|
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND)
|
Facility
OP
|
$878.00
|
|
|
Service Code
|
CPT 29105
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$40.93 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: Aetna Medicare |
$145.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$175.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$175.25
|
| Rate for Payer: BCBS Complete |
$80.53
|
| Rate for Payer: BCBS MAPPO |
$140.20
|
| Rate for Payer: BCBS Trust/PPO |
$69.04
|
| Rate for Payer: BCN Medicare Advantage |
$140.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$140.20
|
| Rate for Payer: Mclaren Medicaid |
$76.69
|
| Rate for Payer: Mclaren Medicare |
$140.20
|
| Rate for Payer: Meridian Medicaid |
$80.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$147.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$161.23
|
| Rate for Payer: PACE Medicare |
$133.19
|
| Rate for Payer: PACE SWMI |
$140.20
|
| Rate for Payer: PHP Medicare Advantage |
$140.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$76.69
|
| Rate for Payer: Priority Health Medicare |
$140.20
|
| Rate for Payer: Railroad Medicare Medicare |
$140.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.02
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$140.20
|
| Rate for Payer: UHC Exchange |
$40.93
|
| Rate for Payer: UHC Medicare Advantage |
$144.41
|
| Rate for Payer: VA VA |
$140.20
|
|
|
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC
|
Facility
OP
|
$878.00
|
|
|
Service Code
|
CPT 29125
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: PACE SWMI |
$113.66
|
| Rate for Payer: Aetna Medicare |
$118.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$142.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$142.08
|
| Rate for Payer: BCBS Complete |
$65.29
|
| Rate for Payer: BCBS MAPPO |
$113.66
|
| Rate for Payer: BCBS Trust/PPO |
$55.77
|
| Rate for Payer: BCN Medicare Advantage |
$113.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$113.66
|
| Rate for Payer: Mclaren Medicaid |
$62.17
|
| Rate for Payer: Mclaren Medicare |
$113.66
|
| Rate for Payer: Meridian Medicaid |
$65.29
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$119.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$130.71
|
| Rate for Payer: PACE Medicare |
$107.98
|
| Rate for Payer: PHP Medicare Advantage |
$113.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$62.17
|
| Rate for Payer: Priority Health Medicare |
$113.66
|
| Rate for Payer: Railroad Medicare Medicare |
$113.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.94
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$113.66
|
| Rate for Payer: UHC Exchange |
$39.95
|
| Rate for Payer: UHC Medicare Advantage |
$117.07
|
| Rate for Payer: VA VA |
$113.66
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$90.70 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$922.68
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.77
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$90.70
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.86 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$1,152.52
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.05
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$81.86
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
APREPITANT 125 MG (1)-80 MG (2) CAPSULES IN A DOSE PACK
|
Facility
OP
|
$2,664.56
|
|
|
Service Code
|
NDC 0006-3862-03
|
| Hospital Charge Code |
35490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,065.82 |
| Max. Negotiated Rate |
$2,398.10 |
| Rate for Payer: Aetna Commercial |
$2,264.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,731.96
|
| Rate for Payer: BCBS Complete |
$1,065.82
|
| Rate for Payer: Cash Price |
$2,131.65
|
| Rate for Payer: Cofinity Commercial |
$1,865.19
|
| Rate for Payer: Cofinity Commercial |
$2,291.52
|
| Rate for Payer: Healthscope Commercial |
$2,398.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,264.88
|
| Rate for Payer: PHP Commercial |
$2,264.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,865.19
|
| Rate for Payer: Priority Health SBD |
$1,678.67
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
OP
|
$1,505.57
|
|
|
Service Code
|
NDC 0006-0461-02
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$602.23 |
