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$154.31
|
| Rate for Payer: Priority Health Medicare |
$287.89
|
| Rate for Payer: Railroad Medicare Medicare |
$287.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$810.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$287.89
|
| Rate for Payer: UHC Medicare Advantage |
$287.89
|
| Rate for Payer: UHCCP Medicaid |
$162.08
|
| Rate for Payer: VA VA |
$287.89
|
|
|
UNLISTED PROCEDURE, PELVIS OR HIP JOINT
|
Facility
|
OP
|
$658.55
|
|
|
Service Code
|
CPT 27299
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$658.55 |
| Rate for Payer: Aetna Medicare |
$243.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$292.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$292.44
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: BCBS MAPPO |
$233.95
|
| Rate for Payer: BCN Medicare Advantage |
$233.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$233.95
|
| Rate for Payer: Mclaren Medicaid |
$125.40
|
| Rate for Payer: Mclaren Medicare |
$233.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$245.65
|
| Rate for Payer: Meridian Medicaid |
$131.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: PACE Medicare |
$222.25
|
| Rate for Payer: PACE SWMI |
$233.95
|
| Rate for Payer: PHP Medicare Advantage |
$233.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$125.40
|
| Rate for Payer: Priority Health Medicare |
$233.95
|
| Rate for Payer: Railroad Medicare Medicare |
$233.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$658.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$233.95
|
| Rate for Payer: UHC Medicare Advantage |
$233.95
|
| Rate for Payer: UHCCP Medicaid |
$131.71
|
| Rate for Payer: VA VA |
$233.95
|
|
|
UNLISTED PROCEDURE, PHARYNX, ADENOIDS, OR TONSILS
|
Facility
|
OP
|
$637.52
|
|
|
Service Code
|
CPT 42999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$121.39 |
| Max. Negotiated Rate |
$637.52 |
| Rate for Payer: Aetna Medicare |
$235.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$283.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$283.10
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: BCBS MAPPO |
$226.48
|
| Rate for Payer: BCN Medicare Advantage |
$226.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$226.48
|
| Rate for Payer: Mclaren Medicaid |
$121.39
|
| Rate for Payer: Mclaren Medicare |
$226.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$237.80
|
| Rate for Payer: Meridian Medicaid |
$127.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.45
|
| Rate for Payer: PACE Medicare |
$215.16
|
| Rate for Payer: PACE SWMI |
$226.48
|
| Rate for Payer: PHP Medicare Advantage |
$226.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$121.39
|
| Rate for Payer: Priority Health Medicare |
$226.48
|
| Rate for Payer: Railroad Medicare Medicare |
$226.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$637.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$226.48
|
| Rate for Payer: UHC Medicare Advantage |
$226.48
|
| Rate for Payer: UHCCP Medicaid |
$127.51
|
| Rate for Payer: VA VA |
$226.48
|
|
|
UNLISTED PROCEDURE, RECTUM
|
Facility
|
OP
|
$2,502.92
|
|
|
Service Code
|
CPT 45999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$476.60 |
| Max. Negotiated Rate |
$2,502.92 |
| Rate for Payer: Aetna Medicare |
$924.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,111.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,111.46
|
| Rate for Payer: BCBS Complete |
$500.42
|
| Rate for Payer: BCBS MAPPO |
$889.17
|
| Rate for Payer: BCN Medicare Advantage |
$889.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$889.17
|
| Rate for Payer: Mclaren Medicaid |
$476.60
|
| Rate for Payer: Mclaren Medicare |
$889.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$933.63
|
| Rate for Payer: Meridian Medicaid |
$500.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,022.55
|
| Rate for Payer: PACE Medicare |
$844.71
|
| Rate for Payer: PACE SWMI |
$889.17
|
| Rate for Payer: PHP Medicare Advantage |
$889.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$476.60
|
| Rate for Payer: Priority Health Medicare |
$889.17
|
| Rate for Payer: Railroad Medicare Medicare |
$889.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,502.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$889.17
|
| Rate for Payer: UHC Medicare Advantage |
$889.17
|
| Rate for Payer: UHCCP Medicaid |
$500.60
|
| Rate for Payer: VA VA |
$889.17
|
|
|
UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE
|
Facility
|
OP
|
$545.50
|
|
|
Service Code
|
CPT 17999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$103.87 |
| Max. Negotiated Rate |
$545.50 |
| Rate for Payer: Aetna Medicare |
