|
COMPOUNDING VEHICLE SUSPENSION NO.7 ORAL
|
Facility
|
IP
|
$210.02
|
|
|
Service Code
|
NDC 00574030316
|
| Hospital Charge Code |
118921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.31 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
|
|
COMPOUNDING VEHICLE SUSPENSION NO.7 ORAL
|
Facility
|
OP
|
$210.02
|
|
|
Service Code
|
NDC 00574030316
|
| Hospital Charge Code |
118921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.01 |
| Max. Negotiated Rate |
$189.02 |
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Aetna Medicare |
$105.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.51
|
| Rate for Payer: BCBS Complete |
$84.01
|
| Rate for Payer: Cash Price |
$168.02
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.02
|
| Rate for Payer: Healthscope Commercial |
$189.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.52
|
| Rate for Payer: PHP Commercial |
$178.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.51
|
| Rate for Payer: Priority Health SBD |
$132.31
|
|
|
COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL
|
Facility
|
IP
|
$164.61
|
|
|
Service Code
|
NDC 39328001416
|
| Hospital Charge Code |
176500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.70 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.00
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$115.23
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.69
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.92
|
| Rate for Payer: PHP Commercial |
$139.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.00
|
| Rate for Payer: Priority Health SBD |
$103.70
|
|
|
COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL
|
Facility
|
OP
|
$164.61
|
|
|
Service Code
|
NDC 39328001416
|
| Hospital Charge Code |
176500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.84 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: Aetna Medicare |
$82.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.00
|
| Rate for Payer: BCBS Complete |
$65.84
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$115.23
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.69
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.92
|
| Rate for Payer: PHP Commercial |
$139.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.00
|
| Rate for Payer: Priority Health SBD |
$103.70
|
|
|
CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 57520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,745.82
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 57522
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,745.82
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET
|
Facility
|
IP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110081
|
| Hospital Charge Code |
9973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,607.22 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET
|
Facility
|
OP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110081
|
| Hospital Charge Code |
9973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,020.46 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna Medicare |
$1,275.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: BCBS Complete |
$1,020.46
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM
|
Facility
|
OP
|
$1,572.69
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
9977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$629.08 |
| Max. Negotiated Rate |
$1,415.42 |
| Rate for Payer: Aetna Commercial |
$1,336.79
|
| Rate for Payer: Aetna Medicare |
$786.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.25
|
| Rate for Payer: BCBS Complete |
$629.08
|
| Rate for Payer: Cash Price |
$1,258.15
|
| Rate for Payer: Cofinity Commercial |
$1,100.88
|
| Rate for Payer: Cofinity Commercial |
$1,352.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,100.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.15
|
| Rate for Payer: Healthscope Commercial |
$1,415.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,336.79
|
| Rate for Payer: PHP Commercial |
$1,336.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,022.25
|
| Rate for Payer: Priority Health SBD |
$990.79
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM
|
Facility
|
IP
|
$1,572.69
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
9977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$990.79 |
| Max. Negotiated Rate |
$1,415.42 |
| Rate for Payer: Aetna Commercial |
$1,336.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.25
|
| Rate for Payer: Cash Price |
$1,258.15
|
| Rate for Payer: Cofinity Commercial |
$1,100.88
|
| Rate for Payer: Cofinity Commercial |
$1,352.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,100.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.15
|
| Rate for Payer: Healthscope Commercial |
$1,415.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,336.79
|
| Rate for Payer: PHP Commercial |
$1,336.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,022.25
|
| Rate for Payer: Priority Health SBD |
$990.79
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$1,175.88
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
9972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.14 |