| Max. Negotiated Rate |
$1,355.01 |
| Rate for Payer: Aetna Commercial |
$1,279.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$978.62
|
| Rate for Payer: BCBS Complete |
$602.23
|
| Rate for Payer: Cash Price |
$1,204.46
|
| Rate for Payer: Cofinity Commercial |
$1,053.90
|
| Rate for Payer: Cofinity Commercial |
$1,294.79
|
| Rate for Payer: Healthscope Commercial |
$1,355.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,279.73
|
| Rate for Payer: PHP Commercial |
$1,279.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,053.90
|
| Rate for Payer: Priority Health SBD |
$948.51
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
IP
|
$16.19
|
|
|
Service Code
|
HCPCS J7605
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$14.57 |
| Rate for Payer: Aetna Commercial |
$13.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.52
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$11.33
|
| Rate for Payer: Cofinity Commercial |
$13.92
|
| Rate for Payer: Healthscope Commercial |
$14.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.76
|
| Rate for Payer: PHP Commercial |
$13.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.33
|
| Rate for Payer: Priority Health SBD |
$10.20
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
IP
|
$412.73
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
152708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$260.02 |
| Max. Negotiated Rate |
$371.46 |
| Rate for Payer: Aetna Commercial |
$350.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$268.27
|
| Rate for Payer: Cash Price |
$330.18
|
| Rate for Payer: Cofinity Commercial |
$288.91
|
| Rate for Payer: Cofinity Commercial |
$354.95
|
| Rate for Payer: Healthscope Commercial |
$371.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$350.82
|
| Rate for Payer: PHP Commercial |
$350.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.91
|
| Rate for Payer: Priority Health SBD |
$260.02
|
|
|
ARGATROBAN 50 MG/50 ML (1 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV
|
Facility
IP
|
$473.78
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
155428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.48 |
| Max. Negotiated Rate |
$426.40 |
| Rate for Payer: Aetna Commercial |
$402.71
|
| Rate for Payer: Aetna Commercial |
$687.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$525.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.96
|
| Rate for Payer: Cash Price |
$379.02
|
| Rate for Payer: Cash Price |
$646.82
|
| Rate for Payer: Cofinity Commercial |
$407.45
|
| Rate for Payer: Cofinity Commercial |
$331.65
|
| Rate for Payer: Cofinity Commercial |
$565.96
|
| Rate for Payer: Cofinity Commercial |
$695.33
|
| Rate for Payer: Healthscope Commercial |
$426.40
|
| Rate for Payer: Healthscope Commercial |
$727.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$687.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$402.71
|
| Rate for Payer: PHP Commercial |
$687.24
|
| Rate for Payer: PHP Commercial |
$402.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$331.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$565.96
|
| Rate for Payer: Priority Health SBD |
$298.48
|
| Rate for Payer: Priority Health SBD |
$509.37
|
|
|
ARIPIPRAZOLE 10 MG TABLET
|
Facility
IP
|
$2,008.88
|
|
|
Service Code
|
NDC 59148-008-13
|
| Hospital Charge Code |
34369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,265.59 |
| Max. Negotiated Rate |
$1,807.99 |
| Rate for Payer: Aetna Commercial |
$1,707.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,305.77
|
| Rate for Payer: Cash Price |
$1,607.10
|
| Rate for Payer: Cofinity Commercial |
$1,406.22
|
| Rate for Payer: Cofinity Commercial |
$1,727.64
|
| Rate for Payer: Healthscope Commercial |
$1,807.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,707.55
|
| Rate for Payer: PHP Commercial |
$1,707.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,406.22
|
| Rate for Payer: Priority Health SBD |
$1,265.59
|
|
|
ARIPIPRAZOLE 10 MG TABLET
|
Facility
IP
|
$136.77
|
|
|
Service Code
|
NDC 65162-898-03
|
| Hospital Charge Code |
34369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.17 |
| Max. Negotiated Rate |
$123.09 |
| Rate for Payer: Aetna Commercial |
$116.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.90
|
