|
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
CPT 29823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$590.71 |
| Max. Negotiated Rate |
$7,632.00 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$2,065.81
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$649.78
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$590.71
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])
|
Facility
|
OP
|
$5,427.00
|
|
|
Service Code
|
CPT 29822
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$540.28 |
| Max. Negotiated Rate |
$5,427.00 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$2,274.21
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$594.31
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$540.28
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$1,780.22
|
|
|
Service Code
|
CPT 29826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$167.00 |
| Max. Negotiated Rate |
$1,780.22 |
| Rate for Payer: BCBS Trust/PPO |
$1,780.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$183.70
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$167.00
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)
|
Facility
|
OP
|
$7,632.00
|
|
|
Service Code
|
CPT 29824
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$674.20 |
| Max. Negotiated Rate |
$7,632.00 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$2,065.81
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$741.62
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$674.20
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION
|
Facility
|
OP
|
$7,957.04
|
|
|
Service Code
|
CPT 29807
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,023.91 |
| Max. Negotiated Rate |
$7,957.04 |
| Rate for Payer: Aetna Medicare |
$6,620.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,957.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,957.04
|
| Rate for Payer: BCBS Complete |
$3,656.42
|
| Rate for Payer: BCBS MAPPO |
$6,365.63
|
| Rate for Payer: BCBS Trust/PPO |
$3,222.89
|
| Rate for Payer: BCN Medicare Advantage |
$6,365.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,365.63
|
| Rate for Payer: Mclaren Medicaid |
$3,482.00
|
| Rate for Payer: Mclaren Medicare |
$6,365.63
|
| Rate for Payer: Meridian Medicaid |
$3,656.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,683.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,320.47
|
| Rate for Payer: PACE Medicare |
$6,047.35
|
| Rate for Payer: PACE SWMI |
$6,365.63
|
| Rate for Payer: PHP Medicare Advantage |
$6,365.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,482.00
|
| Rate for Payer: Priority Health Medicare |
$6,365.63
|
| Rate for Payer: Railroad Medicare Medicare |
$6,365.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,126.30
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,365.63
|
| Rate for Payer: UHC Exchange |
$1,023.91
|
| Rate for Payer: UHC Medicare Advantage |
$6,556.60
|
| Rate for Payer: VA VA |
$6,365.63
|
|
|
ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR
|
Facility
|
OP
|
$7,957.04
|
|
|
Service Code
|
CPT 29827
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,056.33 |
| Max. Negotiated Rate |
$7,957.04 |
| Rate for Payer: Aetna Medicare |
$6,620.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,957.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,957.04
|
| Rate for Payer: BCBS Complete |
$3,656.42
|
| Rate for Payer: BCBS MAPPO |
$6,365.63
|
| Rate for Payer: BCBS Trust/PPO |
$3,065.23
|
| Rate for Payer: BCN Medicare Advantage |
$6,365.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,365.63
|
| Rate for Payer: Mclaren Medicaid |
$3,482.00
|
| Rate for Payer: Mclaren Medicare |
$6,365.63
|
| Rate for Payer: Meridian Medicaid |
$3,656.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,683.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,320.47
|
| Rate for Payer: PACE Medicare |
$6,047.35
|
| Rate for Payer: PACE SWMI |
$6,365.63
|
| Rate for Payer: PHP Medicare Advantage |
$6,365.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,482.00
|
| Rate for Payer: Priority Health Medicare |
$6,365.63
|
| Rate for Payer: Railroad Medicare Medicare |
$6,365.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,161.96
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,365.63
|
| Rate for Payer: UHC Exchange |
$1,056.33
|
| Rate for Payer: UHC Medicare Advantage |
$6,556.60
|
| Rate for Payer: VA VA |
$6,365.63
|
|
|
ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY
|
Facility
|
OP
|
$8,925.64
|
|
|
Service Code
|
CPT 23044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$564.18 |
| Max. Negotiated Rate |
$8,925.64 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$1,234.36
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,925.64
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Priority Health Narrow Network |
$7,140.51
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$620.60
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$564.18
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY
|
Facility
|
OP
|
$8,925.64
|
|
|
Service Code
|
CPT 27610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$641.13 |
| Max. Negotiated Rate |
$8,925.64 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$1,322.54
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,925.64
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Priority Health Narrow Network |
$7,140.51
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$705.24
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$641.13
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY
|
Facility
|
OP
|
$8,925.64
|
|
|
Service Code
|
CPT 23040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$714.15 |
| Max. Negotiated Rate |
$8,925.64 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$1,322.54
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,925.64
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Priority Health Narrow Network |
$7,140.51
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$785.56
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$714.15
