|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$91.80
|
|
|
Service Code
|
NDC 00338978212
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$82.62 |
| Rate for Payer: Aetna Commercial |
$78.03
|
| Rate for Payer: Aetna Medicare |
$45.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.67
|
| Rate for Payer: BCBS Complete |
$36.72
|
| Rate for Payer: Cash Price |
$73.44
|
| Rate for Payer: Cofinity Advantage |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$78.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.44
|
| Rate for Payer: Healthscope Commercial |
$82.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.85
|
| Rate for Payer: PHP Commercial |
$78.03
|
| Rate for Payer: Priority Health SBD |
$57.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.67
|
| Rate for Payer: UHC Core |
$47.83
|
| Rate for Payer: UHC Exchange |
$36.08
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$47.85
|
|
|
Service Code
|
NDC 00338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.81 |
| Max. Negotiated Rate |
$43.06 |
| Rate for Payer: Aetna Commercial |
$40.67
|
| Rate for Payer: Aetna Medicare |
$23.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.10
|
| Rate for Payer: BCBS Complete |
$19.14
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Advantage |
$33.49
|
| Rate for Payer: Cofinity Commercial |
$41.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$43.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$38.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.89
|
| Rate for Payer: PHP Commercial |
$40.67
|
| Rate for Payer: Priority Health SBD |
$30.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.10
|
| Rate for Payer: UHC Core |
$24.93
|
| Rate for Payer: UHC Exchange |
$18.81
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$91.80
|
|
|
Service Code
|
NDC 00338978212
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.83 |
| Max. Negotiated Rate |
$82.62 |
| Rate for Payer: Aetna Commercial |
$78.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.67
|
| Rate for Payer: Cash Price |
$73.44
|
| Rate for Payer: Cofinity Advantage |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$78.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.44
|
| Rate for Payer: Healthscope Commercial |
$82.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$78.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.85
|
| Rate for Payer: PHP Commercial |
$78.03
|
| Rate for Payer: Priority Health SBD |
$57.83
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
IP
|
$79.75
|
|
|
Service Code
|
NDC 00338000403
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.24 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Advantage |
$55.83
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health SBD |
$50.24
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
OP
|
$63.80
|
|
|
Service Code
|
NDC 00338000404
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna Medicare |
$31.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.47
|
| Rate for Payer: BCBS Complete |
$25.52
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Advantage |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.85
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health SBD |
$40.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.47
|
| Rate for Payer: UHC Core |
$33.24
|
| Rate for Payer: UHC Exchange |
$25.07
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
OP
|
$82.62
|
|
|
Service Code
|
NDC 00338000347
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.47 |
| Max. Negotiated Rate |
$74.36 |
| Rate for Payer: Aetna Commercial |
$70.23
|
| Rate for Payer: Aetna Medicare |
$41.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.70
|
| Rate for Payer: BCBS Complete |
$33.05
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: Cofinity Advantage |
$57.83
|
| Rate for Payer: Cofinity Commercial |
$71.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.10
|
| Rate for Payer: Healthscope Commercial |
$74.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.97
|
| Rate for Payer: PHP Commercial |
$70.23
|
| Rate for Payer: Priority Health SBD |
$52.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.70
|
| Rate for Payer: UHC Core |
$43.05
|
| Rate for Payer: UHC Exchange |
$32.47
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
OP
|
$79.75
|
|
|
Service Code
|
NDC 00338000403
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.34 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Medicare |
$39.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: BCBS Complete |
$31.90