$201.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$242.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$242.24
|
| Rate for Payer: BCBS Complete |
$109.07
|
| Rate for Payer: BCBS MAPPO |
$193.79
|
| Rate for Payer: BCN Medicare Advantage |
$193.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$193.79
|
| Rate for Payer: Mclaren Medicaid |
$103.87
|
| Rate for Payer: Mclaren Medicare |
$193.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$203.48
|
| Rate for Payer: Meridian Medicaid |
$109.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$222.86
|
| Rate for Payer: PACE Medicare |
$184.10
|
| Rate for Payer: PACE SWMI |
$193.79
|
| Rate for Payer: PHP Medicare Advantage |
$193.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$103.87
|
| Rate for Payer: Priority Health Medicare |
$193.79
|
| Rate for Payer: Railroad Medicare Medicare |
$193.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$545.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$193.79
|
| Rate for Payer: UHC Medicare Advantage |
$193.79
|
| Rate for Payer: UHCCP Medicaid |
$109.10
|
| Rate for Payer: VA VA |
$193.79
|
|
|
UNLISTED PROCEDURE, URINARY SYSTEM
|
Facility
|
OP
|
$667.69
|
|
|
Service Code
|
CPT 53899
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$127.14 |
| Max. Negotiated Rate |
$667.69 |
| Rate for Payer: Aetna Medicare |
$246.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$296.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$296.50
|
| Rate for Payer: BCBS Complete |
$133.50
|
| Rate for Payer: BCBS MAPPO |
$237.20
|
| Rate for Payer: BCN Medicare Advantage |
$237.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$237.20
|
| Rate for Payer: Mclaren Medicaid |
$127.14
|
| Rate for Payer: Mclaren Medicare |
$237.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$249.06
|
| Rate for Payer: Meridian Medicaid |
$133.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$272.78
|
| Rate for Payer: PACE Medicare |
$225.34
|
| Rate for Payer: PACE SWMI |
$237.20
|
| Rate for Payer: PHP Medicare Advantage |
$237.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$127.14
|
| Rate for Payer: Priority Health Medicare |
$237.20
|
| Rate for Payer: Railroad Medicare Medicare |
$237.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$667.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$237.20
|
| Rate for Payer: UHC Medicare Advantage |
$237.20
|
| Rate for Payer: UHCCP Medicaid |
$133.54
|
| Rate for Payer: VA VA |
$237.20
|
|
|
URETHROLYSIS, TRANSVAGINAL, SECONDARY, OPEN, INCLUDING CYSTOURETHROSCOPY (EG, POSTSURGICAL OBSTRUCTION, SCARRING)
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 53500
|
|
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 Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,893.77
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE)
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 53460
|
|
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 Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,893.77
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY, FEMALE
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 53502
|
|
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 Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,893.77
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE
|
Facility
|
OP
|
$13,956.13
|
|
|
Service Code
|
CPT 53505
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,657.46 |
| Max. Negotiated Rate |
$13,956.13 |
| Rate for Payer: Aetna Medicare |
$5,156.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,197.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,197.44
|
| Rate for Payer: BCBS Complete |
$2,790.33
|
| Rate for Payer: BCBS MAPPO |
$4,957.95
|
| Rate for Payer: BCN Medicare Advantage |
$4,957.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,957.95
|
| Rate for Payer: Mclaren Medicaid |
$2,657.46
|
| Rate for Payer: Mclaren Medicare |
$4,957.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,205.85
|
| Rate for Payer: Meridian Medicaid |
$2,790.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,701.64
|
| Rate for Payer: PACE Medicare |
$4,710.05
|
| Rate for Payer: PACE SWMI |
$4,957.95
|
| Rate for Payer: PHP Medicare Advantage |
$4,957.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,657.46
|
| Rate for Payer: Priority Health Medicare |
$4,957.95
|
| Rate for Payer: Railroad Medicare Medicare |
$4,957.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,956.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,957.95
|
| Rate for Payer: UHC Medicare Advantage |
$4,957.95
|
| Rate for Payer: UHCCP Medicaid |
$2,791.33
|
| Rate for Payer: VA VA |
$4,957.95
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
IP
|
$233.33
|
|
|
Service Code
|
NDC 00904689004