| Rate for Payer: Cash Price |
$109.42
|
| Rate for Payer: Cofinity Commercial |
$117.62
|
| Rate for Payer: Cofinity Commercial |
$95.74
|
| Rate for Payer: Healthscope Commercial |
$123.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$116.25
|
| Rate for Payer: PHP Commercial |
$116.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.74
|
| Rate for Payer: Priority Health SBD |
$86.17
|
|
|
ARIPIPRAZOLE 10 MG TABLET
|
Facility
IP
|
$195.27
|
|
|
Service Code
|
NDC 43547-304-03
|
| Hospital Charge Code |
34369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.02 |
| Max. Negotiated Rate |
$175.74 |
| Rate for Payer: Aetna Commercial |
$165.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.93
|
| Rate for Payer: Cash Price |
$156.22
|
| Rate for Payer: Cofinity Commercial |
$136.69
|
| Rate for Payer: Cofinity Commercial |
$167.93
|
| Rate for Payer: Healthscope Commercial |
$175.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.98
|
| Rate for Payer: PHP Commercial |
$165.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.69
|
| Rate for Payer: Priority Health SBD |
$123.02
|
|
|
ARIPIPRAZOLE 10 MG TABLET
|
Facility
IP
|
$93.75
|
|
|
Service Code
|
NDC 27241-053-03
|
| Hospital Charge Code |
34369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.06 |
| Max. Negotiated Rate |
$84.38 |
| Rate for Payer: Aetna Commercial |
$79.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.94
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cofinity Commercial |
$65.62
|
| Rate for Payer: Cofinity Commercial |
$80.62
|
| Rate for Payer: Healthscope Commercial |
$84.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.69
|
| Rate for Payer: PHP Commercial |
$79.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.62
|
| Rate for Payer: Priority Health SBD |
$59.06
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
IP
|
$30.88
|
|
|
Service Code
|
NDC 60687-191-11
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.45 |
| Max. Negotiated Rate |
$27.79 |
| Rate for Payer: Aetna Commercial |
$26.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.07
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cofinity Commercial |
$26.56
|
| Rate for Payer: Cofinity Commercial |
$21.62
|
| Rate for Payer: Healthscope Commercial |
$27.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.25
|
| Rate for Payer: PHP Commercial |
$26.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.62
|
| Rate for Payer: Priority Health SBD |
$19.45
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
IP
|
$591.52
|
|
|
Service Code
|
NDC 0904-6512-04
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$372.66 |
| Max. Negotiated Rate |
$532.37 |
| Rate for Payer: Aetna Commercial |
$502.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$384.49
|
| Rate for Payer: Cash Price |
$473.22
|
| Rate for Payer: Cofinity Commercial |
$414.06
|
| Rate for Payer: Cofinity Commercial |
$508.71
|
| Rate for Payer: Healthscope Commercial |
$532.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$502.79
|
| Rate for Payer: PHP Commercial |
$502.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.06
|
| Rate for Payer: Priority Health SBD |
$372.66
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
IP
|
$926.19
|
|
|
Service Code
|
NDC 60687-191-21
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$583.50 |
| Max. Negotiated Rate |
$833.57 |
| Rate for Payer: Aetna Commercial |
$787.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$602.02
|
| Rate for Payer: Cash Price |
$740.95
|
| Rate for Payer: Cofinity Commercial |
$648.33
|
| Rate for Payer: Cofinity Commercial |
$796.52
|
| Rate for Payer: Healthscope Commercial |
$833.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$787.26
|
| Rate for Payer: PHP Commercial |
$787.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.33
|
| Rate for Payer: Priority Health SBD |
$583.50
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
IP
|
$199.16
|
|
|
Service Code
|
NDC 60505-3075-3
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.47 |
| Max. Negotiated Rate |
$179.24 |
| Rate for Payer: Aetna Commercial |
$169.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.45
|
| Rate for Payer: Cash Price |
$159.33
|
| Rate for Payer: Cofinity Commercial |
$139.41
|