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Advantage |
$55.83
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health SBD |
$50.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.84
|
| Rate for Payer: UHC Core |
$41.55
|
| Rate for Payer: UHC Exchange |
$31.34
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
NDC 00338000404
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.19 |
| Max. Negotiated Rate |
$57.42 |
| Rate for Payer: Aetna Commercial |
$54.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.47
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Advantage |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$54.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$57.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.85
|
| Rate for Payer: PHP Commercial |
$54.23
|
| Rate for Payer: Priority Health SBD |
$40.19
|
|
|
WATER FOR IRRIGATION, STERILE SOLUTION
|
Facility
|
IP
|
$82.62
|
|
|
Service Code
|
NDC 00338000347
|
| Hospital Charge Code |
7485
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.05 |
| Max. Negotiated Rate |
$74.36 |
| Rate for Payer: Aetna Commercial |
$70.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.70
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: Cofinity Advantage |
$57.83
|
| Rate for Payer: Cofinity Commercial |
$71.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.10
|
| Rate for Payer: Healthscope Commercial |
$74.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.97
|
| Rate for Payer: PHP Commercial |
$70.23
|
| Rate for Payer: Priority Health SBD |
$52.05
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Medicare |
$13.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.07
|
| Rate for Payer: BCBS Complete |
$11.12
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Advantage |
$19.46
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.85
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: Priority Health SBD |
$17.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.07
|
| Rate for Payer: UHC Core |
$14.48
|
| Rate for Payer: UHC Exchange |
$10.93
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.51 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.07
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Advantage |
$19.46
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.85
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: Priority Health SBD |
$17.51
|
|
|
WHITE PETROLATUM EYE OINTMENT WRAPPER
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
301577
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.51 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.07
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Advantage |
$19.46
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.85
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: Priority Health SBD |
$17.51
|
|
|
WHITE PETROLATUM EYE OINTMENT WRAPPER
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
301577
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$25.02 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Medicare |
$13.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.07
|
| Rate for Payer: BCBS Complete |
$11.12
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Advantage |
$19.46
|
| Rate for Payer: Cofinity Commercial |
$23.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$25.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.85
|
| Rate for Payer: PHP Commercial |
$23.63
|
| Rate for Payer: Priority Health SBD |
$17.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.07
|
| Rate for Payer: UHC Core |
$14.48
|
| Rate for Payer: UHC Exchange |
$10.93
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM
|
Facility
|
OP
|
$12.88
|
|
|
Service Code
|
NDC 61924017804
|
| Hospital Charge Code |
11371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna Medicare |
$6.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.37
|
| Rate for Payer: BCBS Complete |
$5.15
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Advantage |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.66
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health SBD |
$8.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.37
|
| Rate for Payer: UHC Core |
$6.71
|
| Rate for Payer: UHC Exchange |
$5.06
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM
|
Facility
|
IP
|
$12.88
|
|
|
Service Code
|
NDC 61924017804
|
| Hospital Charge Code |
11371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.37
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Advantage |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.66