| Max. Negotiated Rate |
$1,103.61 |
| Rate for Payer: Aetna Commercial |
$999.50
|
| Rate for Payer: Aetna Medicare |
$407.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$764.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$490.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$490.07
|
| Rate for Payer: BCBS Complete |
$220.65
|
| Rate for Payer: BCBS MAPPO |
$392.06
|
| Rate for Payer: BCN Medicare Advantage |
$392.06
|
| Rate for Payer: Cash Price |
$940.70
|
| Rate for Payer: Cash Price |
$940.70
|
| Rate for Payer: Cofinity Commercial |
$823.12
|
| Rate for Payer: Cofinity Commercial |
$1,011.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$823.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$940.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$392.06
|
| Rate for Payer: Healthscope Commercial |
$1,058.29
|
| Rate for Payer: Mclaren Medicaid |
$210.14
|
| Rate for Payer: Mclaren Medicare |
$392.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$411.66
|
| Rate for Payer: Meridian Medicaid |
$220.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$999.50
|
| Rate for Payer: PACE Medicare |
$372.46
|
| Rate for Payer: PACE SWMI |
$392.06
|
| Rate for Payer: PHP Commercial |
$999.50
|
| Rate for Payer: PHP Medicare Advantage |
$392.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$210.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$764.32
|
| Rate for Payer: Priority Health Medicare |
$392.06
|
| Rate for Payer: Priority Health SBD |
$740.80
|
| Rate for Payer: Railroad Medicare Medicare |
$392.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,103.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$392.06
|
| Rate for Payer: UHC Medicare Advantage |
$392.06
|
| Rate for Payer: UHCCP Medicaid |
$220.73
|
| Rate for Payer: VA VA |
$392.06
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$1,175.88
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
9972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$740.80 |
| Max. Negotiated Rate |
$1,058.29 |
| Rate for Payer: Aetna Commercial |
$999.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$764.32
|
| Rate for Payer: Cash Price |
$940.70
|
| Rate for Payer: Cofinity Commercial |
$1,011.26
|
| Rate for Payer: Cofinity Commercial |
$823.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$823.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$940.70
|
| Rate for Payer: Healthscope Commercial |
$1,058.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$999.50
|
| Rate for Payer: PHP Commercial |
$999.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$764.32
|
| Rate for Payer: Priority Health SBD |
$740.80
|
|
|
CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD
|
Facility
|
OP
|
$353.86
|
|
|
Service Code
|
CPT 30903
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$353.86 |
| Rate for Payer: Aetna Medicare |
$130.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$70.77
|
| Rate for Payer: VA VA |
$125.71
|
|
|
CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD
|
Facility
|
OP
|
$353.86
|
|
|
Service Code
|
CPT 30901
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$353.86 |
| Rate for Payer: Aetna Medicare |
$130.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$70.77
|
| Rate for Payer: VA VA |
$125.71
|
|
|
COPPER 380 SQUARE MM INTRAUTERINE DEVICE
|
Facility
|
IP
|
$2,689.90
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
167586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,694.64 |
| Max. Negotiated Rate |
$2,420.91 |
| Rate for Payer: Aetna Commercial |
$2,286.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,748.43
|
| Rate for Payer: Cash Price |
$2,151.92
|
| Rate for Payer: Cofinity Commercial |
$1,882.93
|
| Rate for Payer: Cofinity Commercial |
$2,313.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,882.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,151.92
|
| Rate for Payer: Healthscope Commercial |
$2,420.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,286.41
|
| Rate for Payer: PHP Commercial |
$2,286.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,748.43
|
| Rate for Payer: Priority Health SBD |
$1,694.64
|
|
|
COPPER 380 SQUARE MM INTRAUTERINE DEVICE
|
Facility
|
OP
|
$2,689.90
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
167586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,075.96 |
| Max. Negotiated Rate |
$2,420.91 |
| Rate for Payer: Aetna Commercial |
$2,286.41
|
| Rate for Payer: Aetna Medicare |
$1,344.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,748.43
|
| Rate for Payer: BCBS Complete |
$1,075.96
|
| Rate for Payer: Cash Price |
$2,151.92
|
| Rate for Payer: Cofinity Commercial |
$1,882.93
|
| Rate for Payer: Cofinity Commercial |
$2,313.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,882.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,151.92
|
| Rate for Payer: Healthscope Commercial |
$2,420.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,286.41
|
| Rate for Payer: PHP Commercial |
$2,286.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,748.43
|
| Rate for Payer: Priority Health SBD |
$1,694.64
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 28296