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORATION, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY
|
Facility
|
OP
|
$19,834.21
|
|
|
Service Code
|
CPT 23107
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$663.72 |
| Max. Negotiated Rate |
$19,834.21 |
| Rate for Payer: Aetna Medicare |
$6,620.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,957.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,957.04
|
| Rate for Payer: BCBS Complete |
$3,656.42
|
| Rate for Payer: BCBS MAPPO |
$6,365.63
|
| Rate for Payer: BCBS Trust/PPO |
$2,299.99
|
| Rate for Payer: BCN Medicare Advantage |
$6,365.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,365.63
|
| Rate for Payer: Mclaren Medicaid |
$3,482.00
|
| Rate for Payer: Mclaren Medicare |
$6,365.63
|
| Rate for Payer: Meridian Medicaid |
$3,656.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,683.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,320.47
|
| Rate for Payer: PACE Medicare |
$6,047.35
|
| Rate for Payer: PACE SWMI |
$6,365.63
|
| Rate for Payer: PHP Medicare Advantage |
$6,365.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,482.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,834.21
|
| Rate for Payer: Priority Health Medicare |
$6,365.63
|
| Rate for Payer: Priority Health Narrow Network |
$15,867.37
|
| Rate for Payer: Railroad Medicare Medicare |
$6,365.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$730.09
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,365.63
|
| Rate for Payer: UHC Exchange |
$663.72
|
| Rate for Payer: UHC Medicare Advantage |
$6,556.60
|
| Rate for Payer: VA VA |
$6,365.63
|
|
|
ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR
|
Facility
|
OP
|
$8,817.68
|
|
|
Service Code
|
CPT 27334
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$684.68 |
| Max. Negotiated Rate |
$8,817.68 |
| Rate for Payer: Aetna Medicare |
$2,995.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,600.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,600.14
|
| Rate for Payer: BCBS Complete |
$1,654.34
|
| Rate for Payer: BCBS MAPPO |
$2,880.11
|
| Rate for Payer: BCBS Trust/PPO |
$1,322.54
|
| Rate for Payer: BCN Medicare Advantage |
$2,880.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,880.11
|
| Rate for Payer: Mclaren Medicaid |
$1,575.42
|
| Rate for Payer: Mclaren Medicare |
$2,880.11
|
| Rate for Payer: Meridian Medicaid |
$1,654.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,024.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,312.13
|
| Rate for Payer: PACE Medicare |
$2,736.10
|
| Rate for Payer: PACE SWMI |
$2,880.11
|
| Rate for Payer: PHP Medicare Advantage |
$2,880.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,575.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,817.68
|
| Rate for Payer: Priority Health Medicare |
$2,880.11
|
| Rate for Payer: Priority Health Narrow Network |
$7,054.14
|
| Rate for Payer: Railroad Medicare Medicare |
$2,880.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$753.15
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,880.11
|
| Rate for Payer: UHC Exchange |
$684.68
|
| Rate for Payer: UHC Medicare Advantage |
$2,966.51
|
| Rate for Payer: VA VA |
$2,880.11
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
IP
|
$58.14
|
|
|
Service Code
|
NDC 0536-1325-94
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.63 |
| Max. Negotiated Rate |
$52.33 |
| Rate for Payer: Aetna Commercial |
$49.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.79
|
| Rate for Payer: Cash Price |
$46.51
|
| Rate for Payer: Cofinity Commercial |
$50.00
|
| Rate for Payer: Cofinity Commercial |
$40.70
|
| Rate for Payer: Healthscope Commercial |
$52.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.42
|
| Rate for Payer: PHP Commercial |
$49.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.70
|
| Rate for Payer: Priority Health SBD |
$36.63
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$68.15
|
|
|
Service Code
|
NDC 904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.93 |
| Max. Negotiated Rate |
$61.34 |
| Rate for Payer: Aetna Commercial |
$57.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.30
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Cofinity Commercial |
$58.61
|
| Rate for Payer: Healthscope Commercial |
$61.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.93
|
| Rate for Payer: PHP Commercial |
$57.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.70
|
| Rate for Payer: Priority Health SBD |
$42.93
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 1184505171
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.42 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.35
|
| Rate for Payer: Priority Health SBD |
$44.42
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 7985430105
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.43 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.01
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Cofinity Commercial |
$90.48
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.48
|
| Rate for Payer: Priority Health SBD |
$81.43
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 904052372
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.48 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$115.48
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 1184551701
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
| Rate for Payer: Priority Health SBD |
$53.30
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 7985430035
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.58 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health SBD |
$69.58
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$1,239.50
|
|
|
Service Code
|
NDC 62332-198-31
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$780.88 |
| Max. Negotiated Rate |
$1,115.55 |
| Rate for Payer: Aetna Commercial |
$1,053.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.68
|
| Rate for Payer: Cash Price |
$991.60
|
| Rate for Payer: Cofinity Commercial |
$1,065.97
|
| Rate for Payer: Cofinity Commercial |
$867.65
|
| Rate for Payer: Healthscope Commercial |