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health SBD |
$8.11
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$55,582.30
|
|
|
Service Code
|
MSDRG 464
|
| Min. Negotiated Rate |
$23,417.60 |
| Max. Negotiated Rate |
$55,582.30 |
| Rate for Payer: Aetna Medicare |
$25,636.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30,812.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30,812.62
|
| Rate for Payer: BCBS MAPPO |
$24,650.10
|
| Rate for Payer: BCBS Trust/PPO |
$55,582.30
|
| Rate for Payer: BCN Commercial |
$55,582.30
|
| Rate for Payer: BCN Medicare Advantage |
$24,650.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24,650.10
|
| Rate for Payer: Mclaren Medicare |
$24,650.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25,882.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28,347.62
|
| Rate for Payer: Molina Medicare/Medicaid |
$27,115.11
|
| Rate for Payer: Nomi Health Commercial |
$40,179.63
|
| Rate for Payer: PACE Medicare |
$23,417.60
|
| Rate for Payer: PACE SWMI |
$24,650.10
|
| Rate for Payer: PHP Medicare Advantage |
$24,650.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$50,215.63
|
| Rate for Payer: Priority Health Medicare |
$24,650.10
|
| Rate for Payer: Priority Health Tiered Network |
$40,172.50
|
| Rate for Payer: Railroad Medicare Medicare |
$24,650.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50,769.61
|
| Rate for Payer: UHC Core |
$42,475.16
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$24,650.10
|
| Rate for Payer: UHC Exchange |
$34,688.41
|
| Rate for Payer: VA VA |
$24,650.10
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$101,782.67
|
|
|
Service Code
|
MSDRG 463
|
| Min. Negotiated Rate |
$42,394.74 |
| Max. Negotiated Rate |
$101,782.67 |
| Rate for Payer: Aetna Medicare |
$46,411.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$55,782.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$55,782.55
|
| Rate for Payer: BCBS MAPPO |
$44,626.04
|
| Rate for Payer: BCBS Trust/PPO |
$101,782.67
|
| Rate for Payer: BCN Commercial |
$101,782.67
|
| Rate for Payer: BCN Medicare Advantage |
$44,626.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44,626.04
|
| Rate for Payer: Mclaren Medicare |
$44,626.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$46,857.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51,319.95
|
| Rate for Payer: Molina Medicare/Medicaid |
$49,088.64
|
| Rate for Payer: Nomi Health Commercial |
$73,523.55
|
| Rate for Payer: PACE Medicare |
$42,394.74
|
| Rate for Payer: PACE SWMI |
$44,626.04
|
| Rate for Payer: PHP Medicare Advantage |
$44,626.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$91,888.14
|
| Rate for Payer: Priority Health Medicare |
$44,626.04
|
| Rate for Payer: Priority Health Tiered Network |
$73,510.50
|
| Rate for Payer: Railroad Medicare Medicare |
$44,626.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92,901.85
|
| Rate for Payer: UHC Core |
$77,724.08
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$44,626.04
|
| Rate for Payer: UHC Exchange |
$63,475.33
|
| Rate for Payer: VA VA |
$44,626.04
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$31,724.86
|
|
|
Service Code
|
MSDRG 465
|
| Min. Negotiated Rate |
$13,939.33 |
| Max. Negotiated Rate |
$31,724.86 |
| Rate for Payer: Aetna Medicare |
$15,259.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,341.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,341.22
|
| Rate for Payer: BCBS MAPPO |
$14,672.98
|
| Rate for Payer: BCBS Trust/PPO |
$31,724.86
|
| Rate for Payer: BCN Commercial |
$31,724.86
|
| Rate for Payer: BCN Medicare Advantage |
$14,672.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,672.98
|
| Rate for Payer: Mclaren Medicare |
$14,672.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15,406.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,873.93
|
| Rate for Payer: Molina Medicare/Medicaid |
$16,140.28
|
| Rate for Payer: Nomi Health Commercial |
$23,525.73
|
| Rate for Payer: PACE Medicare |
$13,939.33
|
| Rate for Payer: PACE SWMI |
$14,672.98
|
| Rate for Payer: PHP Medicare Advantage |
$14,672.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$29,401.95
|
| Rate for Payer: Priority Health Medicare |
$14,672.98
|
| Rate for Payer: Priority Health Tiered Network |
$23,521.55
|
| Rate for Payer: Railroad Medicare Medicare |
$14,672.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29,726.31
|
| Rate for Payer: UHC Core |
$24,869.80
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,672.98
|
| Rate for Payer: UHC Exchange |
$20,310.55