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 28299
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,922.50
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD
|
Facility
|
OP
|
$35,323.48
|
|
|
Service Code
|
CPT 28297
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,726.13 |
| Max. Negotiated Rate |
$35,323.48 |
| Rate for Payer: Aetna Medicare |
$13,050.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,685.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,685.94
|
| Rate for Payer: BCBS Complete |
$7,062.44
|
| Rate for Payer: BCBS MAPPO |
$12,548.75
|
| Rate for Payer: BCN Medicare Advantage |
$12,548.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,548.75
|
| Rate for Payer: Mclaren Medicaid |
$6,726.13
|
| Rate for Payer: Mclaren Medicare |
$12,548.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,176.19
|
| Rate for Payer: Meridian Medicaid |
$7,062.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,431.06
|
| Rate for Payer: PACE Medicare |
$11,921.31
|
| Rate for Payer: PACE SWMI |
$12,548.75
|
| Rate for Payer: PHP Medicare Advantage |
$12,548.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,726.13
|
| Rate for Payer: Priority Health Medicare |
$12,548.75
|
| Rate for Payer: Railroad Medicare Medicare |
$12,548.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35,323.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,548.75
|
| Rate for Payer: UHC Medicare Advantage |
$12,548.75
|
| Rate for Payer: UHCCP Medicaid |
$7,064.95
|
| Rate for Payer: VA VA |
$12,548.75
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL METATARSAL OSTEOTOMY, ANY METHOD
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 28295
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 28298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,922.50
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 28292
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 28285
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,781.56
|
| Rate for Payer: VA VA |
$3,164.40
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$131.82
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
9686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.73 |
| Max. Negotiated Rate |
$118.64 |
| Rate for Payer: Aetna Commercial |
$112.05
|
| Rate for Payer: Aetna Commercial |
$70.35
|
| Rate for Payer: Aetna Commercial |
$247.43
|
| Rate for Payer: Aetna Medicare |
$41.38
|
| Rate for Payer: Aetna Medicare |
$65.91
|
| Rate for Payer: Aetna Medicare |
$145.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.21
|
| Rate for Payer: BCBS Complete |
$116.44
|
| Rate for Payer: BCBS Complete |
$52.73
|
| Rate for Payer: BCBS Complete |
$33.11
|
| Rate for Payer: Cash Price |
$66.22
|
| Rate for Payer: Cash Price |
$105.46
|
| Rate for Payer: Cash Price |
$232.87
|
| Rate for Payer: Cofinity Commercial |
$71.18
|
| Rate for Payer: Cofinity Commercial |
$92.27
|
| Rate for Payer: Cofinity Commercial |
$113.37
|
| Rate for Payer: Cofinity Commercial |
$250.34
|
| Rate for Payer: Cofinity Commercial |
$203.76
|
| Rate for Payer: Cofinity Commercial |
$57.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.46
|
| Rate for Payer: Healthscope Commercial |
$261.98
|
| Rate for Payer: Healthscope Commercial |
$118.64
|
| Rate for Payer: Healthscope Commercial |
$74.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.05
|
| Rate for Payer: PHP Commercial |
$247.43
|
| Rate for Payer: PHP Commercial |
$112.05
|
| Rate for Payer: PHP Commercial |
$70.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.21
|
| Rate for Payer: Priority Health SBD |
$52.15
|
| Rate for Payer: Priority Health SBD |
$183.39
|
| Rate for Payer: Priority Health SBD |
$83.05
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$291.09
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
9686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.39 |
| Max. Negotiated Rate |
$261.98 |
| Rate for Payer: Aetna Commercial |
$247.43
|
| Rate for Payer: Aetna Commercial |
$112.05
|
| Rate for Payer: Aetna Commercial |
$70.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.21
|
| Rate for Payer: Cash Price |
$232.87
|
| Rate for Payer: Cash Price |
$105.46
|
| Rate for Payer: Cash Price |
$66.22
|
| Rate for Payer: Cofinity Commercial |
$57.94
|
| Rate for Payer: Cofinity Commercial |
$71.18
|
| Rate for Payer: Cofinity Commercial |
$250.34
|
| Rate for Payer: Cofinity Commercial |
$92.27
|
| Rate for Payer: Cofinity Commercial |
$113.37
|
| Rate for Payer: Cofinity Commercial |
$203.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.22
|
| Rate for Payer: Healthscope Commercial |
$118.64
|
| Rate for Payer: Healthscope Commercial |
$261.98
|
| Rate for Payer: Healthscope Commercial |
$74.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.35
|
| Rate for Payer: PHP Commercial |
$112.05
|
| Rate for Payer: PHP Commercial |
$247.43
|
| Rate for Payer: PHP Commercial |
$70.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.80
|
| Rate for Payer: Priority Health SBD |
$52.15
|
| Rate for Payer: Priority Health SBD |
$83.05
|
| Rate for Payer: Priority Health SBD |
$183.39
|
|