$1,115.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,053.58
|
| Rate for Payer: PHP Commercial |
$1,053.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$867.65
|
| Rate for Payer: Priority Health SBD |
$780.88
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$123.95
|
|
|
Service Code
|
NDC 62332-198-10
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.09 |
| Max. Negotiated Rate |
$111.56 |
| Rate for Payer: Aetna Commercial |
$105.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.57
|
| Rate for Payer: Cash Price |
$99.16
|
| Rate for Payer: Cofinity Commercial |
$106.60
|
| Rate for Payer: Cofinity Commercial |
$86.76
|
| Rate for Payer: Healthscope Commercial |
$111.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$105.36
|
| Rate for Payer: PHP Commercial |
$105.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.76
|
| Rate for Payer: Priority Health SBD |
$78.09
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$1,239.65
|
|
|
Service Code
|
NDC 59762-2012-6
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$780.98 |
| Max. Negotiated Rate |
$1,115.68 |
| Rate for Payer: Aetna Commercial |
$1,053.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.77
|
| Rate for Payer: Cash Price |
$991.72
|
| Rate for Payer: Cofinity Commercial |
$1,066.10
|
| Rate for Payer: Cofinity Commercial |
$867.76
|
| Rate for Payer: Healthscope Commercial |
$1,115.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,053.70
|
| Rate for Payer: PHP Commercial |
$1,053.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$867.76
|
| Rate for Payer: Priority Health SBD |
$780.98
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$1,052.95
|
|
|
Service Code
|
NDC 51991-358-60
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$663.36 |
| Max. Negotiated Rate |
$947.66 |
| Rate for Payer: Aetna Commercial |
$895.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$684.42
|
| Rate for Payer: Cash Price |
$842.36
|
| Rate for Payer: Cofinity Commercial |
$905.54
|
| Rate for Payer: Cofinity Commercial |
$737.06
|
| Rate for Payer: Healthscope Commercial |
$947.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$895.01
|
| Rate for Payer: PHP Commercial |
$895.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$737.06
|
| Rate for Payer: Priority Health SBD |
$663.36
|
|
|
ASENAPINE 5 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$206.61
|
|
|
Service Code
|
NDC 59762-2012-1
|
| Hospital Charge Code |
99754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.16 |
| Max. Negotiated Rate |
$185.95 |
| Rate for Payer: Aetna Commercial |
$175.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.30
|
| Rate for Payer: Cash Price |
$165.29
|
| Rate for Payer: Cofinity Commercial |
$144.63
|
| Rate for Payer: Cofinity Commercial |
$177.68
|
| Rate for Payer: Healthscope Commercial |
$185.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.62
|
| Rate for Payer: PHP Commercial |
$175.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.63
|
| Rate for Payer: Priority Health SBD |
$130.16
|
|
|
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 20612
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$24.62 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: Aetna Medicare |
$274.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$329.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$329.42
|
| Rate for Payer: BCBS Complete |
$151.38
|
| Rate for Payer: BCBS MAPPO |
$263.54
|
| Rate for Payer: BCBS Trust/PPO |
$24.62
|
| Rate for Payer: BCN Medicare Advantage |
$263.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$263.54
|
| Rate for Payer: Mclaren Medicaid |
$144.16
|
| Rate for Payer: Mclaren Medicare |
$263.54
|
| Rate for Payer: Meridian Medicaid |
$151.38
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$276.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$303.07
|
| Rate for Payer: PACE Medicare |
$250.36
|
| Rate for Payer: PACE SWMI |
$263.54
|
| Rate for Payer: PHP Medicare Advantage |
$263.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$144.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$813.49
|
| Rate for Payer: Priority Health Medicare |
$263.54
|
| Rate for Payer: Priority Health Narrow Network |
$650.79
|
| Rate for Payer: Railroad Medicare Medicare |
$263.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44.31
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$263.54
|
| Rate for Payer: UHC Exchange |
$40.28
|
| Rate for Payer: UHC Medicare Advantage |
$271.45
|
| Rate for Payer: VA VA |
$263.54
|
|
|
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER
|
Facility
|
OP
|
$5,561.92
|
|
|
Service Code
|
CPT 51102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$138.18 |
| Max. Negotiated Rate |
$5,561.92 |
| Rate for Payer: Aetna Medicare |
$1,884.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,265.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,265.42
|
| Rate for Payer: BCBS Complete |
$1,041.01
|
| Rate for Payer: BCBS MAPPO |
$1,812.34
|
| Rate for Payer: BCBS Trust/PPO |
$802.43
|
| Rate for Payer: BCN Medicare Advantage |
$1,812.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,812.34
|
| Rate for Payer: Mclaren Medicaid |
$991.35
|
| Rate for Payer: Mclaren Medicare |
$1,812.34
|
| Rate for Payer: Meridian Medicaid |
$1,041.01
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,902.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,084.19
|
| Rate for Payer: PACE Medicare |
$1,721.72
|
| Rate for Payer: PACE SWMI |
$1,812.34
|
| Rate for Payer: PHP Medicare Advantage |
$1,812.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$991.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,561.92
|
| Rate for Payer: Priority Health Medicare |
$1,812.34
|
| Rate for Payer: Priority Health Narrow Network |
$4,449.54
|
| Rate for Payer: Railroad Medicare Medicare |
$1,812.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$152.00
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,812.34
|
| Rate for Payer: UHC Exchange |
$138.18
|
| Rate for Payer: UHC Medicare Advantage |
$1,866.71
|
| Rate for Payer: VA VA |
$1,812.34
|
|