|
| Rate for Payer: VA VA |
$14,672.98
|
|
|
WOUND DEBRIDEMENTS FOR INJURIES WITH CC
|
Facility
|
IP
|
$43,040.29
|
|
|
Service Code
|
MSDRG 902
|
| Min. Negotiated Rate |
$14,605.97 |
| Max. Negotiated Rate |
$43,040.29 |
| Rate for Payer: Aetna Medicare |
$15,989.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19,218.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19,218.39
|
| Rate for Payer: BCBS MAPPO |
$15,374.71
|
| Rate for Payer: BCBS Trust/PPO |
$43,040.29
|
| Rate for Payer: BCN Commercial |
$43,040.29
|
| Rate for Payer: BCN Medicare Advantage |
$15,374.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,374.71
|
| Rate for Payer: Mclaren Medicare |
$15,374.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16,143.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,680.92
|
| Rate for Payer: Molina Medicare/Medicaid |
$16,912.18
|
| Rate for Payer: Nomi Health Commercial |
$24,697.05
|
| Rate for Payer: PACE Medicare |
$14,605.97
|
| Rate for Payer: PACE SWMI |
$15,374.71
|
| Rate for Payer: PHP Medicare Advantage |
$15,374.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$30,865.84
|
| Rate for Payer: Priority Health Medicare |
$15,374.71
|
| Rate for Payer: Priority Health Tiered Network |
$24,692.67
|
| Rate for Payer: Railroad Medicare Medicare |
$15,374.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,206.35
|
| Rate for Payer: UHC Core |
$26,108.04
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$15,374.71
|
| Rate for Payer: UHC Exchange |
$21,321.79
|
| Rate for Payer: VA VA |
$15,374.71
|
|
|
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC
|
Facility
|
IP
|
$68,404.58
|
|
|
Service Code
|
MSDRG 901
|
| Min. Negotiated Rate |
$31,360.72 |
| Max. Negotiated Rate |
$68,404.58 |
| Rate for Payer: Aetna Medicare |
$34,331.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$41,264.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$41,264.10
|
| Rate for Payer: BCBS MAPPO |
$33,011.28
|
| Rate for Payer: BCBS Trust/PPO |
$66,099.51
|
| Rate for Payer: BCN Commercial |
$66,099.51
|
| Rate for Payer: BCN Medicare Advantage |
$33,011.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$33,011.28
|
| Rate for Payer: Mclaren Medicare |
$33,011.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$34,661.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37,962.97
|
| Rate for Payer: Molina Medicare/Medicaid |
$36,312.41
|
| Rate for Payer: Nomi Health Commercial |
$54,136.14
|
| Rate for Payer: PACE Medicare |
$31,360.72
|
| Rate for Payer: PACE SWMI |
$33,011.28
|
| Rate for Payer: PHP Medicare Advantage |
$33,011.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$67,658.17
|
| Rate for Payer: Priority Health Medicare |
$33,011.28
|
| Rate for Payer: Priority Health Tiered Network |
$54,126.53
|
| Rate for Payer: Railroad Medicare Medicare |
$33,011.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68,404.58
|
| Rate for Payer: UHC Core |
$57,229.03
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$33,011.28
|
| Rate for Payer: UHC Exchange |
$46,737.53
|
| Rate for Payer: VA VA |
$33,011.28
|
|
|
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,913.61
|
|
|
Service Code
|
MSDRG 903
|
| Min. Negotiated Rate |
$9,137.04 |
| Max. Negotiated Rate |
$23,913.61 |
| Rate for Payer: Aetna Medicare |
$10,002.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,022.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,022.42
|
| Rate for Payer: BCBS MAPPO |
$9,617.94
|
| Rate for Payer: BCBS Trust/PPO |
$23,913.61
|
| Rate for Payer: BCN Commercial |
$23,913.61
|
| Rate for Payer: BCN Medicare Advantage |
$9,617.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,617.94
|
| Rate for Payer: Mclaren Medicare |
$9,617.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10,098.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,060.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$10,579.73
|
| Rate for Payer: Nomi Health Commercial |
$15,087.84
|
| Rate for Payer: PACE Medicare |
$9,137.04
|
| Rate for Payer: PACE SWMI |
$9,617.94
|
| Rate for Payer: PHP Medicare Advantage |
$9,617.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$18,856.45
|
| Rate for Payer: Priority Health Medicare |
$9,617.94
|
| Rate for Payer: Priority Health Tiered Network |
$15,085.16
|
| Rate for Payer: Railroad Medicare Medicare |
$9,617.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,064.48
|
| Rate for Payer: UHC Core |
$15,949.84
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9,617.94
|
| Rate for Payer: UHC Exchange |
$13,025.84
|
| Rate for Payer: VA VA |