| Rate for Payer: Cofinity Commercial |
$171.28
|
| Rate for Payer: Healthscope Commercial |
$179.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$169.29
|
| Rate for Payer: PHP Commercial |
$169.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.41
|
| Rate for Payer: Priority Health SBD |
$125.47
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
IP
|
$93.75
|
|
|
Service Code
|
NDC 27241-051-03
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.06 |
| Max. Negotiated Rate |
$84.38 |
| Rate for Payer: Aetna Commercial |
$79.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.94
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cofinity Commercial |
$65.62
|
| Rate for Payer: Cofinity Commercial |
$80.62
|
| Rate for Payer: Healthscope Commercial |
$84.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.69
|
| Rate for Payer: PHP Commercial |
$79.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.62
|
| Rate for Payer: Priority Health SBD |
$59.06
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
IP
|
$2,008.88
|
|
|
Service Code
|
NDC 59148-006-13
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,265.59 |
| Max. Negotiated Rate |
$1,807.99 |
| Rate for Payer: Aetna Commercial |
$1,707.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,305.77
|
| Rate for Payer: Cash Price |
$1,607.10
|
| Rate for Payer: Cofinity Commercial |
$1,406.22
|
| Rate for Payer: Cofinity Commercial |
$1,727.64
|
| Rate for Payer: Healthscope Commercial |
$1,807.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,707.55
|
| Rate for Payer: PHP Commercial |
$1,707.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,406.22
|
| Rate for Payer: Priority Health SBD |
$1,265.59
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
IP
|
$103.64
|
|
|
Service Code
|
NDC 65162-896-03
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.29 |
| Max. Negotiated Rate |
$93.28 |
| Rate for Payer: Aetna Commercial |
$88.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.37
|
| Rate for Payer: Cash Price |
$82.91
|
| Rate for Payer: Cofinity Commercial |
$72.55
|
| Rate for Payer: Cofinity Commercial |
$89.13
|
| Rate for Payer: Healthscope Commercial |
$93.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.09
|
| Rate for Payer: PHP Commercial |
$88.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.55
|
| Rate for Payer: Priority Health SBD |
$65.29
|
|
|
ARIPIPRAZOLE 5 MG TABLET
|
Facility
IP
|
$204.45
|
|
|
Service Code
|
NDC 16729-279-01
|
| Hospital Charge Code |
36438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$173.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.89
|
| Rate for Payer: Cash Price |
$163.56
|
| Rate for Payer: Cofinity Commercial |
$175.83
|
| Rate for Payer: Cofinity Commercial |
$143.12
|
| Rate for Payer: Healthscope Commercial |
$184.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$173.78
|
| Rate for Payer: PHP Commercial |
$173.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.12
|
| Rate for Payer: Priority Health SBD |
$128.80
|
|
|
ARIPIPRAZOLE 5 MG TABLET
|
Facility
IP
|
$1,773.41
|
|
|
Service Code
|
NDC 0904-6510-61
|
| Hospital Charge Code |
36438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,117.25 |
| Max. Negotiated Rate |
$1,596.07 |
| Rate for Payer: Aetna Commercial |
$1,507.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,152.72
|
| Rate for Payer: Cash Price |
$1,418.73
|
| Rate for Payer: Cofinity Commercial |
$1,241.39
|
| Rate for Payer: Cofinity Commercial |
$1,525.13
|
| Rate for Payer: Healthscope Commercial |
$1,596.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,507.40
|
| Rate for Payer: PHP Commercial |
$1,507.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,241.39
|
| Rate for Payer: Priority Health SBD |
$1,117.25
|
|
|
ARSENIC TRIOXIDE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
OP
|
$3,639.86
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
185456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$3,275.87 |
| Rate for Payer: Aetna Commercial |
$3,093.88
|
| Rate for Payer: Aetna Medicare |
$16.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,365.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.73
|
| Rate for Payer: BCBS Complete |
$9.07
|
| Rate for Payer: BCBS MAPPO |
$15.78
|