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$198.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.66
|
| Rate for Payer: Cash Price |
$186.66
|
| Rate for Payer: Cofinity Commercial |
$163.33
|
| Rate for Payer: Cofinity Commercial |
$200.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$163.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.66
|
| Rate for Payer: Healthscope Commercial |
$210.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$198.33
|
| Rate for Payer: PHP Commercial |
$198.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.66
|
| Rate for Payer: Priority Health SBD |
$147.00
|
|
|
URSODIOL 250 MG TABLET
|
Facility
|
OP
|
$233.33
|
|
|
Service Code
|
NDC 00904689004
|
| Hospital Charge Code |
22660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.33 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$198.33
|
| Rate for Payer: Aetna Medicare |
$116.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.66
|
| Rate for Payer: BCBS Complete |
$93.33
|
| Rate for Payer: Cash Price |
$186.66
|
| Rate for Payer: Cofinity Commercial |
$163.33
|
| Rate for Payer: Cofinity Commercial |
$200.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$163.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.66
|
| Rate for Payer: Healthscope Commercial |
$210.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$198.33
|
| Rate for Payer: PHP Commercial |
$198.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.66
|
| Rate for Payer: Priority Health SBD |
$147.00
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$365.75
|
|
|
Service Code
|
NDC 42806050301
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.42 |
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Aetna Commercial |
$310.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.74
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$256.02
|
| Rate for Payer: Cofinity Commercial |
$314.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$329.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: PHP Commercial |
$310.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health SBD |
$230.42
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$8.80
|
|
|
Service Code
|
NDC 50268079711
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$7.92 |
| Rate for Payer: Aetna Commercial |
$7.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.72
|
| Rate for Payer: Cash Price |
$7.04
|
| Rate for Payer: Cofinity Commercial |
$6.16
|
| Rate for Payer: Cofinity Commercial |
$7.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.04
|
| Rate for Payer: Healthscope Commercial |
$7.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.48
|
| Rate for Payer: PHP Commercial |
$7.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.72
|
| Rate for Payer: Priority Health SBD |
$5.54
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$365.75
|
|
|
Service Code
|
NDC 42806050301
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.30 |
| Max. Negotiated Rate |
$329.18 |
| Rate for Payer: Aetna Commercial |
$310.89
|
| Rate for Payer: Aetna Medicare |
$182.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.74
|
| Rate for Payer: BCBS Complete |
$146.30
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$256.02
|
| Rate for Payer: Cofinity Commercial |
$314.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$256.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$329.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: PHP Commercial |
$310.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health SBD |
$230.42
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$558.24
|
|
|
Service Code
|
NDC 00527132601
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$351.69 |
| Max. Negotiated Rate |
$502.42 |
| Rate for Payer: Aetna Commercial |
$474.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$362.86
|
| Rate for Payer: Cash Price |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$390.77
|
| Rate for Payer: Cofinity Commercial |
$480.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$390.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$446.59
|
| Rate for Payer: Healthscope Commercial |
$502.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$474.50
|
| Rate for Payer: PHP Commercial |
$474.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.86
|
| Rate for Payer: Priority Health SBD |
$351.69
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$568.88
|
|
|
Service Code
|
NDC 00904622106
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$227.55 |
| Max. Negotiated Rate |
$511.99 |
| Rate for Payer: Aetna Commercial |
$483.55
|
| Rate for Payer: Aetna Medicare |
$284.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$369.77
|
| Rate for Payer: BCBS Complete |