$9,617.94
|
|
|
ZIDOVUDINE 100 MG CAPSULE
|
Facility
|
IP
|
$676.32
|
|
|
Service Code
|
NDC 65862010701
|
| Hospital Charge Code |
11692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$426.08 |
| Max. Negotiated Rate |
$608.69 |
| Rate for Payer: Aetna Commercial |
$574.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$439.61
|
| Rate for Payer: Cash Price |
$541.06
|
| Rate for Payer: Cofinity Advantage |
$473.42
|
| Rate for Payer: Cofinity Commercial |
$581.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$541.06
|
| Rate for Payer: Healthscope Commercial |
$608.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$574.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$507.24
|
| Rate for Payer: PHP Commercial |
$574.87
|
| Rate for Payer: Priority Health SBD |
$426.08
|
|
|
ZIDOVUDINE 100 MG CAPSULE
|
Facility
|
OP
|
$676.32
|
|
|
Service Code
|
NDC 65862010701
|
| Hospital Charge Code |
11692
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.79 |
| Max. Negotiated Rate |
$608.69 |
| Rate for Payer: Aetna Commercial |
$574.87
|
| Rate for Payer: Aetna Medicare |
$338.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$439.61
|
| Rate for Payer: BCBS Complete |
$270.53
|
| Rate for Payer: Cash Price |
$541.06
|
| Rate for Payer: Cofinity Advantage |
$473.42
|
| Rate for Payer: Cofinity Commercial |
$581.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$541.06
|
| Rate for Payer: Healthscope Commercial |
$608.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$541.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$574.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$507.24
|
| Rate for Payer: PHP Commercial |
$574.87
|
| Rate for Payer: Priority Health SBD |
$426.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$439.61
|
| Rate for Payer: UHC Core |
$352.36
|
| Rate for Payer: UHC Exchange |
$265.79
|
|
|
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$126.65
|
|
|
Service Code
|
HCPCS J3485
|
| Hospital Charge Code |
11691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$113.98 |
| Rate for Payer: Aetna Commercial |
$107.65
|
| Rate for Payer: Aetna Medicare |
$1.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.89
|
| Rate for Payer: BCBS Complete |
$0.83
|
| Rate for Payer: BCBS MAPPO |
$1.51
|
| Rate for Payer: BCBS Trust/PPO |
$3.79
|
| Rate for Payer: BCN Commercial |
$3.79
|
| Rate for Payer: BCN Medicare Advantage |
$1.51
|
| Rate for Payer: Cash Price |
$101.32
|
| Rate for Payer: Cash Price |
$101.32
|
| Rate for Payer: Cofinity Advantage |
$88.66
|
| Rate for Payer: Cofinity Commercial |
$108.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.51
|
| Rate for Payer: Healthscope Commercial |
$113.98
|
| Rate for Payer: Mclaren Medicaid |
$0.79
|
| Rate for Payer: Mclaren Medicare |
$1.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.59
|
| Rate for Payer: Meridian Medicaid |
$1.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.74
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.65
|
| Rate for Payer: Nomi Health Commercial |
$4.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.99
|
| Rate for Payer: PACE Medicare |
$1.43
|
| Rate for Payer: PACE SWMI |
$1.51
|
| Rate for Payer: PHP Commercial |
$107.65
|
| Rate for Payer: PHP Medicare Advantage |
$1.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$4.79
|
| Rate for Payer: Priority Health Medicare |
$1.51
|
| Rate for Payer: Priority Health SBD |
$79.79
|
| Rate for Payer: Priority Health Tiered Network |
$3.83
|
| Rate for Payer: Railroad Medicare Medicare |
$1.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.49
|
| Rate for Payer: UHC Core |
$2.49
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1.51
|
| Rate for Payer: UHC Exchange |
$2.49
|
| Rate for Payer: UHC Medicaid |
$0.79
|
| Rate for Payer: UHCCP Medicaid |
$0.79
|
| Rate for Payer: VA VA |
$1.51
|
|
|
ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$126.65
|
|
|
Service Code
|
HCPCS J3485
|
| Hospital Charge Code |
11691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.79 |
| Max. Negotiated Rate |
$113.98 |
| Rate for Payer: Aetna Commercial |
$107.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.32
|
| Rate for Payer: Cash Price |
$101.32
|
| Rate for Payer: Cofinity Advantage |
$88.66
|
| Rate for Payer: Cofinity Commercial |
$108.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.32
|
| Rate for Payer: Healthscope Commercial |
$113.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.99
|
| Rate for Payer: PHP Commercial |
$107.65
|
| Rate for Payer: Priority Health SBD |
$79.79
|
|