| Rate for Payer: BCBS Trust/PPO |
$46.72
|
| Rate for Payer: BCN Medicare Advantage |
$15.78
|
| Rate for Payer: Cash Price |
$2,911.89
|
| Rate for Payer: Cash Price |
$2,911.89
|
| Rate for Payer: Cofinity Commercial |
$2,547.90
|
| Rate for Payer: Cofinity Commercial |
$3,130.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.78
|
| Rate for Payer: Healthscope Commercial |
$3,275.87
|
| Rate for Payer: Mclaren Medicaid |
$8.63
|
| Rate for Payer: Mclaren Medicare |
$15.78
|
| Rate for Payer: Meridian Medicaid |
$9.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,093.88
|
| Rate for Payer: PACE Medicare |
$14.99
|
| Rate for Payer: PACE SWMI |
$15.78
|
| Rate for Payer: PHP Commercial |
$3,093.88
|
| Rate for Payer: PHP Medicare Advantage |
$15.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,547.90
|
| Rate for Payer: Priority Health Medicare |
$15.78
|
| Rate for Payer: Priority Health SBD |
$2,293.11
|
| Rate for Payer: Railroad Medicare Medicare |
$15.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.78
|
| Rate for Payer: UHC Medicare Advantage |
$16.26
|
| Rate for Payer: VA VA |
$15.78
|
|
|
ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION
|
Facility
OP
|
$15,411.76
|
|
|
Service Code
|
CPT 36819
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$702.36 |
| Max. Negotiated Rate |
$15,411.76 |
| Rate for Payer: Aetna Medicare |
$5,085.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,112.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,112.15
|
| Rate for Payer: BCBS Complete |
$2,808.66
|
| Rate for Payer: BCBS MAPPO |
$4,889.72
|
| Rate for Payer: BCBS Trust/PPO |
$3,210.31
|
| Rate for Payer: BCN Medicare Advantage |
$4,889.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,889.72
|
| Rate for Payer: Mclaren Medicaid |
$2,674.68
|
| Rate for Payer: Mclaren Medicare |
$4,889.72
|
| Rate for Payer: Meridian Medicaid |
$2,808.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,134.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,623.18
|
| Rate for Payer: PACE Medicare |
$4,645.23
|
| Rate for Payer: PACE SWMI |
$4,889.72
|
| Rate for Payer: PHP Medicare Advantage |
$4,889.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,674.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,411.76
|
| Rate for Payer: Priority Health Medicare |
$4,889.72
|
| Rate for Payer: Priority Health Narrow Network |
$12,329.41
|
| Rate for Payer: Railroad Medicare Medicare |
$4,889.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$772.60
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,889.72
|
| Rate for Payer: UHC Exchange |
$702.36
|
| Rate for Payer: UHC Medicare Advantage |
$5,036.41
|
| Rate for Payer: VA VA |
$4,889.72
|
|
|
ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION
|
Facility
OP
|
$15,411.76
|
|
|
Service Code
|
CPT 36818
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$663.40 |
| Max. Negotiated Rate |
$15,411.76 |
| Rate for Payer: Aetna Medicare |
$5,085.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,112.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,112.15
|
| Rate for Payer: BCBS Complete |
$2,808.66
|
| Rate for Payer: BCBS MAPPO |
$4,889.72
|
| Rate for Payer: BCBS Trust/PPO |
$1,840.79
|
| Rate for Payer: BCN Medicare Advantage |
$4,889.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,889.72
|
| Rate for Payer: Mclaren Medicaid |
$2,674.68
|
| Rate for Payer: Mclaren Medicare |
$4,889.72
|
| Rate for Payer: Meridian Medicaid |
$2,808.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,134.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,623.18
|
| Rate for Payer: PACE Medicare |
$4,645.23
|
| Rate for Payer: PACE SWMI |
$4,889.72
|
| Rate for Payer: PHP Medicare Advantage |
$4,889.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,674.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,411.76
|
| Rate for Payer: Priority Health Medicare |
$4,889.72
|
| Rate for Payer: Priority Health Narrow Network |
$12,329.41
|
| Rate for Payer: Railroad Medicare Medicare |
$4,889.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$729.74
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,889.72
|
| Rate for Payer: UHC Exchange |
$663.40
|
| Rate for Payer: UHC Medicare Advantage |
$5,036.41
|
| Rate for Payer: VA VA |
$4,889.72
|
|