$227.55
|
| Rate for Payer: Cash Price |
$455.10
|
| Rate for Payer: Cofinity Commercial |
$398.22
|
| Rate for Payer: Cofinity Commercial |
$489.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$398.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.10
|
| Rate for Payer: Healthscope Commercial |
$511.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$483.55
|
| Rate for Payer: PHP Commercial |
$483.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$369.77
|
| Rate for Payer: Priority Health SBD |
$358.39
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$439.68
|
|
|
Service Code
|
NDC 50268079715
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.87 |
| Max. Negotiated Rate |
$395.71 |
| Rate for Payer: Aetna Commercial |
$373.73
|
| Rate for Payer: Aetna Medicare |
$219.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$285.79
|
| Rate for Payer: BCBS Complete |
$175.87
|
| Rate for Payer: Cash Price |
$351.74
|
| Rate for Payer: Cofinity Commercial |
$307.78
|
| Rate for Payer: Cofinity Commercial |
$378.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$307.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$351.74
|
| Rate for Payer: Healthscope Commercial |
$395.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$373.73
|
| Rate for Payer: PHP Commercial |
$373.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.79
|
| Rate for Payer: Priority Health SBD |
$277.00
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$558.24
|
|
|
Service Code
|
NDC 00527132601
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$223.30 |
| Max. Negotiated Rate |
$502.42 |
| Rate for Payer: Aetna Commercial |
$474.50
|
| Rate for Payer: Aetna Medicare |
$279.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$362.86
|
| Rate for Payer: BCBS Complete |
$223.30
|
| Rate for Payer: Cash Price |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$390.77
|
| Rate for Payer: Cofinity Commercial |
$480.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$390.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$446.59
|
| Rate for Payer: Healthscope Commercial |
$502.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$474.50
|
| Rate for Payer: PHP Commercial |
$474.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$362.86
|
| Rate for Payer: Priority Health SBD |
$351.69
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$568.88
|
|
|
Service Code
|
NDC 00904622106
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$358.39 |
| Max. Negotiated Rate |
$511.99 |
| Rate for Payer: Aetna Commercial |
$483.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$369.77
|
| Rate for Payer: Cash Price |
$455.10
|
| Rate for Payer: Cofinity Commercial |
$398.22
|
| Rate for Payer: Cofinity Commercial |
$489.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$398.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.10
|
| Rate for Payer: Healthscope Commercial |
$511.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$483.55
|
| Rate for Payer: PHP Commercial |
$483.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$369.77
|
| Rate for Payer: Priority Health SBD |
$358.39
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$439.68
|
|
|
Service Code
|
NDC 50268079715
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$277.00 |
| Max. Negotiated Rate |
$395.71 |
| Rate for Payer: Aetna Commercial |
$373.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$285.79
|
| Rate for Payer: Cash Price |
$351.74
|
| Rate for Payer: Cofinity Commercial |
$307.78
|
| Rate for Payer: Cofinity Commercial |
$378.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$307.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$351.74
|
| Rate for Payer: Healthscope Commercial |
$395.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$373.73
|
| Rate for Payer: PHP Commercial |
$373.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.79
|
| Rate for Payer: Priority Health SBD |
$277.00
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$8.80
|
|
|
Service Code
|
NDC 50268079711
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$7.92 |
| Rate for Payer: Aetna Commercial |
$7.48
|
| Rate for Payer: Aetna Medicare |
$4.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.72
|
| Rate for Payer: BCBS Complete |
$3.52
|
| Rate for Payer: Cash Price |
$7.04
|
| Rate for Payer: Cofinity Commercial |
$6.16
|
| Rate for Payer: Cofinity Commercial |
$7.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.04
|
| Rate for Payer: Healthscope Commercial |
$7.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.48
|
| Rate for Payer: PHP Commercial |
$7.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.72
|
| Rate for Payer: Priority Health SBD |
$5.54
|
|
